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American Healthcare: Fighting Through Red Herrings

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

Through a combination of mass misinformation, complete lack of curiosity and laziness, I am noticing of late a tendency of blind acceptance of the way things are. I see people who pass themselves off as “experts” exposing themselves as nothing more than stenographers of conventional wisdom. Any idea that makes anyone remotely uncomfortable must have dirt thrown on it and summarily dismissed.

Let me start the St. Patrick’s Day Weekend reverie by offering a different approach, that being hard work, logic and openness to ideas. As always, I’ll help us all get started with some clarity about the (cue the fireworks, waving flags and citizen salutes to the clouds) American Healthcare System, brought to you by….AMERICA!

I begin with a news release from this week. The Congressional Budget Office (CBO), which theoretically operates in a strictly actuarial capacity, put out a report this week that stated that based on budget estimates, and taking into account our aging population, spending for Medicare and Medicaid could double by 2022. As a reasonable person who likes to discuss how to improve things, my first instinct is to think of ways to avoid this. Since my first instincts are comedic and cynical, I think of quick fixes such as Senior NASCAR, raising the military volunteer age to 85 and a new game show called Canasta for Surgery, but I quickly see the possibly unpopular nature of these ideas.

However, I could argue that at least I’m offering ideas (however twisted) as to how to solve the problem posed by the CBO numbers. What we get from the people in charge of fixing it are recriminations about how everything would be great if the people on the other side of the aisle would just do it our way, plans to obliterate Medicare and Medicaid entirely or (as has been the case for the last 15 years) punting the problem down the road for someone else to fix. You will notice that none of these options remotely resembles a workable solution. We expect a high end pork loin from our legislation, and instead we get scrapple. I eat scrapple, but only because by the time I was old enough to figure out what was in it, I was already addicted, much like virtually every other thing that has been stuffed down our throats in this country over the past four decades.

At the time of his departure, I ruminated about Donald Berwick, the immediate past CMS administrator. Because one side of the political divide decided very early on that they would use Dr. Berwick for rhetorical target practice, Mr. Berwick remained mostly silent during his tenure as CMS Administrator, which ended back on December 2nd. No longer shackled by his office, Berwick has come out in favor of finding a comprehensive vision for the agency free of constant Congressional meddling, underfunding and chronic under-staffing.

In a widely disseminated article this week, Berwick was joined by a number of past employees of the agency voicing similar concerns, chief among them the fact that the average tenure of a CMS Administrator is 14 months. Given the staffing vacuum, it’s a wonder that any CMS initiative is introduced at all. CMS has 4,900 direct employees, with the balance of work farmed out to contractors (we all know my low opinion of MACs and RACs by now, I hope). Even counting the contractors, CMS’ staffing is dwarfed by the Social Security Administration’s 62,000 employees. To pay Social Security benefits, you wait until someone gets old, disabled or insane and you cut a check. Paying a Medicare claim is significantly more complex, but the government employs fewer people to do it, which gives us the abominable payment error rate of the program. Add on the dozens of health care initiatives going on at the agency right now, and we learn a new respect for the employees of CMS for trying as best they can to keep it all straight. If only the Legislative Branch of our government was as solutions-oriented, but there are TV cameras that require their attention.

Finally, I feel I need to respond to the lazy voices in the health information management community regarding my feelings on ICD-10. Among others in our field, I have raised the issue of our health care system preparing itself to step into a new paradigm of being left behind. After two decades of waiting, ICD-10 will be the standard sometime in the next two years (remembering that CMS has decided that they are delaying the October 1, 2013 compliance date). I suggested in 2008, and reiterated recently that ICD-10 should be skipped for ICD-11, given that the worldwide release date by the World Health Organization is now May of 2015.

The popular response to my suggestion, now being widely parroted by professional acquaintances, is three-tiered, with all levels of argument being  so devoid of logic, curiosity and self-awareness that I feel I must now openly mock them.

