Friday, May 30, 2014

link from the Atlantic about Hospitals purchasing physician practices

This article in the Atlantic monthly discusses how hospitals are purchasing physician practices.

Speaking from my own personal experience as both an employed physician and an independent physician, I think that being an employed physician was worse, both for the patient and for the physician.

The Atlantic article hits on a key point- when you do not have control over your own environment, it hurts morale.  From a patient standpoint, you can tell when your physician has low morale, and it affects the quality of your care and the quality of your patient experience.

I'll give one seemingly small but crucial element where I love being an independent physician- calling to make an appointment.  One common trend amongst employed physicians is a "central call" system, where you call the hospital operator, and get stuck in a phone tree.  It's unpleasant and tedious, and even more importantly can lead to errors in being sent to the wrong clinic.

In our office, when you call, you reach a live person who is in the same office as Garrett and I.  If they have a question, they can walk 5 meters and ask us a question.  It makes life easier, more pleasant, and dramatically increases the likelihood that we are the appropriate clinic for the patient's needs.

Thursday, May 29, 2014

What to expect from a diagnostic ultrasound and ultrasound guided procedure

For more detailed information on musculoskeletal ultrasound and its benefits please see this blog post.

Diagnostic ultrasound
When being examined, the doctor will be scanning the desired area by placing gel on the skin and applying the probe. The doctor will then proceed to look at the different structures in a systematic manner using established protocols. To make sure they don't miss important structures, they may not start with the area that bothers you first, but don't worry- they will indeed scan your most painful area.

When the physicians are scanning your body, they will often find structural changes to different body parts that are not painful, and may be incidental findings.  This would the equivalent to taking a high resolution photo of an older home- there may be many small signs of wear and tear that do not actually affect the function of the house.  This is especially true when scanning the body with ultrasound- since ultrasound is extremely high resolution (over three times higher than MRI), incidental structural changes are extremely common.

To help distinguish between incidental structural changes and those that are symptomatic, an important part of the examination is sonopalpation, which is applying pressure using the ultrasound probe.  This is one of the greatest strengths of diagnostic ultrasound- we can identify those structures that both have architectural changes and are also painful.  We refer to this as concordantly painful.  Throughout the exam the doctor will often ask if you are experiencing any pain. While the positioning of the body part itself may be uncomfortable, when asking this question, they are referring specifically to where the probe currently is being placed.

Some clinics will use an ultrasound tech to perform their ultrasound imaging.  At Lake Washington Sports & Spine, all of our studies are personally performed by the physicians, Dr. Chimes and Dr. Hyman.  One of the reasons we do it this way is that our physicians primarily view the ultrasound as an opportunity to educate their patients, helping patients become more aware of their bodies and how their structures influence their function and discomfort.  We encourage patients to ask questions, and they are welcome to bring friends, family members, and members of their treatment team with them.  We've had patients bring their physical therapist, personal trainer, or chiropractors to join them at the visit, which is a fun and educational way to make sure everyone on the team is on the same page.

Ultrasound Guided Procedures
While there are a number of different procedures performed in the office at Lake Washington Sports and Spine, the most common is a cortisosteroid injection, the so-called "cortisone shot". We encourage patients not to refer to these as cortisone shots though, because almost all injections are corticosteroid injections, and this does not help distinguish different injections from one another.  It would be analogous to referring to a surgery as a "scalpel surgery"- while this is technically true, it would not distinguish a small bowel resection from a breast reconstruction.

The most relevant information for any injection is two factors:
1. Where the medication was placed
2. How it got there

For example, we may refer to an injection as an "ultrasound-guided subacromial bursa injection."  This means that the injection was targeted to a very specific location within the shoulder (the sub-acromial bursa), and how we know how we targeted the injection (using ultrasound-guidance).   We specifically like to know if imaging was used to guide the injection, which dramatically increases the likelihood that the needle was actually where we thought it was.   For injections that don't use guidance, some use the term "blind" injections, since you are not directly visualizing the needle tip.  We usually refer to blind injections as "landmark-guided", meaning that the clinician used touch sensation to feel for the intended location.

The exact procedure will differ depending on what the body part is and what structure is being targeted, but the next paragraph will give a general idea for what to expect when having one of these done in our office.

