Posts Tagged ‘Medicine’

The Dark Side of Quality

Nobody stands up to argue against quality and value in healthcare. You might as well argue against motherhood, or puppies. Yet many physicians are inherently skeptical of definitions of “quality” that are imposed from above, whether by outside evaluators like The Joint Commission, or (worse) by the government.

There’s good reason for skepticism. Some of the “evidence” behind “evidence-based medicine” has turned out to be flawed, tainted by financial conflict of interest, or outright fraudulent. Any experienced physician knows that there are fads in healthcare just as there are in fashion, and today’s evidence-based medicine may be tomorrow’s malpractice. Let’s take a closer look at what’s really going on in the world of quality metrics, and why it matters if payments to you and your hospital are increasingly linked to how you score.

Surgical Site Infections

The financial toll of surgical site infections (SSIs) is huge, estimated in the U.S. at more than $10 billion a year.(1)  A recent retrospective review from the Veterans Affairs Surgical Quality Improvement Program showed that the majority of SSIs are diagnosed only after hospital discharge, and that 57% will require hospital readmission within 30 days.(2)  The Centers for Medicare and Medicaid Services (CMS) stopped paying for care related to SSIs in 2008 by designating them as “never events”, or non-reimbursable serious hospital-acquired conditions. Now SSIs are part of a long list of hospital-acquired conditions that can result in reduced CMS payments to hospitals, and will bring further reduction in payments over the next several years with the implementation of “value-based purchasing”. More than 1400 hospitals will see their Medicare payments cut by as much as 1.25% this year–a margin that could spell financial disaster for hospitals already struggling.(3)

You may already be among the more than 50% of anesthesiologists who have been reporting performance metrics to the Physician Quality Reporting System (PQRS), which is administered by CMS. When the system started in 2007, CMS offered a bonus payment of 1.5% for successful participation, but that soon shrank to 0.5% and will be discontinued after 2014. Starting in 2015, CMS will impose a 1.5% payment reduction for physicians who do not participate in PQRS, and will push the pay cut to 2% in 2016.

If you participate in PQRS reporting, you know that two of the measures that anesthesiologists report are directly aimed at SSI prevention: perioperative temperature management, and antibiotic timing. PQRS measure #193 specifies that the patient must receive “active warming” or have a temperature above 36C recorded within 30 minutes before or 15 minutes after anesthesia end time. Measure #30 specifies that prophylactic parenteral antibiotics must be administered within one hour before skin incision. Compliance with these two measures isn’t hard to achieve, though no one seems to question the cost to the American healthcare system of all those forced-air warming blankets and machines, or ask why giving antibiotics 61 minutes instead of 59 minutes before skin incision is an automatic “fail”.

But have CMS threats and PQRS compliance done any good? A just-published editorial in Anesthesiology concluded: “Despite early efficacy literature establishing the value of specific antibiotic timing and active warming, repeated large database analyses have not observed robust effectiveness across hundreds of hospitals.”(4)   Simply put, as many of us have noticed in our own hospitals, SSI rates have remained about the same.

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We were startled to learn recently that Sheridan Healthcare Inc., a physician services company based in Florida, has bought one of the largest private anesthesiology group practices in California, the Medical Anesthesia Consultants Medical Group Inc. (MAC) of San Ramon.

The deal, which closed November 14, is Sheridan’s first in California, and “provides a platform that will accelerate our expansion in the California marketplace,” said John Carlyle, Sheridan’s CEO, in a recent statement.

By all accounts, MAC is a well-respected and highly successful anesthesia practice, with more than 100 physicians—shareholders, non-shareholders, and independent contractors—who provide anesthesiology services to five hospitals and 23 ambulatory surgery settings in northern California.  So why did this group decide to sell?

Was this a hostile takeover, or did hospital administrators force the group’s hand?  Not at all, says a senior partner in the MAC group (who prefers not to be named).  The senior shareholders actively sought a purchaser, hired an investment bank to broker the deal, and voted unanimously to approve it.  Apparently, there are no plans yet to hire nurse anesthetists or change the MD-only composition of the group.  Hospital administrators didn’t instigate the sale but all supported it, the anesthesiologist said. “For us right now, it looked like the right thing to do.”

It’s doubtful that the non-shareholders in MAC are quite as enthusiastic.

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New research just out in the journal Psychology and Aging says pessimists live longer and healthier lives. If this is true, then contemplating the future of anesthesiology ought to make us immortal, because our professional prospects don’t look bright.  As we teach residents to do what we’ve always done, shouldn’t we ask ourselves honestly if we’re training them for a future that doesn’t exist?

Especially here in California, it seems likely that our predominantly MD-provided, fee-for-service practice of anesthesiology will not survive indefinitely, and perhaps not for long.  We can blame the reelection of President Obama and the passage of the Affordable Care Act if we like, but the reality is that market forces were eventually going to catch up with us whether or not Mitt Romney went to the White House.