The first response I get is that ICD-11 is based on ICD-10, and we can’t introduce the former without the latter. This one is as easy to punch holes in as Glass Joe in the classic arcade game “Punch-Out“. Version 5010 of the X12 billing standard was mainly designed for ICD-10. If ICD-11 is based on ICD-10, what’s the problem with skipping? Second, the American Association of Professional Coders (AAPC) is warning coders not to become too familiar with the ICD-10 code set until we get close to implementation. If virtually no one knows how to code a claim using ICD-10 currently, than we are not faced with a Labor of Hercules to skip ICD-10 in favor of the the newer global standard. You need a better reason than perceived codependence to convince me.  

The second response sounds something like “CMS has so many initiatives going that are built around ICD-10 that adapting it is now inevitable”. As I pointed out earlier in this piece, CMS is understaffed. If the cost of waiting 18 months for the latest and best disease reporting system is that over-burdened CMS employees move on to other timely tasks, the inevitability argument begins to sound a lot like a cult preacher telling you that the end of the world is a week away and that he has something really tasty for you to drink.

Finally, there’s the third argument, which I’ll again puncture like the foil top on a bottle of antifreeze. There’s this belief that an American clinical modification of ICD-11 can’t be available until 2020. Bluntly, this is a lie borne out of acceptance of the current status quo in American Healthcare being the absolute best we can do. ICD-11 will include a clinical modification upon release. What the ICD-10 Final Rule was referencing when they put this idea forth was an industry-approved clinical modification which will enable insurance carriers of all types to more effectively deny claims. Given the long-standing abuses of Big Insurance, what provider advocate in their right mind would argue waiting for that?

Going from ICD-9 to ICD-10 with ICD-11 so close on the horizon has the effect of waiting in a line for 20 years for the expressed purpose of moving to another 20-year line. It displays the quitter’s mentality of someone who has given up asking questions and accepts things the way they are. As St. Patrick’s Day approaches, I know full well how good beer should taste. To those who’ve quit trying, I’ll ask one final question: what do defeat and red herrings taste like?

Paul Spencer will appear at the Fi-Med RAC Summit coming up on April 16th and 17th, 2012. Click here for more information about this unique education opportunity.

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March 16th, 2012 | No Comments »

OIG Report Provides Dark View of the Afterglow

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

Like every other person for whom the majority of his or her life exists as fading objects in a rear view mirror, I have a tendency to think about the world that has surrounded me during my existence. On the surface, I should have a very hard time thinking fondly about the 1990’s. I spent the first half working in the insurance industry and the second half ensconsed in a slow-motion traffic accident of a first marriage. Yet the one thing that the ’90s had going for it was a brief window of time when the country was seemingly free of a big threat to its existence. From the moment in 1989 when the Berlin Wall was torn down, to September 11, 2001, the United States enjoyed a time when thoughts of the sudden annihilation of a large portion of its population did not hang over every major decision.

The 9/11 attacks had the effect of changing that perception for the balance of my life. I remember having a conversation a few days after the attacks with someone I knew at the time, talking about how best to prepare for similar incidents in the future. I felt that every community should have a disaster plan similar to the air raid wardens of World War II or the nuclear attack drills of the 1950’s, which would integrate public employees and buildings, along with the local health infrastructure, to provide an organized and coordinated response to such incidents.

Instead, we received the “War on Terror”, color-coded paranoia and the Big Brother-esque overreach of the Patriot Act. I stopped being optimistic shortly after that. Perhaps it’s my tendency to watch old post-nuclear science fiction films during my late-night fits of insomnia that informs my decision making, but when I heard the head of the Department of Homeland Security tell me that my best defense against future attacks was plastic and duct tape, I was immediately skeptical about our country’s ability to handle future disasters.

It was with all of this in mind that I read a 44-page report released this week from the OIG entitled Local Public Health Preparedness for Radiological and Nuclear Incidents. The report was commissioned based on the belief of our current national security apparatus that the greatest danger to America is a terrorist attack utilizing a nuclear weapon. To assess planning and coordination in the event of such an incident, the OIG requested information from 40 localities from around the country, representing the largest metropolitan areas in and around cities in 23 states, totalling just over 50% of the total population of the United States. The findings of this report clearly show that preparedness for radiological and nuclear incidents is far behind where it needs to be.