The doctor will apply some gel to the skin and place the ultrasound probe over the area and scan it to localize the target. After this is done, the gel will be cleaned off and the skin will be cleaned with cleaning solution. At this point, the doctor will then inject numbing medication into the skin using a very thin needle.  To the extent that there is much pain during a procedure, the numbing is usually the worst part, although it is not particularly painful.  It causes a burning that lasts on average 8 seconds, and is usually significantly less painful than a blood draw or flu shot.

After numbing the skin, more gel is then applied and the probe is used to visualize the target. Once the target is adequately visualized, another needle is inserted and directed towards the target. Once the needle has reached the target, the medication is then injected. Often patients will feel some pressure in the area, but it should not be especially painful. Once the medication is administered, the needle is removed, the skin is cleaned off, and a Band-Aid is applied.

Patients will often ask what they are supposed to expect after the injection. Most patients will come off the table feeling at least some level of relief. Typically this is due to the numbing medication that was injected along with the steroid, which takes about 8 seconds to take effect. How long the numbing lasts for is variable depending on the patient, but can last anywhere from 2 hours to forever. The steroid medication works more gradually and often can take about 2 weeks before its peak effectiveness. 

It is not unusual for patients to feel relief for 2 hours or so before having the pain return. This is completely normal, and we advise patients to ice regularly and monitor how they are feeling until we see them for a follow up, normally about 2 weeks post injection.

The post-injection follow-up is important.  The injection is part of the overall treatment plan, but is not a substitute for other parts of the treatment, which will nearly always involve an exercise prescription, and may also include physical therapy or chiropractic care.  At Lake Washington Sports & Spine, we strongly believe in the need to "Rehabilitate beyond the Resolution of Symptoms," and a major focus of our aftercare is to make sure patients not only feel better, but also know how to prevent recurrences, and know tactics to bring their symptoms under control if they have a recurrence.

Who profits from Obamacare? It's not patients, and it's not physicians

This link from the NY Times highlights an important point about current health care changes - they are shifting money AWAY from care, and TOWARD support of infrastructure

Physician salaries are going down, and accordingly, so is the incentive for talented people to go into medicine, or stay in medicine.  Physicians are retiring early, sometimes as early as in their 30s.

On the other hand, administrator salaries are increasing, and outstrip that of physicians.  According to this NY Times article, the average hospital administrator makes 43% more than the average family physician.  Does that make sense to you?

It's important to remind patients- buildings do not take care of patients.  People do.

Tuesday, May 13, 2014

The Power of Choice: Lake Bell, Bill Simmons, Rick Gottlieb, and why patients should care about the Long Tail

I was listening to a fantastic BS Report Podcast with Bill Simmons, where he was interviewing the actress Lake Bell about the upcoming movie "Million Dollar Arm".

For those not familiar with the movie, it's a true story of how a baseball agent/scout (played by Jon Hamm) travels to India and arranges a contest to find young Indian cricket players to come to the USA to play baseball.

During the course of the interview, Bill Simmons was noting Lake Bell's interesting career, where she initally had a traditional Hollywood actress pathway of some marginally-successful runs on TV shows and movies, despite being clearly immensely talented.  She has found a new pathway to success, through things like the Emmy-winning web series "Children's Hospital."

Bill asked her at one point in the interview if Lake was interested in "getting on real TV."  Lake gracefully laughed that she actually preferred being on "fake TV."  This was a fascinating conversation for several reasons, which I'll highlight here:

1. Lake very appropriately realized that Hollywood was not savvy enough to take advantage of her talents, and she sensed a market inefficiency.  In particular, she noted that only a small % of movies are directed by women, even though they do a high % of movie ticket purchases.  FiveThirtyEight had an excellent blog post about this a few weeks ago, noting that this is a true inefficiency - Hollywood would do better financially if they took the women's view into mind more.

2. Lake had one area of particular passion, which was voice over work.  She noted that there is an enormous bias that has men do the vast majority of voice over work, and she struggled to find such work as a woman.  She took a brave and pro-active approach to correcting this- she made her own independent movie about a woman struggling to get voice over work, called "In a World" which parodies the ubiquitous movie trailers that begin with that phrase.   Check out the very funny trailer here.

3. A super important point here- Lake is VERY successful.  She is not on a network TV show, but she doesn't WANT to be on one.  Instead, she's on an Emmy-winning web series, directing her own movie, about to come out in a big studio movie, recently married, and happy.  She created her own pathway to success.

