Archive for the ‘Medical economics’ Category

Surviving grizzly bear attacks, controlling drug prices, and training a Dragon.

July 13, 2017

The thought that gives me a scare

Has do to with a grizzly bear

For he’s big and he’s massive

And pretty aggressive

And, out here, not terribly rare.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to travel and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent US assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

Some people survive events far beyond the usual human experience.

Lightning strikes more citizens of New Mexico than any other state, and when I worked there I met several. The Natives hold such survivors in high esteem; some tribes elevate them, obligatorily, to Medicine Man status.

Alaska, with the highest percentage of licensed pilots in the country, seemed to have a disproportionately large number of people who lived to tell about plane crashes. I met survivors of gunshot wounds there and in Nebraska.

Today I spoke with a person who survived a grizzly bear encounter.

Most of the bears around here are black bears. Though they’ll eat anything, the majority of their diet comes from plants.  They climb trees, and do their best to avoid people.

Grizzlies are different. The largest land predator on the planet, they have an aggressive temperament.

The bear only bit my patient once, then retreated to keep track of her cubs (the person gave me permission to write a good deal more than I have). If you’re in bear country with the inexperienced, before you start out, make sure everyone knows to freeze if a grizzly approaches, and never to run.  Carry either bear spray or a rifle, and be prepared to use it.

I really wanted to talk to the patient about life and work in this area, but my primary job, fixing people, comes first.

-*-*-*

Price of medication exceeds the price for physician services. In the US, the prices have escalated beyond reason, making the drug company stocks some of the best.  Insurance leaves a lot of Americans without adequate medical coverage, and the cost of medication becomes an important consideration.  When I worked Community Health, all our prescriptions went through our pharmacy. The pharmacists determined the formulary (the choice of drugs), and did a good job of containing costs.  The facilities in Alaska have a similar system; in those places the people don’t pay for their prescriptions.

For most in this town, employers pay for health insurance to cover what the Province’s Medical Service Plan (MSP) doesn’t, like medications.  PharmaCare, a government program, buys the meds  for the low income segment.  Only a very few lack money for drugs, and most of those are self-employed.  The Indigenous and Metis (of mixed Native and other descent) have all their drugs paid for.

*_*_*_

Over the weekend the facility got new dictation software installed. The previous version had worked just well enough to let you think you wouldn’t have to proofread, but still made glaring errors.  Today I used the system for the first time, training my Dragon over the lunch hour.  It did pretty well, but, once, when I said Prince George it typed first gorge.

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Great ice cream and no spoon. I still love the 21st century

August 30, 2012

Going back doesn’t sound like a blast,

Sure, time is moving too fast.

There were things to endure

That now we can cure.

Nostalgia’s a thing of the past.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

Doctors tend to suffer from nostalgia.  Many of us express a longing for the good old days when having MD or DO after your name automatically brought you respect, a simpler time, before technology kept butting between the doc and the patient, when government and insurance companies didn’t interfere with clinical decisions.  Sometimes I’ll say to a colleague, “Pick a year, any year, not this one.  When would you rather live and practice?”

Don’t get me wrong.  I resent the second guessing by health care bureaucrats, whether private or public.  Clearly physicians rely too much on MRIs and not enough on physical examination, and the constant fear of a lawsuit detracts from every patient encounter. 

But I don’t want to go back. 

Immunizations have done away with more than 80% of the pediatrics problems leading to hospitalization in 1982, the year I finished residency.  I can now distinguish between a true positive TB skin test and a false positive from a BCG vaccination(given in another country) with a test called IGRA.  Testicular cancer patients now have better than a 90% chance of cure.  PET scanners, more available now than ever before, show up malignancies with incredible accuracy.  Outpatient surgery has become the norm. 

We can cure schistosomiasis and we can treat rheumatoid arthritis.  Cure rate on Hepatitis C has gone  from 10% to 60% in ten years.  We have good, solid drugs for alcoholism and nicotine addiction.  The generic $4 list includes a lot of medications that used to fetch three figures a month.

In addition to the incredible technology and the great pharmaceuticals, we have consultants of unprecedented caliber. 

I’m fond of saying that if you want 1990’s medicine you can have it at 1990’s prices or lower, but you have to pay for the updates.

Our clinic has a contract with a program for the medically indigent.  Briefly, we get $20 per visit for patients who can’t pay for medical care.  If they need services outside the range of primary care, we can send them to fine specialists 4 to 6 hours away.