Thirty-six of the 40 surveyed localities have conducted some type of risk assessment for a disaster. Because the OIG report did not specifically name the four localities that did not, I am unable to tell anyone specifically to begin digging holes for your survivalist bunker. Of the 36 that did conduct a risk assessment, 30 specifically identified non-power plant related radiological/nuclear incidents as a threat, with 24 of those determining the specific threat level. Taken as a whole, this means that there are 16 major population centers in the country that have not fully determined the risk of a nuclear attack in their area. Only four of the 40 localities have identified radiological incidents as a high-priority threat, but only one had a specific plan in place to respond to such an incident.

The OIG assessed the preparedness of each locality in five areas of responsibility in public health: Monitoring of the population for exposure, decontamination, planning for laboratory analysis, fatality management and communications. Only 21 of the forty had any sort of public health plan in place in case of a nuclear incident that encompassed any one of these areas, but only two localities had plans that included all five. Perhaps the scariest thing to me was that only 8 major population centers in the United States have fatality management plans to limit the amount of exposure to the surviving population emanating from those that will have already perished in such an attack. Knowing this bit of information suddenly reminds me that thoughts of a zombie apocalypse are not as rib-tickling as they were prior to the release of this report.  

When the issue of greater coordination with federal, state and local partners was assessed, only 16 localities have plans that coordinate with any one federal department, with 10 coordinating with their state agencies and 14 coordinating with local entities such as hospitals, county health departments or other emergency medical personnel.

Taking all of this information into account, I have determined that the community health plan for most population centers in the event of a nuclear event consists of three steps: hoping for survival, fitting your vehicle with a plow attachment to move the bodies out of the street, and concluding with more hope for survival. I know it’s hard to see my face in that this is written material, but it is important for you to know that I didn’t crack a smile when I wrote that last sentence.

Chances are fairly good that when you drive home tonight, you’ll pass an older public building with a faded sign that says “Fallout Shelter” on it. There was a time in America, corresponding to the existence of a country known as West Germany, when that sign was brand new, painted a bright yellow, with everyone in the community having acute awareness of what it meant. Perhaps you’re even old enough to remember a “duck-and-cover” drill, the CONELRAD system, the letters ”CD” standing for “Civil Defense” rather than “Compact Disc” or some other quaint custom that kept the idea of the dangers of radiation exposure in the forefront of your mind.

Since this is a health care forum, I ask the reader to save a thought for how they believe their local health infrastructure would respond to such an attack. We find ourselves in an era of consolidation of health care resources under the ACO model that is designed mainly to reduce cost. While IT initiatives have mentioned such things as better coordination of care and improved public health reporting, all of these good intentions will crumble during a cataclysmic event without a disaster plan in place in the communities surrounding the hospitals. The OIG report shows that many areas don’t  have one that is adequate. Additionally, if the recent breakup of the band REM didn’t already drive the point home for some of you, know that the relatively tranquil and naive days of the 1990’s are an increasingly distant memory on the roadways of our lives.

Paul Spencer will be a presenter at the Fi-Med RAC Summit in Milwaukee, WI on April 16th and 17th, 2012. Go to the Summit website for further information on this unique educational opportunity. Use promo code “SPENCER” to receive $50 off the registration price for a limited time.

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January 27th, 2012 | 1 Comment »

High Tech & Health: Of Cholera, Cars and Clairvoyance

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

Today marks the final day of the Consumer Electronics Show (CES) in Las Vegas. For four days every January, thousands of electronics firms display gadgets of every kind for seemingly every purpose. Some of the wares are destined to saturate the market, while some return to the their makers, never to be seen again.

In the last 50 years, technology has changed the way we live. Other than what surrounds us in our homes, institutions such as aviation, public libraries and finance have seen paradigm shifts thanks to the core technologies at the heart of their operations. Perhaps no other sector has been altered quite like the world of health care.

Over the past few days, with CES’ shadow looming over the landscape, a few indicators of the changes that have either come to or are on the horizon for health care came to light.

