Promoting Mediocrity through Medicare

By Garrett Hyman, MD, MPH

An article in today's NY Times applauds the public release of Medicare data on provider payments (http://www.nytimes.com/2014/04/09/business/sliver-of-medicare-doctors-get-big-share-of-payouts.html).  The authors, Reed Abelson and Sarah Cohen, state, "While total Medicare spending - including hospitals, doctors and drugs - is approaching $600 billion a year, payments to doctors have long been shrouded in secrecy."  Sounds a lot like the start of a suspense novel.  One might imagine these journalists have uncovered a clue that might lead to the big arrest that makes our nation safer from the epidemic of corrupt and opportunistic physicians -- like an episode of "CSI: CDU (aka Corrupt Doctors Unit)" -- as if this group of highly motivated and intelligent, type-A, over-educated, devoted, hard-working, do-gooders is prone to acts of mal-intent.  Follow the money, and you will see the trail ends in your doctor's wallet -- is the obvious message of this article.     

The implication is that this now open-source information about the Medicare earnings of your doctor will finally provide you with critical financial information that will allow you to make more informed healthcare choices.  Specifically, you learn what your doctor bills and what your doctor is paid, and the numbers of procedures your doctor performed in 2012 on Medicare patients.  Then with this data you decide whether or not, for you, your physician is the most appropriate.  So let's try it out....using my Medicare payment data as an example.....say you're a 35 year old male Microsoft employee and avid soccer player with knee pain....you search the database and find that I've performed 30 'Arthrocentesis, aspiration and/or injection......large joint...including the knee' on 18 Medicare patients, for which I charged an average of $195 per procedure, and was reimbursed on average $57.  

Alright now, we have the data -- let's be deliberate, methodical and purposeful, and logically sort through these numbers to make an informed healthcare decision.  Can we relate this to healthcare quality?  No.  Outcomes?  No.   Efficiency?  No.  How can the healthcare consumer make use of this data?  I don't know.  Now, should you be a healthcare insurer looking to identify physicians that perform higher numbers of procedures so that you can refuse admission to, or drop a physician from your panel, well then this data may come in handy.  There's a way to increase corporate profits!  Never mind that, said physician, may be THE regional expert in restoring function to patients with chronic musculoskeletal problems with office-based and cost-effective approaches, specifically using targeted injection procedures, thereby helping these patients avoid a more costly surgery.  Where does the Medicare payments data tell you this important information?  It doesn't.

What should it cost to manage the knee pain of a 35 year old soccer player?  The answer -- it depends.  As you might expect, not all knees and not all persons are created equal.  I won't attempt herein to go into all of the potential causes of knee pain in an active 35 year old -- that's a treatise to itself -- but rest assured, there are many unique causes.  In fact, it is just this unique variation that creates the need for...you guessed it...dedicated, expert healthcare providers.    

I have no idea whatsoever how to make this data useful for either the 35 year old soccer athlete or the 80 year old masters tennis player with knee pain.  

I'm an experienced specialist physician, and I can't follow the logic.  Can you?  

Interestingly, the article authors did find a physician who can make use of this data; only he no longer practices medicine.  They quote a physician turned venture capitalist, Bob Kocher, who says "This is actually the most useful dataset that Medicare has ever released."  They also note that Dr. Kocher formally served in the Obama administration before parlaying his political influence into a plum job.  Now Dr. Kocher diagnoses more lucrative ways to make a living rather than treating patients.  What irony in the authors' choice to support their narrative of the corrupt physician (and to be clear, I do not, at all, fault any enterprising physician who elects to leave medicine to purposefully pursue a profit)!  Dr. Kocher is correct in one important respect -- this will be the most useful dataset ever released by Medicare for health insurers and for industry who can then use this data to select out specific physicians for their proclivity to perform procedures.  For example, the pharmaceutical company that makes a drug or device that is delivered via joint injection would love to know that I perform twice the number of joint injections compared to Dr. Smith down the street -- much easier to target their marketing directly to me!

