The Health-Care System [from the more insurance advance system]

The Health-Care System Is So Broken, It’s Time for Doctors to Strike

http://www.thedailybeast.com/articles/2014/04/29/the-health-care-system-is-so-broken-it-s-time-for-doctors-to-strike.html
By Daniela Drake

Doctors are miserable, patients are miserable, and there’s no end in sight. It’s time to revamp the health-care system from the ground up—starting with primary care.

Dr. Zubin Damania thinks physicians should go on strike. “Physicians go into medicine with the best intentions,” Damania said, “and then we find ourselves working in a system that’s abhorrent to us. But if we rose up together, this broken system wouldn’t stand long.”

Dr. Damania, founder of an innovative medical center in Las Vegas called Turntable Health, believes that the health-care system is so broken—and the proposed fixes so feeble—that doctors need to take matters into their own hands. “Practicing doctors on the front lines are the ones with the most skin in the game,” he told The Daily Beast. “We can make changes that work. No one wants it more than we do.”

What he means by “practicing physicians” is that they aren’t also consultants, insurance executives, policy experts, medical leadership, media doctors, or academics—the so-called “thought leaders.” Instead, the revolution must be led by over-worked, over-burdened, quasi-burnt-out physicians—82% of whom feel powerless to influence the profession.

It may not be as impossible as it sounds. Motivating demoralized doctors is something that Dr. Pamela Wible, a family physician in Oregon, has some experience with. As she describes in her Tedx talk, she was once so miserable as an employed physician that she went on strike, refusing to work in a place that didn’t give patients the time they needed.

A few months later, she opened her own practice. “It was simple. I went to my community to find out what they wanted in health care. I held nine town hall meetings,” Dr. Wible told The Daily Beast. “They wanted less technology and more humanity. I ended up creating an ideal clinic designed by my patients.” Her trick? She keeps her overhead so low she doesn’t even have any staff. That was nine years ago, and she’s still going strong.

Dr. Wible is part of the Ideal Medical Practice movement—with over 500 clinics across the country— that minimizes costs so doctors can spend time with patients, not paperwork. The goal is the happiness of both patient andphysician.  “Doctors are happiest taking care of patients,” Wible said. “When we love our work, we give the best care.”

For last three years she’s been hosting affordableworkshops to teach doctors how to open their own Ideal clinics. “At first doctors don’t believe they can do it, because they feel so powerless,” Wible explained. “By the time they leave, they have a vision and a plan. Some quit their jobs and open Ideal clinics a few months later.”

When asked if doctors should go on strike, Wible responded, “By boycotting inhumane workplaces… we free ourselves to be healers again. I’ve been practicing medicine this way for a decade. Imagine if all doctors did the same.”

But to get physicians to see they aren’t powerless, Dr. Wible believes they first need to be healed. So she hosts her workshops at a tranquil, forested retreat. “The trauma we experience in medicine so often disconnects us from our heart and soul,” she said. “When doctors lose connection with their purpose, some cope by becoming money-focused, power-hungry—some prey on other physicians.  But many become silenced, helpless victims.”

That sense of powerlessness is something that Dr. Damania can relate to. He was a hospitalist at Stanford University Medical Center in what “became a soul-crushing, lather-rinse-repeat” cycle of hospital medicine. Likening doctors to the “the undead” in his TedMed talk, “Are Zombie Doctors Taking Over America?,” he described himself as “a disconnected, burnt-out zombie with a stethoscope.”

So, in an act of rebellion, while still at Stanford, Damania began posting Youtube videos as ZDoggMD.  In a twist of events, his videos caught the eye of Zappos CEO Tony Hsieh. “Tony thought I was losing my mind,” Damania said, “but he thought maybe I was just nuts enough to come up with something out-of-the-box for health care.” So Hsieh hired Damania to create a health-care program for Las Vegas, where Hsieh has a downtown redevelopment project.

As a hospitalist, Damania thought a lot about why patients ended up in the emergency room. It wasn’t that the excellent Stanford community physicians needing to do more training, clicking, or charting. In fact, the breakdown stemmed from too much of that stuff. “Clinicians know best how to help their patients,” he said. “Anything that interferes with that relationship is part of the problem.”

The conclusion? Damania realized that traditional models of health insurance simply have no place in primary care.

Indeed, more than a decade ago, practicing physicians around the country had already figured that out. They developed a model called Direct Primary Care that charges a monthly membership fee—usually $50 to $100—so that doctors can focus on taking care of patients, not billing insurance—which can actually be a lotcheaper for patients.