The first was a study appearing in the American Journal of Tropical Medicine and Hygiene (now THAT’S specialized) that looked at the role of social media in the reporting of the post-earthquake cholera outbreak in Haiti in 2010. Given the ubiquitous nature of Twitter, the study looked at “tweets” emanating from the quake zone in the time leading up to when the outbreak was widely reported by the news media. What was discovered was that Twitter users were reporting the cholera outbreak and bringing forth case data to the world a full two weeks before then outbreak was widely reported.

This story teaches us that in bold terms that the news cycle is evolving to “up-to-the-minute” faster than any of us anticipated. In the case of a disease outbreak, time between identification and treatment can prevent further loss of life. With the threat of pandemics such as SARS and avian flu over the past decade, we now have scientifically-vetted proof that social media can play a very important part in shrinking that time frame.

Part of CES is what is called a “Digital Health Summit”, where a particular innovation or initiative takes center stage during the keynote address. This year was no different, with Ford Motor Company stating that they are partnering with Microsoft and two other tech companies to design a car that will monitor the driver’s health while traveling.

In reading this item, I was immediately reminded of my car trip this past summer that saw me drive from Milwaukee, WI to St. John’s, Newfoundland, Canada and back. In particular, the drive back became what I can only describe as driving between memory gaps. After setting off at 7 AM in St. John’s, I had planned to stop for the night on a Thursday in Moncton, New Brunswick after 12 hours of driving across Newfoundland, 7 hours on a ferry and roughly 5 more hours on the road from Northern Nova Scotia. What I didn’t count on was that apparently Thursday night is “Take Your Mistress Out To Dinner Night” in Moncton, as every hotel room in the town was booked. What followed was 22 more consecutive hours of driving from Moncton to Milwaukee, with stops only for gas, fast food & caffeinated beverages on the New York Thruway and moose hallucinations along the darkened roads of Maritime Canada. Somehow, I arrived safely in Milwaukee at 2 in the morning on a Saturday.

It would have been nice to have had a car that knew I was seeing antlered mirages, so it could shut off and pull over to the side of the road until it detected REM sleep. I hope that Ford follows through on their concept, not just for the exhausted, but for the drivers with health risks that could pose a hidden danger to themselves and other nearby motorists.

The last bit of technology news borrows something from the dark arts of psychic phenomena. On the heels of a study at the University of California-San Francisco which covered development of useful prognostic indicators for older adults, a new website has been created to help create a mostly accurate estimate of an elderly patient’s remaining life expectancy. While planning end-of-life care is a neglected part of the health care debate in this country, there is something about this technology that sends a shiver up my back. One of my all-time favorite short stories is “Imagine A Day At The End Of Your Life” by Ann Beattie. Someday, when my time comes and with the help of this website, I’ll not only be able to imagine such a day, but I may very well be able to mark it on a calendar. Having always believed that life doesn’t include a two-minute warning, I shall look deep within myself in the intervening years to decide how I feel about such a website.

The lightning pace of technological innovation has brought dramatic change to the science of medicine. It would be naive to think that the emerging technologies indicated above are simply novelties, as for every failed invention comes the spark of furthern imagination. Upon my retirement 25 years from now, it is very possible that one or all of these current technological leaps will be considered a quaint stepping stone to what exists at that future moment in time.

Paul Spencer will be presenting at the Fi-Med RAC Summit in Milwaukee, April 16-17, 2012. Go to the summit website for further information. Use promo code “SPENCER” to receive $50 off the registration price for a limited time only.

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January 13th, 2012 | 1 Comment »

The (Actual) Value of a Health Care CEO

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

As it pertains to the weather, Wisconsin just completed a rather mild Autumn. As compared to previous years, the usual seasonal chill was a late arrival. As unseasonably warm as it was, it didn’t appear to have an effect on the chilly relations between the two prevailing sides in our ongoing political and economic debate.