NY Times columnists Abelson and Cohen paint a decidedly grim picture of the financial practices of American physicians who participate in Medicare.  They go on to relate, per a NY Times analysis of the data, that "about 2 percent of doctors account for about $15 billion in Medicare payments, roughly a quarter of the total."  The article notes that "the American Medical Association and others have blocked the release of information (for decades)."  How incredibly devious and unscrupulous of these medical-mafioso!  How the plot thickens as we see that it is not only individual doctors but also organized medicine is 'on-the-take.'

This, in truth, is a precautionary tale of misguided though perhaps well-intended persons of influence (i.e. government and the media) who have it all wrong, but have the influence to widely spread a fallacy and in so doing generate strong negative popular opinions about the individuals sworn to uphold our nation's health.  Go ahead, hate your doctor(s).  And when your doctor decides to turn in his stethoscope for a consulting job or a stockbroker license, be sure to ingratiate yourself with your new care provider, likely a physician assistant or nurse practitioner, because it's going to be hard to get an appointment , and they work on the clock!

Go ahead and make this government financial data transparent.  I'm very comfortable with financial transparency.  (I've cut and pasted my personal data below for all readers)

And so, while we know the villain, the heroes in this story include, "fraud investigators, health insurance plans, researchers," and of course, the NY Times -- they will "spend weeks poring over the information about how many tests were ordered and procedures performed for every provider who received Medicare payments under Part B."  They've clearly figured out the conundrum of skyrocketing healthcare costs.  It was the doctors all along!  Uh, no.  Physician earnings do represent a significant piece of total healthcare costs.  But this piece is approximately 8% of total healthcare costs in the USA (see http://lakewass.blogspot.mx/2014/02/meet-expert-brian-white-do-particular.html for a more detailed discussion) -- a significant sum of money, yet even if we eliminated all payments to physicians, clearly we would make little progress in controlling overall costs.

And think about how backwards it is that physician compensation makes up such a SMALL piece of healthcare spending.  We should pay our physicians handsomely, particularly those that provide exceptional care.  In many other areas of life we are more than willing to pay top dollar for the best services or items.  For example, Nordstrom's has built their business around providing the very best customer service experience in their industry -- their prices are higher than Macy's and JC Penny, yet discriminating customers are more than willing to pay extra because they trust in Nordstrom's satisfaction guarantee and fabulous return policy.  I know that when it comes to a dining, hotel, or other hospitality experience, I prize excellent service above all else.  I will pay a premium for excellent service.   

I just had the good fortune of spending several days at a resort in Mexico, Las Ventanas Al Paraiso (LVP).  The staff essentially redefined for me and my wife the notion of "5 Star Customer Service."  Our previous experiences with top notch hospitality service were at the hands of the Ritz Carlton and the Four Seasons.  But the LVP team sets the gold standard.  They are always professional, deliberate in their service, and they clearly take pride in everything they do, from setting your lounge chair in the shade, to expertly preparing your turn down service which includes, as you desire, a warm drawn jacuzzi bath.  The embody hospitality in its truest form.  The word, "no," seems not in their lexicon.  A frown may appear across the face of an LVP team member only in the event they cannot fulfill a promise or satisfy the whim of a guest.  When our romantic custom beach-side theater DVD movie event hit a glitch (the last 30 mins of the movie wouldn't play), the team worked hard to find an immediate solution, and when they couldn't, they apologized profusely for days, and then surprised us with an in-room theater with an HD projector, bottle of champagne, and all the popcorn, candy, and chocolates that one could wish for.  They constantly are checking in; for example, if you desire a shaded lounge chair, the pool attendant literally follows the sun for you, making regular adjustments to your shade-providing umbrella.  They run, not walk, to provide assistance when you make a solo attempt to adjust the angle of the head of your lounge chair.  The LVP staff, on the whole, behaves as if every team member is an owner of the business.

We need medical doctors who focus on patients, not healthcare systems.  

And so how does this freshly available Medicare financial data relate to your healthcare goals?  Now you know.