In a way, we’re the victims of our own success; we’ve made anesthesia so safe that everyone thinks there’s nothing to it. But that’s exactly the point.  Technology has indeed made anesthesia much safer.  When I started learning anesthesia, pulse oximetry and end-tidal CO2 monitoring were new to the market, unproven, and scarce. Now they’re everywhere. We fear the difficult airway less now that we have video laryngoscopes readily at hand.

Since technology is so much better, why do so many of us still believe that every case requires the costly expertise of a board-certified anesthesiologist?  Read the Full Article

The unsolved problem of MD + PR

In my hospital’s preoperative area, upright on her bed, sat an unhappy middle-aged lady who needed an operation to treat complications from her previous bariatric surgery.  She hadn’t lost weight and clearly was feeling discouraged about practically everything.  She was physically uncomfortable, couldn’t even keep down her own saliva because her lower esophagus was obstructed, and was in tears.

As her anesthesiologist, I came to evaluate her prior to surgery.  In fairly short order, I got her a tissue and a warm blanket, listened to her tale of woe, and finished my pre-anesthetic examination.  Nothing special.  At the end, she said,  “You’re so nice.  Were you a nurse before you were a doctor?”

Ouch.

No, I told her, I wasn’t.  Never a nurse; always a doctor.  She looked surprised.

And that little narrative may help to explain why we (physicians as a group) are having so much trouble with public relations, and  with the onslaught and success of mid-level caregivers who want to practice medicine without a license.  Their PR is better than ours because their PR task is easier:  patients already think mid-level health care personnel, especially nurses, are basically nicer and more sympathetic than we are.

Just look at the recent coverage of Hurricane Sandy.  News reporters on radio, TV, print, and online repeatedly and justly praised the heroic efforts that nurses made during the evacuation of patients from dark, flooded hospitals, and showed photos and video clips of nurses hand-ventilating premature infants.  But not once did I hear a mention of the attending physicians and residents who were no doubt working right alongside the nurses, let alone the respiratory therapists, orderlies, and all the other personnel.  Nurses got all the credit in the public’s view.

Anesthesiologists and nurse anesthetists represent perhaps the most visible part of the physician/mid-level conflict, but other physicians are at risk as well.  The American Academy of Family Physicians (AAFP) has recently made public its opinion that nurse practitioners shouldn’t run medical homes, but the Affordable Care Act supports independent practice for nurse practitioners–including admitting privileges to hospitals–just as it supports independent practice for nurse anesthetists.

The latest unbelievable turn of events is Medicare’s decision in favor of nurse anesthetists practicing interventional pain medicine without physician supervision.  Just so we’re clear, this means that a nurse anesthetist with no special qualification other than Medicare’s blessing can bill Medicare for performing invasive pain management procedures that physicians ordinarily train to do with four years of medical school, at least four years of residency, and a fellowship.  These are procedures so risky that my hospital wouldn’t consider me qualified to do them despite my MD degree and anesthesiology residency, because I haven’t taken advanced training in interventional pain management.

What are we going to do to turn around this public perception that doctors are curt, mean, and unsympathetic? And that nurses are always better, kinder, and maybe even smarter?  And can do everything doctors can do, just as well?

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I gained a certain notoriety last summer by suggesting in a New York Times op-ed that it isn’t a good thing for growing numbers of physicians to work part time.  American-trained physicians have an obligation, it seems to me, to make full use of our professional skills because there is a shortage of doctors and because American taxpayers provide so much of the funds for our training.  Now, in a new article in the Atlantic magazine–“Is Medical School a Worthwhile Investment for Women?”–two Yale professors suggest that physicians might as well work full time or more because, if we don’t, medical school is an investment of time and money that doesn’t make financial sense.

This article didn’t surprise me at all.  It specifically points to the example of American primary care doctors who are less well compensated than specialists. Using a tool called net present value (NPV) calculation, Professors Keith Chen and Judith Chevalier compared the costs of earning a degree against the income earned over the likely course of a career.  They compared the NPV of training as a physician assistant (PA) compared to a primary care physician, and also looked at gender differences in anticipated earnings.

Their conclusion?  “We found that, for over half of woman doctors in our data, the NPV of becoming a primary-care physician was less than the NPV of becoming a physician assistant,” the authors wrote.

Was this true for men as well?  No, said the authors.  Most men are better off financially if they become physicians.  But women physicians tend to earn less than their male counterparts, and they also tend to work less.  A male physician “earns more per hour relative to the male PA than the female doctor earns relative to the female PA,” the authors noted.  “However, a big part of the difference comes from an hours gap. The vast majority of male doctors under the age of 55 work substantially more than the standard 40 hour work week. In contrast, most female doctors work between 2 to 10 hours fewer than this per week.”

The professors concluded, “Even though both male and female doctors earn higher wages than their PA counterparts, most female doctors don’t work enough hours at those wages to financially justify the costs of becoming a doctor.”

After reading the Atlantic article, I don’t doubt the reasoning behind it but have other questions to raise.

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