Taking advantage of this year’s strange weather window throughout the Fall, the “Occupy” movement attempted to shine a spotlight on income inequality between the 1% at the top of the ladder and the balance of America. Yet if we were to rely solely on cable news commentary regarding the optics of a billionaire mayor of New York ordering the police to clear Zuccotti Park near Wall Street, we would learn that there is nothing wrong with the economic system, no one knows what ”these people” want and the protesters were just making a mess and needed to leave.

Since the dawn of “trickle-down” economics nearly 31 years ago, CEO salaries, as compared to the employees they direct, have not skyrocketed, for that verb doesn’t go far enough in describing what has happened. Rather, CEO salaries are on a trajectory of a deep space probe to planets several million lights years from our own. We need only consider the six heirs of Sam Walton, the founder of Wal-Mart, who have as much wealth as all people at the bottom 30% of the economic ladder in the United States.

While nowhere near the level of the CEO of Wal-Mart and the salary of their aging, cat food-consuming greeters, the realm of health care is not immune from income disparity and inflated CEO pay. According to a report on 2010 CEO salaries released by the research group GMI Ratings, the two highest paid CEOs in 2010 were in the health care field. If we expand it to the top 10, we also find the outgoing CEO of Aetna and the CEO of CVS, a retail chain that makes at least a portion of its profits through its pharmacy operations within its stores.

While not in the top 10 or generally on the radar of the public at large, the salaries of hospital CEOs have been under the microscope as part of the sudden discovery of wide income separation.

The champion in this club in my region is one Dean Harrison, the CEO of “non-profit” Northwestern Memorial Hospital in Chicago, who made $10 million in 2010, $7.5 million of which was a one-time payment due to vesting of his “supplemental executive retirement plan”. When I think “supplemental”, I tend to think of the Vitamin D I take ever morning due to the cloudy weather in Milwaukee. I don’t tend to think of a hospital-bestowed lottery ticket. To further add context to this particular compensation package, Northwestern Memorial owns Prentice Women’s Hospital, a non-profit facility that lost its property tax exemption status in Illinois last year because the state Department of Revenue determined that it wasn’t providing the adequate level of charity care. Prentice subsequently increased the level of such care by over 50% from the previous threshold.

Whenever the wide gulf between the highest paid and lowest paid worker is in the spotlight, I hear the same tired refrain from those at the top, which thanks to the “folk process”, goes something like this:

“In today’s marketplace, in order for a company to remain competitive, we need to be able to attract the top talent. To not do so would be a risk to the organization’s ongoing well-being.”

One hospital CEO even added to that recently, stating unabashedly and without the slightest hint of irony, that his $3.6 million annual salary “..isn’t going to affect your health care cost.”

Do you know what else is a risk to the ongoing well-being of your hospital and its operations? Employees who can’t take a sick day because they either can’t afford to miss a day of work or their health insurance is actually only an insurance premium generator, leaving them with large out-of-pocket expenses if they actually get sick, which ends up discouraging them from seeking any care. Instead, they come to work at your hospital, which expands the risk to the patients paying health care dollars that eventually end up in the pocket of the CEO.

The very idea of “trickle-down” economics is incredibly insulting; return all tax revenue to people at the top of the ladder, then, when the lords and viscounts decide to throw a few doubloons to the peons, maybe you’ll get yours. Oh, and if you’re not working yourself up from fry cook to the executive boardroom, despite the fact that all that top-tier tax revenue was taken from your local school district, leaving you without the requisite skills to get there, you’re just being lazy and deserve your lot in life of barely keeping your head above water. That is assuming that you haven’t succumbed to the rising water already (*cough* Ninth Ward in New Orleans *cough*).

If nothing else, the idea of income inequality is now front and center, thanks to the Occupy movement. Were it not for similar gatherings across the country, this week’s tax kabuki in Congress may not have received the attention that it did. The issue of CEO pay in the health care field, an industry that odds are will be accessed by every citizen of the country sometime in our lives, is one that needs to move from the realm of idle economic curiosity to front and center of the current debate over the nation’s wealth divide.