Results: 1 health care provider named “Hyman” in 98004

Garrett Hyman                                                                         tOTAL REIMBURSED

1632 116th Ave Ne, Bellevue, WA                                          BY MEDICARE IN 2012

Physical Medicine and Rehabilitation                                        $61,801

SERVICE	PATIENTS	TIMES PERFORMED	AVG. BILLED	AVG. REIMBURSED
Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint,...	18	30	$195	$57
Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance...	27	34	$660	$111
Moderate sedation services (other than those services described by codes 00100-01999) provided by...	23	30	$175	$25
Motor nerve conduction test	26	93	$125	$57
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with...	18	19	$315	$77
Office or other outpatient visit for the evaluation and management of a new patient, which...	39	39	$220	$90
Office or other outpatient visit for the evaluation and management of a new patient, which...	73	73	$320	$136
Office or other outpatient visit for the evaluation and management of an established patient,...	61	80	$155	$60
Office or other outpatient visit for the evaluation and management of an established patient,...	91	170	$200	$89
Sense nerve conduction test	26	147	$125	$51
Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization...	20	31	$325	$180
Ultrasound, extremity, nonvascular, real-time with image documentation; complete	19	21	$275	$110

Source: The information presented here is from a database released by the Centers for Medicare and Medicaid Services. The database excluded, for privacy reasons, any procedures that a doctor performed on 11 or fewer patients. The total reimbursements for each doctor does not include those procedures either. Results shown above include only the individuals like doctors, nurses or technicians but not organizations like Walgreens. While some providers could have multiple offices, the address shown is the main address indicated in the database. Descriptions of the procedures are from the American Medical Association.© 2014 The New York Times Company

Benefits of Owning a Dog!

There's a fantastic article in today's NY Times about the benefits of owning a dog:

http://well.blogs.nytimes.com/2014/04/07/life-with-a-dog-you-meet-people/?_php=true&_type=blogs&_r=0

"Studies of the health ramifications have strongly suggested that pets, particularly dogs, can foster cardiovascular health, resistance to stress, social connectivity and enhanced longevity."

LWSS believes in the benefits of having a canine companion!  If you have been to our office, chances are you encountered Nala, Wynnie or saw Bucky's pictures in Dr. Chimes' exam rooms.  There's something about these furry friends that simply improves life :).

The story of "low fat" diets,and how medical evidence is influenced by politics

Interesting story in NPR about low fat diets, and emerging evidence that they may ultimately be harmful

The story is interesting in of itself, and I agree with the main premise- diets low in fat and high in processed carbohydrates are unhealthy, and healthy fats SHOULD be part of most people's diets.

I am in many ways more interested in a second story here- the way medical evidence is used, and the politics that lead to medical "same think" and prevents implementation of new information.  As was noted in the article, Walter Willett (Chair of Nutrition at Harvard) was concerned that the classic food pyramid (with a focus on high carbohydrates and low fat) was misguided, but had trouble publicizing concerns because of political factors.

Why is this important?  Because one of the assumptions of the ACA (Affordable Care Act, aka Obamacare) is that we already know what we need to know, and what we need to focus on is have physicians cede their judgment and rely more and more on evidence-based guidelines.  This is a mistake.

The great baseball writer Bill James, on his wonderful website Bill James Online in the "Hey Bill" section, had a great recent commentary on the dangers of assuming we already know everything we are going to know:

"I remember my Grade School principal, who attended college just after World War I, told us that when he studied chemistry in college, his professor told the class that they were studying science at the right time, because all the important discoveries had been made now; everything important that was going to be known was known, now, so it was a good time to study science. He told us this, of course, to point out the absurdity of assuming that the search for knowledge is ever finished. . . .. . When Perry Miller was in graduate school at the University of Chicago, late 1920s, he told his advisor that he wanted to study the Puritans. The advisor told him that the Puritans had been studied to death, everything that could be known about them was already known, and he should choose some other subject to work on. He got a different advisor, and stuck with the Puritans. He spent most of his career studying the Puritans, and became one of the greatest historians of the 20th century. He had dozens of protégés over the years, and many of THEM spent THEIR careers studying the Puritans, and many of them went on to distinguished careers, studying the Puritans. . . .. .. Again, the inherent absurdity of suggesting that a field of knowledge is ever "finished". No field of knowledge is ever finished. The intellectual understands that, and accepts it. It's Black Letter Law. A college undergraduate in Physics is allowed to challenge Einstein--if he has argument to make. . . . .. .. It isn't that way, in the rest of the world, and I have spent my career battling this. . ..this turgid, anti-intellectual assumption that everything worth knowing is already known. The non-intellectual world assumes that knowledge is the property of experts, that people who are not experts are not allowed to challenge the experts, but can only learn from them. When I started writing about baseball, I was the undergraduate in Physics who was challenging Einstein; not Einstein, but Casey Stengel, Sparky Anderson, Dick Young and the Elias Charitable Foundation. In the minds of many people I HAD to be wrong, because these other people were the experts, and I hadn't even played the game, so of course I couldn't be right and the experts wrong. I still get the same argument today, in a different form; people will tell me that the advantage inherent in sabermetrics has played itself out now. Everybody knows these things, so the advantage that WAS there, in the Moneyball era, has evaporated. Same argument; everything is known now; shut up and let us go about our business. The gentleman had forgotten this Black Letter Law, and had lapsed into the assertion that I shouldn't offer a novel theory about this, because. . .well, this has been studied; everything worthwhile is known about it. I didn't want to bust his balls about it; I assumed that he would be embarrassed if I pointed out to him what he was saying, so I tried to say it in the gentlest way I could, saying that I would be surprised if any historian were to make that argument. . .. .. .... ...You, on the other hand, I will bust your balls. Pay more attention in class, kid. If you were half as smart as you think you are, I wouldn't have had to explain this to you."

Meet the Experts: Eric Wisotzky

Meet the Experts: Eric Wisotzky

Gary: For our next feature, we are highlighting Eric Wisotzky, a rising star in the world of PM&R.  Eric is a national leader in the emerging field of Cancer Rehabilitation, and has an interesting background that includes time in the military, and leadership work in education.

Eric and I met one another through the world of resident education.  For several years, I ran the Resident and Fellow Workshop at the annual meeting for the Association of Academic Physiatrists.  My co-coordinator Chris Visco was Eric's residency mentor, and Chris praised Eric so highly that Eric became the first resident to serve as a teacher at the workshop.  Several years later, when Chris and I were planning our succession, Eric was a clear choice to take over the workshop, which he now leads along with James Wyss.

Let's start there by way of introduction.  Eric, can you tell us about your love of resident and fellow education?

Eric: I personally felt that many of my educational experiences, especially as a medical student, left a lot to be desired.  As a medical student, I clearly recall times when I said to myself, “It will be my mission to ensure that future students have a better educational experience than mine.”  In that regard, I try to make the educational experiences of my medical students and residents as academic and as fun as possible.  I personally believe that the academic factor and fun factor are equally important and will lead to the most effective learning environment.

Gary: Interesting.  I think that rings true- much of my motivation to become a teacher was, like yours, rooted in less than satisfying experiences as a student.  Similarly, I find that many of my motivations as a physician are rooted in less than satisfying experiences as a patient. 

How do you feel your love of resident and fellow education carries over into your interactions with patients?

Eric:  I feel that the teaching environment that I work in greatly enhances my patient care.  My patients generally enjoy interacting with my residents.  I’m surprised at the number of times patients disappointedly ask me on follow-up visits, “Where is your resident?” if I do not have one with me that day.  I learn a ton from my residents.  They learn from other doctors that may use different approaches and my residents will often say, “Dr so-and-so likes to do this in this situation.”  I consider myself fairly open minded.  I don’t mind when the resident brings up other suggestions and I often learn new approaches this way.  I strongly believe that as supervising physicians, we need to remember that we are not necessarily smarter than our med students and residents, we are simply more experienced.  I feel that not utilizing the brainpower that a student or resident brings to the table is a lost opportunity for patient care.