4. What's incredibly ironic is that this line of questioning is coming from Bill Simmons.  For those not familiar with Bill Simmon's back story, he is often cited as the single most successful individual who has parlayed non-traditional media to create an empire.  He started writing a small web column called "Boston Sports Guy" back in 1997, when there really wasn't such a thing as a web column.  He created a great product, and eventually moved up the ranks through ESPN.  He has been called the "Most Influential Man in Sports Media" by his competitors at Sports Illustrated, and ESPN made him the editor in chief of their influential Grantland website.  In full disclosure, Grantland is my favorite website, and I'm a huge Bill Simmons fan.
     So, what's incredibly ironic is that if there was one human being on the planet who should appreciate that success shouldn't be defined by having to participate in traditional products, it's Bill Simmons.  

Yet, he fell into the trap of assuming that there is only one pathway to success.

Segueing .... in the excellent book The Long Tail, Chris Anderson notes that the trend in the current economy is to offer people choice.  The long tail in the title refers to the shape of a Pareto distribution (see picture above).  The concept in the book is that in the past, consumers had limited choice, and the bulk of sales occurred on the left side of the graph.  For example, the vast majority of books sales were the top 20 best-sellers, the vast majority of record sales were on the Billboard Hot 100, etc.

However, because of services like, ITunes, and (obligatory Microsoft reference) Bing search, consumers have access to far more choice, corresponding to the "Long Tail" on the right side of the curve.  And we LOVE it!

For example, I grew up consuming traditional media.  I read my local newspaper everyday (the Trenton Times), listened to Top 20 radio, and watched The Cosby Show and Facts of Life just like everyone else.  It was ok.

Now, I consume media I really enjoy.  I read my medical websites, but also enjoy Grantland, FiveThirtyEight, but also websites for my favorite niche sport, Mixed Martial Arts.  I listen to lots and lots of Podcasts, which is my favorite form of media.  And I hardly watch TV or listen to radio.  It's a completely different way of consuming media, and I vastly prefer it.  Choice is simply better.

This applies to all walks of life.  I love Chipotle.  That said, I am really glad that Baja Fresh and Qdoba exist.  I love that we have a choice.  Even if you go to Taco Bell, they've had to improve their game because of the competition created by Chipotle.

So, what the heck does this have to do with healthcare?  Well, in every other facet of life, the trend is to embrace the Long Tail, and offer consumers choice.  But the trend in healthcare is in the OPPOSITE direction, to limit choice.  This is not good, and as a consumer, this is not what you want.

One popular model is that idea of a "narrow network", where a large employer or insurer will contract with a limited group of providers, and the consumers will have to use the provider that is within that narrow network.  This, in my opinion, is definitely not in the best interest of the consumer.

I'll give a very specific, real example of how this hurts patients.  On Friday afternoons, I perform my spine procedures at the Overlake Surgery Center in Bellevue.  When I perform procedures, in the operating suite next to me there is another physician who is also performing spine procedures.

He's a great guy and a great physician.  He is so awesome, in fact, that I am going to advertise on his behalf on my blog- his name is Llewellyn Packia Raj, MD.  While I suppose he is technically a competitor of mine, I don't view him that way.  I view him as an amazing, compassionate physician, with great technical skill and wisdom.  I sincerely want him to be successful.  I'd gladly see him as a patient, and would send a loved one to see him.

It is my personal belief that for some patients, Lew will be a better choice, and for other patients, I will be a better choice.  While I think we are both very good at what we do and have some overlaps in skills and personality, I don't think we are equivalent. 

So the question is- who gets to make that choice?  The consumer, or some central agency defining a narrow network?

To me, this is obvious.  The consumer, in this case the patient, should make the choice.  That should be their right, and helps lead to a better fit.


For the final leg of this blog post, I'll comment on a time I deliberately chose to escape a narrow network, and how happy it made me.  When I moved to Pittsburgh, I needed to establish a relationship with a new dentist.  My dental health plan had a narrow network, so I was looking for a specific dentist within that network.

I happened to have a patient who was a brilliant periodontist, and he was someone I also related to on a personal level and trusted.  I asked him who I should see, and he recommended a great general dentist named Rick Gottlieb.  

Dr. Gottlieb was out of my network, but my friend said that Dr. Gottlieb was so good he'd be worth paying cash to see, and gave me some anecdotes on how this would save me money in the long run.  This was a big leap of faith for me- I had never willingly paid cash for something for which I insurance, but I trusted his advice and saw Dr. Gottlieb.