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December 23rd, 2011 | 2 Comments »

Defining The Modern American Doctor

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

I am only 45 years old, which is a pittance with regard to measured time past and upcoming, but thanks to the ever-increasing speed of evolution, there have been some rather remarkable changes in my lifetime. To be clear, I’m not doing the typical old-man-in-checked-pants cliche of complaining about how everything was cheaper when I was growing up. I’m talking about the rapid evolution of things that surround us in daily life. As my 5-year-old son grows older, I am envisioning attempting to explain Pong, vinyl records and Johnny Carson to him as societal touchstones in a world that features Nintendo Wiis, digital music and an increasingly unfunny Jay Leno.

Nowhere is this more apparent than the world of medicine. I was only 20 months old when the first human heart transplant was performed. I have a cousin who was a pioneer in bariatric surgery for the morbidly obese. Yet his surgical method, which was detailed in an article in Time magazine in October of 1965, when compared to today’s techniques of gastric banding and sleeve gastrectomies, could well be viewed as the medical equivalent of bleeding with leeches today.

It isn’t simply in terms of surgery. I am here to ask the reader today to bear some consideration for the evolution of medicine not simply in terms of practice and techniques, but also as it relates to the human element of being a physician in modern times.

I came across a few stories this week that showed in stark terms that the role of the doctor, as we have come to know it, has changed dramatically.

First came this synopsis of an article about physicians using social media to deliver better health care and information to patient populations. Modern patients rely on the internet as an information source in ways that challenge the delivery of health care from the modern practitioner. This article provided a window into the innovative ways that physicians can turn something viewed as a negative into a positive for their patients, as well as their practices’ bottom lines.

Now, in the interest of bringing balance to a universe existing in a constant state of chaos, the mixed-to-bad news. A study in the November issue of Health Affairs indicates that the technical knowledge of new physicians in clinical practice is lacking. The study seems to point the finger at reduced hours in residency as a big contributor, but it also pointed to changes in technology leading to a diminished skill level with regard to performing “open” procedures.

Over the last 40 years, we have seen how a society’s slavish devotion to getting everything cheaper has destroyed job after job in the American marketplace. If you thought that the medical community is immune from such an attack of thrift, think again. It was reported this week that deep in the fetid bowels of an office in Bentonville, Arkansas, Wal-Mart is planning an expansion of their well-documented retail activities into the realm of health care as a reaction to the not-quite-invalidated Affordable Care Act. As a solution to the country’s societal ills, this news ranks only slightly above ”Soylent Green is people”.

Finally, we have the curious case of Conrad Murray, the physician who was convicted of involuntary manslaughter for administering operating-room grade anesthetics to Michael Jackson in the months leading to his death. There are two problems here, the first being why this guy had a medical license to be able to implement a pain treatment plan like this, but there is a second problem here that is not being mentioned.

In this scenario, Conrad Murray is acting as an extremely well-paid concierge physician to someone with the resources to be able to afford this kind of questionable medical care. While there are a number of physicians leaving the insurance payment model to reduce administrative burden and to provide a better standard of care to their existing patient population, the high-dollar end of the concierge model is populated by physicians who are in the practice of  medicine strictly for the money. This is not to say that every physician who chooses this particular population to service is as ethically challenged as Dr. Murray, but Murray’s conviction has the appearance of a case where the number of zeroes in the pay check were directly proportional to the patient acting as his own practitioner, with the doctor acting as a spectator. Did Michael Jackson pay for a doctor, or a pusher with the imprimatur of ”M.D.” after his name in order to keep up appearances? More importantly, how many other doctors serving the well-heeled are following the same model currently, seemingly in opposition to the Hippocratic Oath? 

We have before us an interesting window of time to exist as a gatekeeper in the scientific discipline of medicine in the United States. There is progress, opportunity and danger both to the practitioners and to the patients they treat. While technology and delivery systems will continue to evolve, it is important to remember where medicine has come from since the time of Hippocrates. There will always be a part of medicine that will require a good bedside manner, manual dexterity and something more than a retail exchange. There are many mysteries about the human body yet to be discovered, but the presentation of care, at its core, has been and should remain the same.

