This is a picture of a teenage boy with Gynecomastia. Obviously, gynecomastia is an abnormal enlargement of the male breasts. It happens in some teenagers - and is worse in those with obesity. Just how cruel do you think these kids are treated in high school and middle school?

I have a young boy who is 13 and has marked gynecomastia which has been present for over two years. I requested a plastic surgery consult (which is usually my practice) in this situation and the surgeon agreed that he was a good candidate for a surgical fix and submitted the request to our Medicaid managed care provider. I have never had a denial of this when the situation clearly seemed to warrant this. In fact, this child had been approved to have the procedure done a year prior to now but had not gotten it done out of fears and misconceptions about the procedure.

He is now being denied by the Medicaid managed care company. The grounds? No documentation of degree of enlargement and child not old enough.

Disgraceful.

I seriously considered not putting the above picture up as it is disturbing to look at, but really isn’t that the point? Would you want to be this child?

I had to write a letter for him today stating that he can change for PE in private.

This is abuse. The state prosecutes child abuse. The same organization that runs Medicaid also investigates child abuse. So how can the state sanction this? I have expressed my outrage to the “proper authorities” but got the usual blah, blah, blah.

Saving money at the expense of a child’s psychologic stability is wrong, and makes me mad as hell.

So we have a construction project ahead of us.  American Healthcare is like an old road with two lanes.  The asphalt is cracking and there are potholes every few feet.  The demand could easily fill an interstate highway, but all we have is a curvy slow road.  We need to fix it without making things worse.  We can’t wait long for this to be fixed, since people are being inconvenienced, injured, and even killed by the poor quality of road.  Plus, we need to fix it while leaving it open for traffic.

So what is the first step to get this construction going?  The very foundation of healthcare that is broken at the root is communication.  In previous posts I have documented many areas of breakdown in communication:

• Between doctors and patients. 
• Between primary care physicians and specialists. 
• Between outpatient and hospital physicians.

If I have a heart attack at a local hospital, go home, and then a month later go to a different hospital, there is very little chance that the second hospital will have any information about that hospital stay accept what I can verbally supply them.  The patient is expected to be the vehicle for communication between different segments of the medical system.  “You saw Dr. X?  What did he tell you?” I ask, as I have no consult note in the chart.  “You were in the hospital for two weeks?  What were you there for?  What did they tell you was wrong?”  I ask as a patient is sent to me “for follow-up” after a long hospitalization.

The irony of this is that we live in an age of unparalleled communication.  Take this blog, for instance.  By blogging I am communicating with people all over the world in an instant.  I can call a physician in India on Skype, and can do instant messages with a new friend in Houston.  I can get my ideas out quickly and efficiently, and it is extremely low cost to me. 

Why should an information age such as this continue to produce medical care that relies on incredibly outdated modes of communication?  I haven’t sent my parents a letter in the mail for years, yet we e-mail and talk on the phone regularly.  I haven’t gotten a newspaper delivered to my house for 4 years, yet I read the news daily on my Google home page.  It is absolutely absurd that we still rely on paper to do the bulk of our communication in healthcare.

It is also ironic to me to read rants against EMR on blogs.  Clearly blogging is a means of communication that leverages technology in a major way.  Can we envision a system that allows communication to occur via e-mail, secure messaging, and electronic interface?  If I can have friends around the world who know what I had for dinner tonight (a great chicken casserole, by the way), why can’t I with equal ease communicate instructions to my patients?  Or why can’t the hospitalist communicate with me before the patient gets to my office?

Building the proper infrastructure so this communication can easily happen is the key.  If blogging weren’t so simple to do, only enthusiasts would do it.  Yet it has been made simple by Blogger and Wordpress.  Plus, there is the backbone of the Internet on which the communication can occur.  This type of technology could be applied to healthcare.  The National Health Information Network (NHIN) and the Regional Health Information Organizations (RHIOs) are two examples of these attempts. 

