I welcome fair criticism. I react to misunderstanding. I will try one more time to discuss the emergency physician admission decision.
We do not have a health care system. Rather we have physicians functioning to do their particular function as well as possible, usually without coordination amongst physicians. We do not have coordination, because we provide no incentives for coordination.
I tried very hard to be clear in my previous posts. The patient in question was admitted because the emergency medicine physician made a decision that only through admission could the evaluation proceed efficiently. I am not quarreling with the decision. I am quarreling with the lack of a system that makes such decisions necessary.
Making rounds this morning, we discussed outpatient care for several patients. Part of our rounding was making certain that further evaluation and management would occur efficiently.
The lack of coordination costs money. Given a “system” the lady in question could have had an efficient outpatient evaluation. Therefore, her admission “wasted” our money as a higher cost way to achieve a lower cost process.
Can we solve these problems? Some advocate the status quo as not that bad. The status quo is unsustainable. Most Americans are scared of the alternative to the status quo. How do we reconcile these opinions?
As I have written repeatedly, most citizens want health care but have no idea what it really costs. They do not worry because “they have insurance.”
We have a major knowledge deficit that the insurance process has created. Medicare has amplified this problem.
Will the current health care reform bills solve this fundamental problem? Probably not, but perhaps we will take steps to improve care coordination.
As I wrote last week, I believe the biggest problem is the fear of change. I see the status quo as unacceptable. Therefore, I am looking for intelligent change. Perhaps I am delusional, but I do believe that universal coverage would help. I hope that the medical home would help.
Now Ernie G beat up on me today. I believe he was a bit harsh.
His main point was, I believe, that I should not consider costs when critiquing this admission or colleagues who delay discharges. But costs are the problem are they not. Our biggest health care problem is that too many physicians and patients ignore costs. Who pays for that extra day in the hospital? Who pays for the unnecessary CT scan?
We all pay for inefficiency. We all pay for convenience admissions. We all pay for caring for the uninsured, and their lack of good continuity outpatient care.
So I write this blog to express opinions. I am happy to have civil discussions of problems, but I would hope the Ernie G would be less hostile in his comments. Please disagree with me. I will try to show you the same respect that I hope to receive from you.
I hope that my interchange with Gruntdoc has been civil. I do believe that he now understands that my original post was not really criticizing the doc, but rather the system he lives in. I hope that this blog makes you think.
{ 5 comments… read them below or add one }
I work as a psychiatrist in a community clinic in a large city in California. Most of my patients have Medi-Cal and/or Medicare, so they are “insured.” I see about 200 different patients per month, and have about 600-700 under my direct care.
In any given month, approximately half of my patients make an emergency-room visit for a mental health reason, and of those, maybe one-third are admitted. However, I can count on one hand the number of times in the past YEAR I’ve been called, paged, faxed, or have received copies of discharge summaries from the major hospitals in this county. Most of my patients can’t explain the circumstances of their admission, so I either have to spend time contacting families or the hospital (time for which I am not paid) or start “from scratch,” which unfortunately perpetuates the cycle.
You’re absolutely right— there is NO incentive for communication between hospitals and outpatient physicians. I would gladly spend time talking to an ER doc about one of my patients, or discuss a discharge plan with an attending psychiatrist in the hospital, but there’s no efficient system for doing so (and none of us are compensated for it). Unfortunately, this is the status quo for our “system.”
It is simply not true that we do not have a system. We do, that system has authors, and they have behaved badly. Our medical care will not be put on a sustainable path until they stop.
Specifically to the issue of a shortage of care coordination, we do not have coordinated care because we have a lack of primary care physicians who are there to do the coordinating. It really is that simple.
They are not there because of two reasons. There is a shortage of doctors and we have distorted doctor pay against having sufficient primary care doctors.
We have the shortage because we’ve artificially lowered the number of medical school slots (thank you AMA) and we have too few visas (H1B) for foreign doctors to make up the difference. We have distorted the payments via the government issued payment schedules (medicare/medicaid) which private health insurance companies generally go along with, at least with regard to the ratios between various payment codes. This is entirely the fault of the government, you know, the guys that universal coverage advocates want to give more power and influence.
Saying we do not have a system when we manifestly do have one gives cover so these bad actors get off scott free. This is not right and it is not helpful. Uncoordinated care is expensive but we don’t lack coordination just by chance. It’s baked into the system and will continue to be unless we are very careful with our reform efforts.
My $0.02 as an academic clinician: In a recent interview with Charlie Rose, Denis Cortese, the president/CEO of the Mayo Clinic, rhetorically asked, “where are the system engineers who designed [the healthcare system] so we can blame them for where we are today?”. He makes a good point. Instead of a system, we really work in a healthcare ecology. In this ecology, individuals/groups are encouraged to make decisions that are in their personal best interests, even if they are harmful to society as a whole. Solutions to this kind of “tragedy-of-the-commons” problem appear deceptively easy to achieve at first. But having thought about this problem for a few years (without any great insights), I have come to believe that to meaningfully improve care coordination and delivery, we either must (a) all decide to become more moral and adhere to the Golden Rule (i.e., do unto others…) or (b) submit to a true “system” where most, if not all, of us must contribute for the good of society, even if it’s to our personal disadvantage. In my case that probably means a loss in income and autonomy. Other readers: what will you need to contribute?