I am so glad that I did!  Rick was far and away the best dentist I had ever seen, and I consider him the best clinician I've ever been to.  I found the experience exceedingly pleasant (..... how often to people say that about going to the dentist!), and I felt confident about my dental health.  I thought it was the best run office I've ever been to, and I've used it as a model when I think about how Garrett and I should run our office at Lake Washington Sports & Spine.

In terms of cost- I think my friend was right.  By helping educate me about my long term dental needs, and helping prevent expensive long term periodontal care and other advanced procedures, I am likely going to save thousands of dollars in the long term.  Now, from an insurer's view, they may not care.   They don't care about savings 15 year downstream, and they are willing to be penny wise, even if it's pound foolish.

But here is an even more important point that is lost in the cost-savings debate- I really like Rick as a person.  That means something to me, and it has value.  Rick and I were social acquaintances when I lived in Pittsburgh.  I don't know that it quite reached the level of "friend", but it was meaningful to me, and I knew very clearly that he cared about me as a person and was rooting for my interest, beyond me merely being someone who provided him income.

And I think that this is something that is getting lost in medicine in all of the discussions of cost containment, narrow networks, meaningful use, and similar blather.  Medicine, at it's core, should be about the relationship of the patient and their physician.  Like all relationships in life, you can make a best guess, but ultimately finding the right match is a give and take process, but when you find that match, it's wonderful.

To that end, I encourage physicians to take a stand and fight for patient choice.  There is some risk in that process- you will lose some patients.  But I am ok with that- even more than that, I embrace it!  If someone chooses to see a great physician like Lew Packia Raj instead of me, that is their right, and more importantly, that frees up my schedule to find a patient who is an even better match for me.

...... I can just see the movie trailer now - "In a world, where patients have a choice ....."

Saturday, May 3, 2014

Wonderful link about the power of being mindfull

I absolutely love this link on the Huffington Post about the power of being mindful.

I love my current patient population.  I work with some incredibly thoughtful, creative, and active patients.  One common trend I see, however, is that because they so talented, they are often spread thin, and they have too many responsibilities.

I certainly relate, and one of my main motivations for leaving academia was to create a simpler life for myself that focused on what I considered really important, which was family, health, my dog, nature, exercise, and kindness.

I think there were some key elements the author hit that I think are essential for health:
1. Stay on task.  We can't actually multi-task.  Very smart people can give the illusion of multi-tasking, but multi-tasking creates a drag on efficiency, and it's exhausting.

2. Allow your mind to wander.  Build time into your day to do nothing.   Practice meditation to really embrace that nothingness.

3. Get outside and walk.  This is the greatest gift my dog Bucky gives me (..... besides his love, of course) - reminder that the way we are biologically designed to discharge our autonomic nervous system is by getting outside and walking.  While Bucky may be more animated when he starts getting fidgety from a lack of exercise, humans have the same autonomic reaction.  We need that discharge to recalibrate our system.

4. Enjoy the moments and reflect.  I find this especially enjoyable living in the Pacific Northwest.  Living in such a lush environment with water, flora, and mountains is beautiful.  Take time to enjoy it.  It's such a privilege to be around so many bright, thoughtful, and varied people.  Express gratitude for living in a world where you can engage with them.

Embrace simplicity!

How Obamacare forced a two-tiered system

There is an excellent piece in the Wall Street Journal that explains how the ACA (or as everyone knows it, Obamacare), has forced a two-tiered health care system.

One of the key things to recognize is that physicians did not choose this model, we are just predictably reacting to it.  I know that I, and many physicians I know, warned that Obamacare would DECREASE access to physicians.

The heart of the matter is two-fold:
1. Absurdly low payment.  The Center for Medicare and Medicaid services has acted in a bullying, unreasonable manner in terms of the extent and levels of their cuts.   They were already paying lower rates than private insurers, and they continue to cut rates to levels that are unsustainable.
      Giving some specific examples, one of our most commonly performed procedures is an ultrasound-guided injection.  Medicare was already paying less than other insurers, and then cut payment by another 61% at the beginning of 2014.  This was not a negotiation, mind you, they simply made the unilateral decision to cut payment.
     Similarly, as my colleague Ethan Colliver noted in his excellent interview, cervical epidural steroid injections, depending on setting, are paid $40-50 per injection.  This is less than a massage therapist makes, and this is for a potentially dangerous procedure that requires a high level of skill.  In many cases, this may not even cover the cost of our liability insurance to perform the procedure.
      It is not hyperbolic to say that the Mafia is more generous in their interactions with their "clients."  I know that patients in the Medicare demographic are amongst my favorite patients.  This includes people like my parents, or some of my favorite patients like Margie McMaster, with whom I promised I would grow old together.