A communication infrastructure is basic to reform.  It is impossible to improve the delivery of care if it cannot be analyzed.  It is impossible to analyze care if it is not put in a format that allows analysis.  The only way to do this is to somehow financially motivate the widespread adoption of EMR.  There is no other way.  While this won’t guarantee that change will be positive, good communication is a necessary foundation for any hope for healthcare that will be worth practicing in the years to come.

I am a Med/Peds physician.  That means that my training was in both internal medicine and pediatrics.  I do basically what a family physician does (a little more pediatrics, and less procedures and well-woman care). 

My internal medicine residency training was mostly inpatient in nature.  We spent most of our time on the wards in the hospital, often taking care of intensive care patients.  I never spent much time taking care of patients in the outpatient setting, with a half-day each week alternating between adult and pediatric clinics.  So by the time I was done with residency, I was very comfortable in taking care of inpatients - even ICU patients - but with relatively little experience taking care of patients in the office.

I quickly adjusted, however, with a very complete understanding of the diseases I was treating and trying to prevent.  We cared for our patients both in and out of the hospital, often spending several hours in the morning on our patients in the hospital prior to spending a full day at the office.  We shared call with other internists on weekends, resulting in a number of weekends with little sleep and the vast majority of my time spent in the hospital.

This all changed when a group of intensive care/hospitalist physicians moved to town.  We were contemplating expanding our office hours with a morning walk-in clinic, and we were getting quite tired of our nights on call.  When we looked at the income we were getting from inpatient care for the long hours we put in, it was clear that it was financially best to opt out of it in favor of the hospitalists.  We would still take care of hospitalized pediatric patients (there was no hospitalists for children in our town, and pediatric inpatient care is much less demanding), but all of our adult patients came under the care of the hospitalist group.

It would seem like a no-brainer:  improve your quality of life by drastically improving your call, improve your income, and offer a new convenience for the rest of your patients (using a daily walk-in clinic).  Yet the decision was hard.  I loved inpatient care, and considered it a major part of what it meant to be an internist.  Plus, I would have to sacrifice the ability to care for my patients in the time of their greatest need.  What would our patients think?

It turns out that our fears were well-founded.  Whenever we told our patients that we no longer took care of our patients in the hospital, we were met by a look of bewilderment.  We always tried to counter that look by pointing out the fact that we were now open from 7:30 to 9 AM every morning and 5:30 to 7 PM every evening for walk-in visits.  While this did make sense, it did not erase the disappointment.  

Perhaps the biggest negative about using hospitalists, however, is the fractionation of the care of the patients.  I am not sure if this is the norm for hospitalists, but so far we have had three groups we worked with, and none of them communicated well with outpatient offices.  They don’t seem to understand that the vast majority of the patients’ care goes in in the outpatient setting.  Each hospital visit seems to be treated as an individual episode of care rather than part of their continuum of care.  We are rarely called when patients are admitted to the hospital, and rarely are told when they are discharged.  Often patients come to our office before we know they have been hospitalized at all. 

Despite our frustration, it is basically impossible for us to take back inpatient care.  The lifestyle improvement from using hospitalists is dramatic.  It has enabled us to continue our very popular walk-in clinics and to actually se our families.  Plus, I have now not done inpatient medicine for over eight years.  This means that we have very little leverage when it comes to demanding better communication from the hospitalist groups.  If we don’t like their care, we can do it ourselves.  It just won’t happen.

I have to believe that this is a common scenario.  Anyone who makes the jump to hospitalists will end up in a very weak bargaining position.  Yet the total lack of communication really does damage to the quality of care.  They end up duplicating much of what we do in the office.  When they don’t contact us regarding the patient, they are basically “flying blind,” relying on the memory of the patient as to what has gone on with their care.  We would welcome phone calls, but they don’t come.

I don’t see a real solution here.  Are there any hospitalists out there with an answer to this one?

On my way to work I have to drive through a construction zone. The construction project is huge. The first step is to widen about four miles of one road to four lanes, adding an extra bridge to cross the interstate. The second step will be to totally reroute the interstate exits to do away with some dangerous intersections.

I love watching the process of a big construction process like this. The amazing organization and coordination necessary to pull things off is very impressive to me. Workers are simultaneously working on totally different aspects to the project on opposite ends, while being completely coordinated with each other.