Your quarrel, at least in the original criticism of the ER doc, was that universal coverage would help solve the problem of co-ordination. My criticism was that the mere existence of universal coverage does not guarantee co-ordination of care. Co-ordination of care can occur in any environment as long as there is incentive. The ER doc story does not tell us how universal coverage would lead to co-ordination of care; it only tell us (if you see the story as a critique of our system), that co-ordination of care could cut costs. So, like I stated you want to see this as a universal coverage issue, when really it is a co-ordination failure. If you meant to say the current bill would help co-ordination, then that is a different argument.
My justification of the admission as a reasonable approach to the problem of a newly diagnosed lung cancer is that certain cases may need to be approached differently with real costs involved. I agree that physicians and patients have ignored costs for too long, but the physician was making a judgement call about a medical condition’s treatment– attempts at outpatient diagnosis. In his environment, he looked at the insurance and knew it would be a nightmare. Perhaps it would have cost more in the end because it would have taken more than a few weeks to see the physicians she needed. My point was not to not consider costs when criticizing the ED doc. My point is that you may have failed to consider the others costs if she was not admitted (she was unable to navigate the system). Would universal coverage help? No. The patient has insurance, albeit Medicaid. Would incentive for coordination help? Yes. But how to incentivize? Well, you ask: who pays for the admission, CT etc? In the end it will be the hospital. (Pt is medicaid) So really, this is the hospital’s failure to set up an ED/clinic co-ordinator, (or the admitting physician/resident to co-ordinate a follow up in clinic within a few days, but that is hard to incentivize). Nothing in the system prevents the ED from having a facilitator to push patients to outpatient clinics, knowing they will save money with unnecessary admissions.
You may argue that we need a system through legislation that has co-ordination of care, making it easier for the patient to navigate the system. But this is where TM Lucas is correct– we already have system or ecosystem, but the incentives are not there for this and other cases. The market is not aligned. The question is how to align benefits and costs, not how to provide universal care to solve a problem that has nothing to do with coverage. The patient could have left the ED with a name of a physician, a time, and place for an appointment to follow up within a week.
But then your critique now now centers on efficiency—it was less efficient to admit than to discharge with close follow up. The problem with health care today is not efficiency (most bang for the buck), it is the cost of care. There will never be great efficiency in medicine, it is simply too complex to measure. You are after all, extremely hesitant about even measuring physician’s adherence to performance measures (which are distinct from guidelines, something you tend to confuse—hemoglobin A1C <9 in diabetics is the medicare’s PQRI goal; <7 is the ADA’s optimal level; medicare is not rewarding for A1C’s less than 7), which is a lot easier to measure than physician judgement. How are you proposing to judge cost efficiency if you won’t even let someone measure how physicians, the main providers of care, do? Who is going to determine correct diagnoses and correct use of care? Do you now need someone to look over the ED’s doctors decisions to determine if he did the right thing on that day for that patient? If so, then why isn’t that person doing the doctoring in the first place? (Hmm, sounds like what insurances do everyday)
But even if you thought you could the revamp the system to create efficiency, efficiency is not created by oversite (in other words setting up panels to correctly tell us that the ED doctor was wasteful) or legislation (there are simply too many transaction to regulate). Almost everything will have inefficiency, it is a matter of how those inefficiencies are recognized, exploited, and then corrected. We have to have a health care market that correctly aligns interests, at least in general terms, with allowance for the changes at the bottom. Government has to define the stage for the play, and learn to stay out of the particulars. Rtb is right: it is not helpful to say we do not have a system, then say that having is a solution. I don’t think rtb is right that we all have to be moral, or go against our own self interests. If that is the case, the medicine is dead. Rather TMLucas is right that interest have to be aligned—no one is an angel. The question is how to make health care affordable by bringing cost/benefits analyses closer to the patient/physician while maintaining third party payers (I do not think medicine can be practiced in this country without third party payers unless emergency care is no longer mandatory). I don’t think insurance created the problem, I think it was actually Medicare.
If you take my criticism as hostile, that is your perception to make.
SteveBMD – My internist wife would be tearing a strip off of the people who did not send her a discharge summary and, in the past, has. You’ve been treated badly and need to apply some conditioning to the population who are mistreating your patients by cutting you out of the loop. In extremis a letter to the editor repeating your blog comment would do wonders, bonus points if you quantify the $$ lost to the system per year. A formal bureaucratic system is not necessary to accomplish this. Standing up, naming and shaming to force compliance with already existing norms can be done with any system.
rtb – I think that you’ve got something by the tail but I’m not sure you’re aware how big a fish you’ve got hold of. One of the rising memes in free market economics is to model economic systems as ecosystems instead of more traditional mechanical derived models. This turns the healthcare ecosystem into a feature not a bug. Systems do not have to have system engineers to exist.
The traditional cure to a tragedy of the commons is to introduce ownership into the economic ecology, ie to eliminate the commons. State ownership enlarges the commons. It does not shrink it. A state dominated universal system will worsen the problems of coordination. You can verify this by looking at end stage state systems and looking how well they have coordinated. It hasn’t been very good.
ErnieG – Thank you for your kind words.