2. Increased compliance costs.  Medicare money is dirty money- it comes with a level of requirements that no other payor demands.  The most egregious aspect is that Medicare uses "Recovery Audit Contractors", who are bounty hunters that review physician charts to find ways to deny payments, threaten physician licensure, and potentially criminalize physicians who are trying their best to meet the compliance requirements set by CMS.
       In addition to the unpleasantness of being forced to click buttons instead of listening to patients,  it creates a sense of paranoia that no matter how hard we work to be in compliance, small errors could lead to devastating financial penalties that are out of our control, or an inability to continue practicing as a physician.
       Physicians have attempted to adjust to the increased compliance requirements by taking hundreds of hours of continuing medical education to learn more about Medicare requirements (..... time that otherwise could have been spent learning more about how to treat patients- think of the opportunity cost!), and this is problematic for Medicare.  We are not supposed to succeed!  Medicare is underfunded, and now depends on fining physicians to stay solvent.  So they introduce increasing complex regulations, like ICD-10 (which the new diagnostic coding system), realizing that if they make it impossible for physicians to comply, the don't have to pay physicians there already substantially cut fee schedule.

The combination of low pay and deliberately unworkable compliance system is untenable.  For many senior physicians, the solution is to retire early.  For others, it's to leave medicine.  For many future doctors, the decision is to not enter medicine in the first place.

..... and for the very best physicians, who have a choice in the matter, it's stop taking Medicare.

Patients, however, have a choice.  If you didn't like your experience with a commercial insurance carrier like Aetna, Premara, Regence, Cigna, or United, you could write to the insurance company leadership and let them know that low-balling physicians and increasing their compliance requirements hurts you as a patient.

It so happens that for Medicare, your "insurance administrator" is your congressman.  So write them!  Let them know that what they are doing to physicians is not right, and it causing you to lose access to the best doctors.   Congress has made it clear they don't care what physicians think.  Hopefully, they do care about patients, since ultimately, they work for you.

Meet the Experts: Ethan Colliver, DO

Gary: For our next feature, I am excited to introduce Ethan Colliver, DO.  Ethan, for introduction, can you tell us more about what you do?

Ethan: Sure. Thanks for having me Gary.  I am a fellowship-trained physiatrist specialized in treating Sports & Spine Disorders.  I use diagnostics such as X-rays, MRIs, Ultrasounds, and a functional exam to diagnose a problem and then use a host of treatments such as medications, manipulation, injections, or exercise to alleviate the problem.  

Gary: Many people treats spine and sports conditions.  What makes your approach different?

Ethan: Physiatrists are the Function experts, so I measure the patient's success by how much function they have gained by coming to me, and not necessarily what number they say their pain score currently is.

Gary: My experience has been that some physiatrists make that claim, but in practice they function similar to other physicians.  Do you think you provide a similar experience to other PM&R physicians, or do you do specific things to make sure you legitimately prioritize function?

Ethan: Absolutely.  I have adopted functional tests from great mentors or functional exercise classes I have attended to measure a patient's function.  For example, I can quantify a patient’s ability to do a full squat and use that number to measure their improvement.  I will measure a patient's function, strength, and flexibility throughout their rehabilitation program; if their pain has improved but their function is still lacking, then I will recommend they continue the rehabilitation program.  I prefer this to questionnaires which are subjective.

There are examples where the patient's Physical Therapist has recommending discontinuing therapy, but I felt continuing it was needed to work more on functional goals. Also, one of my most useful tools is a Co-visit, where the patient, physical therapist, and I get together to go over the exercise program in detail and see how we can make it better and more efficient for those patients who are struggling.

If you ask me, the only disease modifying treatment I provide is developing a rehabilitation program to help a patient get back their function.  All other treatments just make that transition easier. 

Gary: I find that patents really have a hard time grasping what "function" means.  What do you mean?  How does that affect the patient interaction?