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November 11th, 2011 | 4 Comments »

The Earth Strikes Back

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

WIth regard to human life on Earth, I am considered something of a dark overlord among my acquaintances. I am firmly of the belief that the planet considers human life an irritant, and will eventually rebel and shake us off in relative terms as quickly as it did the dinosaurs. Those that scream “Save The Planet!” can be viewed as naive, as the planet is a big, unfeeling rock that isn’t going anywhere. Nature adapts, and continues, and knowing that one organism has the ability to consider this fact doesn’t guarantee that particular organism’s survival.

As a species, we learned this in the most uncomfortable of ways in the past week with the E. coli outbreak stemming from organic vegetable sprouts from an organic farm in the Lower Saxony region of Germany. The infected produce killed 31 people and sickened more than 3,000 before the source of the outbreak was narrowed down. This particular strain of E. coli caused hemolytic uremic syndrome in some patients, leading to acute kidney failure.   

On the twisted road to a solution to the mystery, a lot of innocent bystanders were sucked into the Vortex of Blame. The European consumption of lettuce, Spanish cucumbers and tomatoes ground to a halt. Spanish produce suddenly became unpopular among trading partners in the Northeastern Hemisphere. Thanks to the efficiency of German health authorities, the source of contamination was isolated before further incriminations and finger-pointing could continue into other tried and true human interaction classics, such as scapegoating and mob rule.

Currently,we find ourselves buried in a debate regarding the future of health care in America. As a part of that comes response planning to epidemics. Emergency health response since 9/11 has focused on terrorist attack agents such as anthrax and radiation. It is wise to consider that the German outbreak shows in stark time that Nature isn’t waiting around for human-to-human brutality to thin our numbers. The preponderance of evidence in 2011, from tsunamis in Japan to tornadoes in the Southern United States and Massachusetts, and now to bacteria-laden sprouts, indicates that the Earth has grown tired of waiting of evolution to do the work necessary to cull humanity.

We can argue about Medicare remaining in its current form or as a voucher program, and we can pile on the “ACOs-Are-Bad” bus and worry how everyone is going to be paid under such a model. We can wring our hands about audits threatening small healthcare providers and ICD-10 and 5010 and a host of other issues, but as an amateur futurist and an observer of evolutionary trends and a visualizer of the impossible, I have a different challenge for the health care world. Take one minute a day, amidst the regulatory madness, and consider that the biggest threat to the American healthcare system may exist all around us.

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June 10th, 2011 | No Comments »

Tales of The Toxic Doctor

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

As I travel about the decaying world of civilized conversation, I have come to realize that people have varying opinions of physicians. As the gatekeepers of medical care, perceptions of doctors, based on cause-and-effect, eventually determine a person’s level of personal investment in their own health.

Having had five doctors in my family, I have absolutely no fear, and admittedly few ill feelings, towards those on the delivery end of the medical profession. When my pediatrician was “Uncle Ed”, how could I? With that said, knowing the dedication of the physicians in my family has given me a tremendous sense of what I like to refer to as “quack radar”. There have been providers who in the past have only seen me once, and then briefly, as the internal blips in my head have indicated that there is something about the encounter that isn’t in my best interests long term.

Which brings me to a white paper that was released this week regarding disruptive physician behavior. The report is a joint effort between a physician learning and communication collaborative called QuantiaMD and the American College of Physician Executives. The report is the result of a survey of 840 physicians and physician executives.

The report shows that roughly 71% of physicians state that they have noticed at least one instance of disruptive behavior by a fellow physician per month. Among the aberrant behaviors most often encountered are degrading comments or insults, refusal to cooperate with other providers, refusal to follow established protocols and yelling. The use of profanity came in a strong fifth among a list of 13 disruptive behaviors.

It is revealing that the behavior most concerning to the parties surveyed was the refusal to cooperate with other providers. Step back a moment and think not only of our current health care model, but the Accountable Care Organization model currently on the table as the proposed future of patient care. Increased integration and collaboration is envisioned as being the key to the elimination of redundancy and, by extension, the reduction of  healthcare costs, leading to institutional savings.