Gary: Seguing into communication, one of my favorite things about you is how good it feels to talk to you.  I've noticed a few strengths in your communication style- you project warmth, but you also clearly reflect with detail that makes it apparent that you've heard the content of my message.  Two questions for you.  First, is that consistent with how you view yourself as a communicator, and second, is that something that comes natural to you, or is that something you've cultivated over time?

Eric: Yes, I do view myself as a good communicator.  It is something I pride myself upon.  I get such great pleasure out of seeing the understanding on a patient’s face when I explain their medical condition to them.  It is really gratifying when a patient says, “Oh, I never understood what was going on with my body until now.”   I never really understood why some doctors have such a difficult time not speaking medical jargon to patients.  The way I always think of it is that non-medical speak was my first language.  I learned “medical language” later in life.  Therefore, I still think it’s a lot easier for me to explain a patient’s medical condition in laymen’s terms, because the laymen’s terms are my “first language”.

I would like to think that I am very attuned to my strengths and weaknesses.  I am very self critical so I feel very aware of what I need to improve upon.  I know communication is a strength of mine.  I cannot say that I have cultivated it, for whatever reason it has come naturally to me.

Gary: Can you talk more about your military background, and how that has shaped the way you view medicine and communication?

Eric:  I was in the United States Navy for 5 years, 3 of which I served as a flight surgeon.  This essentially means that I was the primary care physician for a group of military aviators.  I took care of a C-130 squadron and had the opportunity to travel the world with them.  My military experience was the most important contributor to my professional development.  Before I worked in the military, my professionalism needed a lot of work.  I learned great leadership skills in the Navy.  My experience in the military makes it harder for me to deal with the managed care system now, because in the military you generally can do whatever you feel is the right treatment for that patient. 

  

Gary: Another thing I've admired about you is your willingness to invest yourself in a career that most people do not know much about.  Can you explain what cancer rehabilitation is?

Eric: Cancer and cancer treatments can really wipe people out.  A huge percentage of cancer patients are healthy and feel good when they are diagnosed with cancer.  It’s not until after they are treated that they become fatigued, deconditioned, and have pain and balance problems, amongst other issues.  Rehabilitation is a standard part of treatment for people who have strokes or brain injuries.  However, historically we have not rehabilitated cancer patients despite major changes in their functional status after cancer treatment.  Cancer rehabilitation aims to bring patients back to their baseline function after battling cancer.

Gary: I am sure a common question you hear is "why do I need a cancer PM&R physician, when I already have an oncologist?"  Shed some light.

Eric: In my mind, this question is like asking, “why do I need a hairdresser when I already have a plumber?”  The skill sets and training of an oncologist and a PM&R physician are very different.  Oncologists are fantastic at treating cancer.  We know this because patients with cancer are living longer and longer.  In the system I work in, the oncologists love working with me, because I help the oncologists do what they do best – treat cancer.  Rather than the oncologists having to spend tons of time trying to manage all the functional side effects of treatment, they can put those issues in my hands.  While most oncologists get some training and experience in managing functional side effects, in general they are not very good at it.  I’m not putting them down in any way, it is just not what they are trained to do.  The oncologists I work closely with agree with this point.  That’s why they love sending patients to me.  They can spend more time with the patient talking about cancer.  I can spend lots of time with the patient talking about their function.  The patients go back to the oncologist and thank them for referring them to me.  Everyone is happy.

Gary:  That's such an important message.  Can you talk a bit more about the role of exercise for patients with cancer? 

Eric: Exercise is a booming area in cancer care.  The body of evidence that demonstrates that exercise can decrease the risk of cancer recurrence is overwhelming at this point.  Studies have shown that exercise can reduce the risk of cancer recurrence just as well as hormone medications such as tamoxifen.  Many experts believe that in the future, all cancer treatment protocols will include exercise, such as: “surgery, chemotherapy, radiation, exercise”.  At this point, any oncologist who is not recommending exercise for their cancer patient, unless there is an obvious contraindication, is doing their patient a major disservice.