Ethan: We discuss with the patient multiple levels of function ranging from a very small scale such as a "dysfunctional" vertebra or one "out of alignment" that can be treated with manipulation; to a kinetic-chain level of function where lack of hip flexibility and strength is causing back pain; to a community level of function such as returning to work, sport, or exercise program.  Our interactions and goals are centered on returning function at each one of these levels.  

I use my specialized training to assess someone's kinetic chain.  I determine where their chain is restricted or not working well, and develop a rehabilitation program to restore function to the chain.  For example, this allows me to tell someone that their back hurts because they have significant hip stiffness, and that if we work on improving hip flexibility and strength then the back pain will improve.

Gary: You mean to say that doing a "pain- relieving" injection, such as an epidural steroid injection, is not enough for someone with back pain.

Ethan:  Exactly.  Almost all treatments for back pain are reactionary.  That means we wait until the patient has pain before we treat.  That treatment may help for a while but if the patient continues to have major restrictions in their kinetic chain like a stiff hip, then they will continue to move in a way that puts stress on their back.  Eventually, their back pain will return.  Improving the patient's flexibility and strength through a rehabilitation program is critical to reduce their chance of future episodes of back pain.  Again, the only disease modifying treatment I provide is developing a rehabilitation program to help a patient get back their function.  

Furthermore, patients are mistaken to think surgery on their spine will “fix” them.  It’s like putting new tires on a bent rim of a car.  You can fix the worn tires but if you continue to drive on the bent rim, then the tires will go bad again, real quick.  This is one reason why people have repeat spinal surgeries- they never fix the underlying issues leading to their back pain.

Gary: When I was contemplating making a transition from academic medicine into private practice, you were one of the first people I spoke to.  You correctly made the observation that I was really making a transition from a large system into a smaller practice model, and that you had made a similar decision successfully.  Tell me more about what you perceive as the differences between large systems and small, independent practices?

Ethan: In a large system, I found that all the clinicians were compartmentalized. I was "The Spine Specialist" and only saw back and neck pain; while this doctor over here was "The Shoulder Surgeon" and only saw shoulder pain.  This approach fails because you may have to treat someone's neck to treat their shoulder pain, or vice versa. Small independent practice allows me to treat the whole patient and not be myopic on just their neck or back pain.

Large systems are like large ships, they are hard to start moving and are slow to change direction.  For example, when I gained expertise in using ultrasound, I couldn't get access to an ultrasound machine because of the bureaucracy.  Or when I needed to add more or less time to my schedule for therapeutic injections, it took a long time to happen, which ultimately hurts patients. Now, I can more efficiently change my schedule or access to new technology or treatments because I have a small clinic.  

Gary: Do you feel you can help patients more, now that you are in physician-run small practice?

Ethan: Yes.  Like small business, small medical practice is where a lot of innovation in medicine takes place.  We can try new emerging treatments more readily.  Some may work, some may not, but our size allows us to quickly adopt changes, where it can take decades for large institutions to implement change. 

Gary: The national trend is clearly for physicians to go in the opposite direction, leaving small physician-owned practices into large systems.  My sense is that this is motivated by fear.  What's your perspective?

Ethan: I think this trend is multifactorial.  I have seen examples of physicians near retiring who think joining a large institution will take away the administrative duties of a small clinic.  I have seen examples where the doctor joins a system because they feel that the system can cover the cost of running the clinic in hopes of making the physician more productive.  The most troubling reason is for fear that if the physician does not join the big system then the physician will not get to see any patients because the big institution will only let their "own physicians" treat "their patients".  This approach is growing in many areas of the country, even though it is illegal.  The difficulty comes in proving an institution is using this approach.

Gary: Why do you think physicians are so risk averse?  How much of this do you attribute, for example, to student loan debt?

Ethan:  Multiple things make new physicians risk averse about starting a practice.  Student loan debt is a huge burden.  My own loans were around $250k and after 30 years of payments would be over $500k.  I have met retiring physicians who paid for medical school while working minimum wage jobs in medical school.  No wonder many earlier physicians opened their own practice - they didn't have much debt.  Nowadays, banks think twice about lending money to open a practice if the doctor already has $250k of debt. New physicians worry about how they will pay this mountain of debt, so they join large institutions that promise to pay some portion of the loan debt.

Also, most small businesses are not started by business majors, they are started by engineers, doctors, cooks, photographers, etc.  These people seldom have a background in business.  Not having this knowledge is seen as a big barrier for new doctors thinking about starting a practice.