To effectively and efficiently finish the project, thousands of jobs must be done, each in a specific order. Certain jobs are foundational and must be done properly for the final result to be long-lasting and high quality. If these jobs are not done well, even though the final product may look good, the reliability of the road may be compromised and the road may even become hazardous.

I have been watching this now for the past year, and am impatient for the final steps to be done and for the 4-lane road to be opened. Yet I am a “results now” kind of person, which is the reason I was never good at building model airplanes or cars when I was a kid. It takes a lot of preparation and patience to do a job like this well, and thankfully, the people in charge of this project seem to understand that.

We have a huge task ahead of us in American healthcare. The system is a mess. Physicians are unhappy; patients are unhappy. All of this is happening while the cost of care skyrockets. Clearly we need to do some major overhauling. Yet I worry at the short vision of the political process. The task of “fixing healthcare” won’t be easy, and there will be a lot of jobs that will first tear up the road before laying a new surface. Not only that, but a good master plan must be laid out in advance and then followed carefully. I am even less optimistic about this. Politics are done on the moment. Politicians are judged on the “here and now” and will not have the political stomach to lay a careful plan, tear up the road, and make sure all of the small jobs are done well before completing the task. They will not follow a master plan, but instead vote for what is politically expedient - what will assure them re-election.

But that is what must happen for the best result. As members of the medical community, we must set the agenda for what needs to be done. We are the ones who know best as to what is broken. We are the engineers, the construction workers; we are the pavement and bridges.

So in coming posts I am going to start going through things that I see need addressing to fix the infrastructure in which we practice. We must not leave this task to politicians. We must not let them be our leaders in something this important. We must be the leaders, the planners, the builders.

If we leave it to politicians, many people will be harmed by the result.

In a recent editorial in the Washington Post, Walter E. Williams states:

Do we want the government employees who run the troubled Walter Reed Army Medical Center to be in charge of our entire health-care system? Or, would you like the people who deliver our mail to also deliver health-care services? How would you like the people who run the motor vehicles department, the government education system, foreign intelligence and other government agencies to also run our health-care system? After all, they are not motivated by the quest for profits, and that might mean they’re truly wonderful, selfless, caring people.

As for me, I would choose profit-driven people to provide my health-care services, people with motives like those who deliver goods to my supermarket, deliver my overnight mail, produce my computer and software programs, assemble my car and produce a host of other goods and services I use.

His argument is that making the system less free than it presently is will make it even worse, pointing to the Canadian, British, and French system failures.

While I don’t disagree with the specifics of what he is saying, and the examples from other systems do raise the question of whether a single-payer system will really be better, he greatly oversimplifies the issue.  Perhaps this is because he is taking one of the most complex problems we have in this country and trying to boil down his commentary to an editorial.  Whatever the reason, I think there are some huge facts that he skips over regarding our system and what change would mean.

The market is not free

Physicians don’t set their prices, insurance companies do.  Yes, I can set a fee schedule for my procedures, but in general, what I am paid won’t be impacted much by that fee schedule.  Patients cannot generally shop for the best price for a product because of this.

The fact is, there are very few within the system who control the cost or spending within the healthcare system.  Pharmaceutical companies must negotiate what they get paid for medications.  Hospitals are also at the mercy of the reimbursement from the payers. 

The only parties in the healthcare equation who have some control are the payers.  Insurance companies can raise their premiums and lower or raise reimbursement.  They compete for business based on the cost of their product and the quality of their service. 

This renders the comparison of the supermarket to the postal service a false comparison.  Physicians see a small percent of what the consumer pays, and so are not really motivated to offer better service.  The real determining factor on the profits of a physician are the reimbursement rates set by insurers as well as the enormous profits being made off of healthcare by other parties.

The market is not a buyer/seller market.

Williams lays the blame of the non-free market on the presence of government controls:

Our health-care system is hampered by government intervention, and the solution is not more government intervention but less. The tax treatment of health insurance, where premiums are deducted from employees’ pretax income, explains why so many of us rely on our employers to select and pay for health insurance. Since there is a third-party payer, we have little incentive to shop around and wisely use health services.