The program looks great in theory but the execution leaves much to be desired.  Some of those patients have to drive 2 hours to get to me.  Scheduling referral services involves a faceless, glacial bureaucracy. 

The geographic imperative rears its ugly head; a six-hour drive represents a huge barrier to quality care, no matter how great the facilities at the other side of the state.

On the one hand, the drive deters overuse of medical care.  On the other hand, I worry that my patients may suffer lasting harm from treatment delay, that the system offers too many opportunities for the ball to drop.

Twenty-first century medical advances have made medicine an incredible profession, but economic realities present huge frustrations.  Like having the world’s best ice cream and no spoon.

I still wouldn’t want to practice in any other era.

 

Warnings over coffee

August 26, 2012

I warned the young doctor, the moaner

Striving to pay off his loaner

All of that debt

Just has to be met.

Please, never turn into an owner.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

Job offers cross my desk and invade my emails every day.  Most weeks include half a dozen calls from recruiters.  Just last week I got a flyer promising a strong six-figure base pay, with an available 66% upgrade for taking call.

I’m not in the market. Just trying to work reasonable hours takes up most of my time.  I forward some of the more interesting opportunities to a couple of colleagues who find themselves between jobs, a status that doesn’t last long for a doctor.

I sat down with one of them today, over coffee, to talk about an offer.  The email promised half the money a teacher makes, but would give the successful hire a chance to improve some skill sets. 

I informally counsel a good number of docs in the early phases of their careers.  If I talk about hanging up a shingle, I caution about the burdens of being an owner, and none of the cautions relate to the rapidly changing medical business climate.

The Affordable Health Care Act increases the regulatory burden on doctors.  With all the forms to fill out and reports to generate, few physicians can continue in small or solo practices unless they reject money from insurance and the government.  But that’s not what I warn the young docs about.

A medical business owner has to worry about overhead, and thus must be willing to fire less than stellar employees.  Few medicos have business training, even fewer have business sense, and most try to keep marginal staff in place, hoping they’ll improve.  If you’re kind enough to want to help people, you hate to fire a patient because they don’t pay bills.

I apply all these criticisms to myself.  Every day I go to work not worrying about management reminds me of how much emotional energy I spent on being a boss.

On the other hand, I finished med school with a mere $3,000 in debt (I had great poverty skills) and I didn’t face six figures of pay back.

More and more doctors marry other professionals and two good incomes decreases the drive to seek the highest paycheck.  At the same time, the physicians now coming out of training have had work hour limits, and hence have better leisure skills than my generation of doctors.

“Don’t get on the hamster wheel,” I cautioned my colleague.  “You’ll find it very difficult to get off before you burn out.”

Still the 40-hour work week, the ideal balance between home and work, eludes every doctor I know of, even the ones on salary.

Two doctors appointments, two views of the future; agreements about realities

November 9, 2010

Some will be choosing to flee

When Medicare starts cutting the fee

     A trend we are gauging,

    Docs and patients are aging

But no one should be working for free

I had two doctor appointments today.

Dr. Donahue, the podiatrist, confirmed my suspicions that I have posterior tibial tendonitis in my right ankle, and gave me permission to write about our conversation.

About ten years ago, I had a surgery for a similar problem in the left ankle, with mediocre results.   Neither of us  relished the idea of another surgery.  She told me to continue my current course:  rest, rigid orthotics, elevation, ice, elastic bandage, and hiking boots with a lot of ankle support; but I need to get an elaborate hinged brace made for my ankle.

I suspect that the same autoimmune tendency that gives me ankylosing spondylitis makes me prone to tendonitis; I’ve had it now in both wrists, both ankles, both elbows, and one shoulder.

We talked about slowing down.

I told her how I just finished two golden weeks in Grand Island, Nebraska, getting regular sleep, working less than forty hours a week, seeing respectful, hardworking patients.

Dr. Donahue has a three-year-old and works 30 hours a week.  We discussed the joys of rational hours.  She gets the best of both worlds; she looks forward to going to work, she looks forward to coming home and she gets regular sleep.  “So,” I said, “THAT explains your clear complexion and your shampoo commercial hair.”

Doctors’ life expectancy runs seven years behind the rest of the population because of stress and sleep deprivation.

If all the doctors do what I’ve done, I said, we won’t have enough doctors.  We can increase the number of doctors going into primary care by democratizing the first two years of medical school, and letting anyone who can pass Part I of the Boards go on to a clinical program.  We would get a lot of docs who would work fewer hours for less money.