  

Gary: In particular, can you talk more about risk of fractures in cancer patients?  I find that many oncologists are so concerned about patients falling and breaking a bone, that they discourage their patients from exercise out of a sense of fear.

Eric: Most cancer patients are not at high risk for fracture.  If cancer has spread to bone, there is a potential risk for fracture.  Scales exist that can help predict the risk for fracture.  If the risk truly is high, often surgery will be recommended to fix the bone before it fractures.  This is because it is safer and easier to fix a bone before it fractures than after it fractures.  For patients with cancer in their bones who are not at high risk for fracture, exercise should be encouraged.  Pain is a great guide.  If a certain exercise causes pain in the area of bony cancer, that exercise should be avoided.  If it does not cause pain, the patient can keep going!  One important additional factor to consider is the patient’s balance.  Chemotherapy can affect nerves, which can impact balance.  If a patient’s balance is considerably affected, then they may be at higher risk of falls and fractures.  This is something that a PM&R specialist can assess and help manage.

Gary: Even amongst the small world of cancer PM&R specialists, you are even more specialized in your usage of ultrasound as a tool to help patients.  Can you tell us more about how ultrasound helps you with your patients? 

Eric: In general, my use of ultrasound is no different than any other musculoskeletalmedicine physician.  It is common for me to see breast cancer patients with rotator cuff tendon problems.  Ultrasound is so useful to characterize these problems in the office.  It is certainly useful to help in performing accurate injections. 

More specifically to the cancer population, I have started performing some less commonly performed nerve injections using ultrasound.  For example, it is very common for breast cancer patients to have pain in the armpit area after lymph nodes are removed.  I never really understood why until I learned my surgical anatomy.  There is a nerve in that area called the intercostobrachial nerve that causes this pain.  I studied the anesthesia literature which helped me learn how to perform an ultrasound-guided injection to block pain from this nerve.  This technique has been very helpful for my patients. 

Another example is in head and neck cancer patients (who badly need rehabilitation).  There is a nerve in the neck that can be affected by surgery and radiation called the greater auricular nerve.  If injured, it can cause severe ear pain.  When I first started seeing these patients with ear pain, I did not know how to explain it.  However, after studying my anatomy, I realized this nerve was the culprit.  I learned how ultrasound can help me inject around this nerve to decrease pain.  So, while I clearly do not need ultrasound to help all of my patients, it can be a very helpful tool for certain patients.

Gary: The more I talk to you, it makes me wish we were in the same region.  So many patients would benefit from your care!  For physicians like my partner Garrett and I, what we can we do to help our patients who have cancer?  In particular, I have some patients who I have already been seeing for other conditions, who then develop cancer.  How can I best be their advocate?

Eric: It is important to think about the pre-existing musculoskeletal, neuromuscular, and functional issues that your patient already has and how they may be affected by cancer.  If your patient has shoulder issues, they most likely will worsen after a breast cancer diagnosis without rehabilitation.  If your patient has a nerve issue, this most likely will worsen if your patient is treated with chemotherapy.  If your patient has difficulty walking, this can worsen after cancer treatments.  The good cancer rehab doctor will try to preempt functional loss that can occur during the trials and tribulations of cancer treatment.

The basic principles of what a cancer PM&R physician does are minimally different from what most PM&R physicians do.  In general, most physiatrists can take great care of these patients.  However, I do believe there are some subtleties to caring for cancer patients.  The first thing that really helps is having a decent understanding of cancer treatments.  You don’t have to be an oncologist, but having a basic understanding of the treatments helps me understand what has happened to my patient’s bodies and how their function has been affected.  Secondly, I think there are few little tricks I know that seem to work well for cancer patients.  I believe going to a cancer rehabilitation symposium like Sloan-Kettering’s annual symposium is a great way to learn some of these tricks.  Also, we should be pushing our national leaders to include cancer rehabilitation lectures at our national meetings.

Gary: Eric, thanks again for this interview.  I sincerely feel that you are one of those people who always brings something positive to the table, and never leaves anything negative.  Thanks for making the world a better place