There are “guaranteed issue” laws that require insurance companies to sell health insurance to any person seeking it. So why not wait until you’re sick before purchasing insurance? Guaranteed issue laws make about as much sense as if you left your house uninsured until you had a fire and then purchased insurance to cover the damage.

Again, I don’t disagree with either of the points, but they do not paint a complete picture.  It is the third-party payment system, the lack of system accountability, and the free reign given to the profiteers in the system that make it inefficient.  Pulling government restrictions off of insurance companies will simply increase their profits, not lower healthcare cost.

There are many layers that stand between consumers and those who sell their service.  A third-party system which is morally obligated to make the highest profit possible off of the system is one that is bound to hurt both consumer and seller of goods.  The transaction between doctor and patient is subsidizing the pharmaceutical, insurance, and device industries.  This means that a large portion of the healthcare dollar is fixed.

Yes, the intervention of the government into the equation does make it more complex, but the fact remains that Medicare uses each dollar it gets far more efficiently than the insurance industry does.  Overhead costs for Medicare are far lower than those of the insurance companies, which is one of the main arguments put forth by those who advocate a single-payer system.

A Free Market In Healthcare is Impossible

Certainly if physicians and hospitals were paid out of pocket by consumers for 100% of their care (like those physicians who no longer accept insurance), it would truly be a free market.  I would suspect that this would greatly reduce the cost of healthcare as well, as the overhead of running a medical practice would go down significantly.

Yet there are very powerful factors causing most Americans to reject such a system:

• The poor.  Should the poor have little access to healthcare services while those with resources can get what they need?  It is one thing to reject a socialized system where there is no way to pay more for better care; it is something completely different to advocate no safety net for the needy at all.  This means that some sort of third-party must exist in the system, hence making it a non-free market.
• The high cost of care.  Since care itself can be so expensive due to the explosion of technology, even those rich enough to afford a medical catastrophe would not want to foot the bill entirely.  I daresay that most wealthy people still carry insurance on their homes and on their cars.  The risk of a financial devastation from medical costs is far greater than the risk from home or car catastrophes.
• No clear concept of “value” in healthcare.  What value is it to get a physical?  What should preventive services be worth?  What are emergency services or hospitalizations worth?  How do you quantify them and say what the cost for these should be?  Since there are many workers within the healthcare system providing value, it is far different from accounting or law, which are often used as the contrast to the payment system in medicine.  When you pay for an attorney, you are paying for their service and perhaps that of their clerical staff.  When you pay for a hospital stay, you are paying for physicians, nurses, medications, pharmacists, administrators, and all sorts of other people (hopefully) adding value to what you get.
• A poor concept of quality.  One of the big cries against the whole concept of pay for performance is the idea of measuring medical quality.  People can’t agree on what quality is and who should measure it.  Even if it were defined, few physicians have the data collection and reporting capability to make it work (this is why the default measurement of quality so far has been done by the insurance industry).

It is now a big Political Issue

Unfortunately, the healthcare industry has not been able to come to a good solution on its own, so it will be a major issue in the upcoming presidential election (perhaps second only to Iraq).  Politicians will be the ones to decide.  Republicans tend to favor a “free” market where the private insurance is made available to all, while democrats tend to favor a more government-run approach. 

The problem is that nobody is going after the root causes of the spiraling cost of care.  To simply call for “more free market” or a “single-payer system” without addressing the incredible waste, lack of accountability, and profiteering by third-parties is simply re-arranging chairs on the Titanic.  It is the unfortunate nature of politicians to take a politically-motivated veneer and layer it on top of a broken system and call it fixed. 

The argument over free-market and government-run healthcare is for the pundits.  The role of the healthcare community should be to turn the focus away from these no-win arguments and to the issues that are really killing healthcare.  If we don’t engage the argument as a group, we’ll end up with the worst possible solution: a political one.

I am very interested to know what you think.  Am I right that the captain of the ship is not as important as its seaworthiness?  If so, what are the real issues?