A few hours later I talked to a doctor while he took care of a premalignant condition.  One of the few people who has read the whole health care bill, I asked him how he plans for the future.  “I’m stockpiling guns and ammunition,” he said. 

I filled him in on what I’d been doing (see my previous posts), and we talked about medical economics.  He pointed out that Congress will soon cut Medicare reimbursement by 29% and another 11% cut will follow a few months later. 

Most family practice offices run 60% overhead.  Where Medicare reimbursement falls below the cost of seeing the patient, many practices have stopped accepting Medicare.  If payment goes down, the trend will continue.

Then, we agreed, we’ll come to a situation where medical care is rationed.

One fourth of our doctors are over the age of 60; the more onerous the regulationsand the lower reimbursement, the earlier the doctors will retire.   Trying to get smart young people to give up seven years out of their ‘20’s is a tough sell now, and will only get harder.

Moose watching in Suburban Anchorage

July 28, 2010

After a supper of chicken a jus,

The workplace had turned us loose.

     We went for a walk

     We had a good talk,

And got close to a young spike bull moose.

Anchorage is not Barrow.  There are divided highways and McDonald’s and Starbucks and strip malls. 

But there are also green belts with pedestrian trails and signs telling you what to do if you encounter moose, black bears, or brown bears.  The newspaper sports section talks about mushing and fishing along with baseball and basketball.  Football in southern Alaska starts in the first week of August.

Les, an Anchorage doc who did the same residency I did, and I took his dog for a walk last night, down suburban streets to a green belt.  On the way we saw a twelve-year-old boy standing in his driveway, clicking away with his camera.  “What are you taking pictures of?” we asked.

He looked up, and then looked back to the place behind the hedge he’d been photographing.   “Moose,” he said.

We stepped into the driveway to see, sure enough, a spike moose chewing his cud on the well-kept suburban lawn, about three paces away.   Mute cement lawn deer looked on.   I hadn’t brought my camera.

We got to the green belt and Les pointed to where the four-lane crosses and said, “That’s where the big boar brownie was killed crossing last year.  Hit by a car.” 

We walked on a bike path, occasionally hearing “On your left!” from behind.  I hadn’t realized how quiet bicycles can be because I usually am the one riding the bicycle.

After a while I looked to the right and said, “Those spruce are looking a little scrawny here.  They just got planted?”

He said, “That’s taiga.  That’s as tall as they’ll get.  Probably a pocket of permafrost under there.  Roots can’t penetrate very far down.”

Further on the path crossed a clear, turbulent stream.  “Are there any salmon?  You see any?” he asked.  We stood on the bridge and looked, and I allowed as how I didn’t.  “A couple of days ago  I heard there were salmon running here,” he said.

I said, “Here, Les, look at the signs here.”  Posted at eye level were three signs advising the dates that fishing was not permitted, and that outside those dates non-residents weren’t allowed to fish, and residents were permitted catch-and –release using artificial lures only.

We walked through the long sub-arctic twilight.  I talked about the positive parts of the Barrow experience.

The doctors have functional communication with no back-stabbing.  If Doctor A and Doctor B have a problem, anyone who tries to enlist Doctor C will just end up looking bad.  Call means twelve hours.   Five days a week the docs meet for thirty to sixty minutes to discuss patients, which results in a lot of learning. 

I also talked about the painful transition from paper-based medical records to electronic medical records, and our discussion turned to practice management.

I told him how great it was to work at the bottom of the totem pole and not have to worry about making systemic decisions.

Non-compete clause and doctor’s karma

May 24, 2010

I am a respecter of laws.

I keep my word, just because

     The reason for smiles

     Thirty good miles

And a standard non-compete clause

 

In December of 1978 I went out to Mongolian Barbeque with Lynne, one of my medical school classmates in Saginaw, Michigan. 

“It’s funny, you know, this karma happens when you get into med school,” she said as we sat in a booth.  “I noticed as soon as we started clinical rotations that people would just start opening up about their medical problems.”

The waitress brought the hot and sour soup and egg rolls.  As two women sat down at the next booth one of them started talking about her rheumatoid arthritis.  Lynne and I shot each other looks.  While paying our tab, the two men in front of us talked about their blood pressure.

Thus it has continued ever since.  People who don’t know my profession, people who don’t even know I’m listening, talk to me about their medical problems or talk about their medical problems within in earshot.  I doubt people talk more about their health now than they did during my musician days.