Gary: One thing I love about private practice is the freedom to be innovative.  For example, you and I have shared ideas on novel ways to help patients, and my main "barrier to implementation" is running it by my partner Garrett.  I like running things like Garrett, because I think that adds a reasonable level of vetting to make sure something is a good idea.  What are your thoughts about innovation within private practice?

Ethan: Like I mentioned earlier, small practices are the "laboratories" of innovation.  Their size allows them to quickly measure the efficacy of emerging technologies and treatments.  Large institutions take a long time to adopt these changes only after small practices have shown these changes to be efficacious. 

Gary: I know you and I have talked off line about our concerns about how insurers are making decisions about reimbursement that are going to hurt patients.  The particular example that, to me, is the most striking is Medicare reimbursement for cervical epidural steroid injections.  Tell me more about your thoughts on this?

Ethan: Medicare and other insurers are pushing to make health insurance cheaper by trying to cut payments to providers.  A physician now gets $40 for doing a potentially dangerous cervical epidural steroid injection for someone with severe neck and arm pain.  Many physicians and institutions cannot afford to keep providing potentially dangerous treatments under such conditions.  I think two things will happen. 

First, the great institutions and physicians may choose to stop treating patients with this insurance because "it's just not worth it"; second, someone less trained and less-qualified such as a CRNA or NP may start doing these procedures at a reduced reimbursement rate.  In that case I think you will get what you pay for; fewer patients may improve and more dangerous complications may occur.

Patients trust doctors with their lives.  Already, a UPS driver can earn more than a physician over their working lifetime when you factor in the physician did not earn meaningful income for 14-15 years while training to be a doctor.  Why would you want to push away the smartest and brightest minds from going into medicine by decreasing their income incentive and replacing them with less trained, cheaper labor.  I don't think it makes sense.

Gary: I feel like a real barrier is that patients love the idea of free or government sponsored healthcare, but are not fully aware about how restrictive this is for medical decision making, and how it can adversely impact their health outcomes.  Do you think patients really understand the restrictions placed by insurance?

Ethan: Socialized medicine and Capitalistic medicine both have their pluses and minuses.  Socialism can offer some degree of basic services to everyone, but most great discoveries in medicine occur in the USA.  Capitalism encourages innovation and compensates the innovator accordingly.  The more healthcare is run by the federal government, the less innovation will occur, and the more the brightest and smartest will steer away from medicine into more rewarding careers and lead the United States away from being a leader in Medicine.  I think that is a mistake.

Gary: So, let's say that tomorrow I can appoint you as "Health Czar." What do you do?  Notice, by the way, I am deliberately not calling you "Health Insurance Czar"

Ethan: Most diseases today are due to lifestyle: obesity, high cholesterol, hypertension, diabetes, heart disease, etc. I think education and encouraging healthy lifestyle changes would be more effective and cheaper than treating a person who is already sick.  Proverbs 22:6 says "Direct your children onto the right path, and when they are older, they will not leave it."    Schools and parents can have a great impact on children by choosing healthy food options, removing junk food vending machines, promoting athletics and physical education.  The Surgeon General in 1960's has effectively decreased the smoking rate to the lowest level in 50 years and had a great impact.  Why can't we take the same approach to eating and exercise?

Thursday, May 1, 2014

ActivAided in the News- Kelly Collier: "Saving the World, One Back at a Time"

This is a great news story about Kelly Collier, who worked with me to develop the Recovery Aid back brace by ActivAided.  I'm the physician mentioned in the story- Kelly and I met when we were both working in Pittsburgh

Some highlights from the story:
"Inventor Kelly Collier first connected with Innovation Works to build her business skills. She had just finished a dual degree in materials science and biomedical engineering from Carnegie Mellon. As part of a class project -- and with guidance from a physician recognized as an expert on spine care and sports medicine -- Collier developed a device to ease back pain. With the makings of a prototype, she then faced challenges with business development. 

"It was hard to convince people to believe me," recalls Collier. "And to get people to believe that this product was going to work the way I said it was going to work."

She attended free public sessions and applied for Innovation Works' AlphaLab program, a business accelerator that funds entrepreneurs with a $25,000 investment and provides intense business mentoring. Collier then obtained additional funding from Innovation Works as her business, ActivAided Orthotics, grew. The RecoveryAid garment is now sold online and through medical supply companies across the country.

"The product works really well," says Collier. "My goal was to try to save the world one back at a time."