If the physician community is encountering barriers to care in the form of lack of cooperation from other health care providers, all models for integration, savings and, ultimately, better patient outcomes, grind to a halt. Consider that 90% of respondents to the survey believe that disruptive behavior either always or sometimes affects patient care. In the pre-ACO world, patients face the choice that I myself have been faced with in the past; stick around for care that would not be in my best interests, or find someone else to be the gatekeeper of my care. The ripple effects are something of a one-to-one measurement of one doctor’s loss to one doctor’s gain.  

Now consider the proposed integrated model. With a healthcare facility as the hub of care, everybody’s reputation stands to take a hit for the actions of a few abrasive personalities. Unless the hub facility has firm policies of reporting such incidents, with appropriate progressive discipline up to and including discharge for the most egregious violations, potentially every provider of services presents a threat to the organization.

Having passed the halfway mark in my life, I’ve made a commitment not to surround myself with miserable people or those whose attitude I find aggressive or prickly. Personalities like this drain the air out of the room and eventually lead to a toxic environment. When such a personality is your medical professional, it could be a direct threat to a healthy existence. From the results of this report, enough physicians see this as an ongoing problem. The question now becomes how important such an issue is to health care organizations, and whether the potential risk to reputation will finally be enough to force them to act.

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May 27th, 2011 | 1 Comment »

The Underlying Trend Behind Hospital Expansion

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

The study of economics is invariably tied to analysis of supply and demand. Certain industries experience booms, then busts. In an age when the internet has become pervasive, the definition of “need” for certain goods and services changes rapidly. Companies such as Compuserve, Prodigy, Lycos, AOL and MySpace, who were once thought indispensable, have faded unceremoniously from the landscape, replaced by companies who offer better solutions.

I’m much more cynical about the economy as a whole, especially as it applies to what I invest in at a given time as a 40-something citizen of an empire in sunset. It’s a safe bet that real estate won’t see any of my investment income. Domestic manufacturing isn’t cutting it these days. With 16.7% true unemployment in the United States, I’ve sunk my money into consumer staples, alcohol and Canada, and my investment income is in great shape.

As it applies to health care, another disturbing indicator has caught my eye in a recent private survey of hospitals and their plans for construction in 2011. According to the survey, 2/3 of hospitals are undergoing some type of construction project in 2011.

Two things jump out at me that point to a disconnect in the current reasoning on health care in this country. First, multiple professional organizations beat a constant drum about costly labor contracts for hospital workers, declining reimbursement and the burdens of the current climate of audits. Despite this, a large number of hospitals have funds for expansion or renovation of existing facilities. The survey respondents stated that 79% of the construction would be focused on patient care.

Second, much like the current boom in the private prison industry, hospital face lifts are fulfilling a need in a country that statistics show is getting sicker by the year. In the same way that current laws on the books related to drug usage and distribution drive a need for more prisons, a bloated and unhealthy population drives a need for expanded and modernized hospitals. On the surface, it certainly appears that the underlying causes of the declining health of the nation are being responded to by what I shall refer to from this day forward as the Health Care Industrial Complex.

PPACA, as it is currently written, calls for an expansion of Medicaid as the solution for the problem of people without insurance. Many of the new governors who have just been sworn in nationwide, including Jerry Brown in California and Andrew Cuomo in New York, are addressing massive budget shortfalls by proposing deep cuts in current Medicaid reimbursement. It could be that the results of the hospital construction survey can be viewed as a pre-emptive strike in preparation for a time 5 years from now when money for such projects isn’t available based on the new coverage paradigm as it is currently written.

Yet demand creates need. With the country’s people slowly getting sicker with a ferocity only matched by the same people’s desire to not alter their lifestyle choices in any way, I have a deep suspicion that the health of the country is about to take a drastic turn for the worse, with costs so high as to be unfathomable to current human logic. In the same way that the drug war is not treating the root cause behind prison expansion, so too is there no attention paid to improving the health of a vast number of citizens behind the widespread hospital expansion. It’s akin to a child building a Lego tower. Eventually, it collapses under its own weight if you stack the blocks too high, much like the patients that will soon occupy the new hospital beds.

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January 21st, 2011 | No Comments »