While eating nachos at a friend’s restaurant this afternoon, another restaurateur walked in.  He’d never met me, he didn’t know my profession.  While he mixed himself a Keystone and Clamato he pulled up his pant leg and showed me the bruise and swelling of his knee.  He’d fallen from a boom truck onto the point of the knee.  I resisted the urge to tell him what to do for his problems, starting with alcohol abstinence.

The non-compete clause of my contract went into force today and I have no intention of violating it.

I am a man of my word. 

It also gives me another reason to go walkabout. 

I met with the insurance agent today, finalizing details of my medical malpractice insurance; it will cost me about a month’s earnings. 

I went to the office and took down some pictures I had forgotten.  I also took my photographic portrait that had hung in the front.

My office manager asked me about keeping my name on the glass door.  Did I want to keep my name up?  Did I want to put the word “Retired” after it?

I admit I had to think.

“Take it down,” I said.  “I’m not retired and I don’t work here anymore.  I don’t want to mislead people with false advertising.”

I stopped into the break room and had a piece of cheese pizza from the stack of sixteen pizzas, brought in by the pharmaceutical manufacturer’s rep.

He came in while I munched and listened to the staff’s conversation.  I’d not met him before.  I dressed in shorts and a button-down shirt, certainly not what a working doc would wear.

He didn’t introduce himself, and I didn’t have to sit still for a sales pitch.

***

I got a lot done today: I cooked Bethany and me breakfast, cleaned the kitchen, spaded up the garden, exchanged my computer at Best Buy, bought reeds and miscellaneous for my new sax, met with the insurance rep, stopped at the office, went grocery shopping, dropped in on friends, bought plants for my garden, led religious services, and exercised at the gym. 

But I didn’t rush through it.

Hyperaldosteronism, Medicare pay cuts, and a good night’s sleep

March 3, 2010

A patient depressed will cry

I said I didn’t know why

            But, I will mention,    

            There was hypertension

And the aldosterone level is high!

A good night’s sleep is a gift directly from heaven, and one of those graced last evening, making for a euphoric morning.

A patient, after being shuffled from doc to doc, came in last week on a new patient visit with high blood pressure disproportionate to age.  Non smoker, non drinker, and two hundred pounds overweight, an elective surgery was delayed for a pressure of 158/116. 

I see a lot of obese people and a lot of high blood pressure, but I don’t see hypertension this high in a person this young who doesn’t drink.  There were other problems, with more lab pending.  I already started vitamin D and booked a follow-up appointment for Friday.

But the aldosterone level came up high in this morning’s lab queue, 30 with normal being less than 16. 

Aldosterone comes from the adrenal gland and usually gets ignored because this hormone rarely goes bad.  I have never, not once, seen a case of hyperaldosteronism before.  On the verge of ordering spironolactone (an aldosterone blocker), I stopped and asked for further blood tests.  On her way to the endocrinologist I wanted to present my consultant with a thorough work-up.

Over lunch, one of the transcriptionists says, “Look at that Medicare cut, 21%.  What do you think about that, Dr. Gordon?”

“Like I care,” I say, “It’s not my problem.”

It’s a national problem in that people reaching Medicare age will not be able to find medical care if the rates get cut.  As it stands, the government pay for patients over the age of 65 is an insult and doesn’t cover the overhead.  But I’m not worried about it bringing down my income because I’m going to be doing Something Else.  I’ve also found that worrying about the government is a waste of time.  I will still enjoy taking care of the elderly, but in short order I’ll be on salary. 

It will be a problem for our oldest daughter, Jesse, currently in her Family Practice residency in Chicago.  She’ll inherit a lot of problems, and Medicare is only one of them.  

I inherited a lot of problems from my father’s generation of doctors.

Every generation of doctors fixes some problems and generates others.  I have never seen a case of polio or smallpox, but HMO’s still seemed like a pretty good idea while I was in med school.  I’ve had to deal with the rise of the Resource Based Relative Value Unit and the pharmacy review board.  As Jesse progresses there will be more and more faceless bureaucrats pushing her around.  I don’t see a remedy for it.  Medicine will still be the most honorable way to make a living.  Chances are she’ll never see a case of measles or mumps.

The quality of medical care keeps getting better and better and consequently the cost keeps going up.  As life expectancy increases, the rewards for not dying young spiral up and up, and the demand for health care keeps increasing.

I don’t think I’m going to solve the problem, but I’m having a blast taking care of patients.