Damania partnered with the direct-care group Iora Health in Massachusetts, which utilizes a nimble electronic medical record (EMR) designed by their own practicing physicians that allows patients to write in their charts—and tracks patients who need close follow-up. With less overhead, Iora provides preventive services that might be considered luxuries: health coaches, support groups for anxiety and depression management, alternative care like acupuncture, and classes in tai chi, cooking, and meditation. Understandably, patient satisfaction is high.

As a bonus for doctors, there are no ICD-9 codes to worry about. No worry thatMedicare will demand repayment. No threat of audits or accusations of fraud. No time wasted documenting irrelevancies. No administrator coming down from the fifth floor to demand increased productivity from a doctor who just coached a scared 18-year-old through her first Pap smear.

“For me, Turntable was more a mission to save providers than anything else. To give them a space where they’re free to practice in the way they always wished they could—and we have great outcomes,” Damania said. “I believe it’s because doctors can bring their innate passion to the job every day—they’re empowered here.”

Not surprisingly, direct-care groups are expanding across the country. And, like many other doctors, Damania believes direct care is the only way to fix primary care. “If we radically restructure primary care,” he said, “we’ll end up reforming the whole medical system from the ground up.”

“Trying to patch the current system is preposterous and destined for failure,” said Dr. Damania. “I always say you can’t polish a turd. That’s what most pundits and consultants are trying to do: hence the advent of the Accountable Care Organization (ACO) and ‘patient centered medical home’ constructs. These do nothing to address the culture. They simply impose more restrictions, mandates, and parameters on dangerously stretched physicians.”

But many careful observers believe that “dangerously stretched physicians” are actually what some people want. After all, dangerously stretched physicians can’t connect well with patients—hence the booming industry of patient satisfaction scores. Dangerously stretched physicians can’t keep up with the literature—hence the need for more frequent physician testing.  Dangerously stretched physiciansmake mistakes, which perpetually empowers those who string doctors up on the iron rack of contingencies in the first place.

What’s more, dangerously stretched physicians can’t refute the pernicious notion that patients want to be customers. “People don’t want a business transaction with their doctor,” said Dr. Wible. “They want to be patients again—they want that sacred relationship back.”

Fed-up doctors want that too—and many have begun to reclaim the covenant between doctor and patient. One doctor started a direct-care clinic and wrote an article titled A Year Into Direct Pay: It Doesn’t Suck to be a Doctor Anymore. Another started an “Ideal Clinic” in New York where volunteers help her do the billing. Physicians started humane direct-care groups, like Iora Health andQliance, that are now attracting investor dollars and expanding.

Dr. Damania sees a seismic shift coming. “Physicians need to see that doctors all over the country are beginning to flip the script—we aren’t powerless,” he said. “I’m really hopeful. I think we can fix this thing.”

A Doctor's Declaration of Independence

http://online.wsj.com/news/articles/SB10001424052702304279904579518273176775310?mod=trending_now_2

By  

DANIEL F. CRAVIOTTO JR.

It's time to defy health-care mandates issued by bureaucrats not in the healing profession.

In my 23 years as a practicing physician, I've learned that the only thing that matters is the doctor-patient relationship. How we interact and treat our patients is the practice of medicine. I acknowledge that there is a problem with the rising cost of health care, but there is also a problem when the individual physician in the trenches does not have a voice in the debate and is being told what to do and how to do it.

As a group, the nearly 880,000 licensed physicians in the U.S. are, for the most part, well-intentioned. We strive to do our best even while we sometimes contend with unrealistic expectations. The demands are great, and many of our families pay a huge price for our not being around. We do the things we do because it is right and our patients expect us to.

So when do we say damn the mandates and requirements from bureaucrats who are not in the healing profession? When do we stand up and say we are not going to take it any more?

The Centers for Medicare and Medicaid Services dictates that we must use an electronic health record (EHR) or be penalized with lower reimbursements in the future. There are "meaningful use" criteria whereby the Centers for Medicare and Medicaid Services tells us as physicians what we need to include in the electronic health record or we will not be subsidized the cost of converting to the electronic system and we will be penalized by lower reimbursements. Across the country, doctors waste precious time filling in unnecessary electronic-record fields just to satisfy a regulatory measure. I personally spend two hours a day dictating and documenting electronic health records just so I can be paid and not face a government audit. Is that the best use of time for a highly trained surgical specialist?

This is not a unique complaint. A study commissioned by the American Medical Association last year and conducted by the RAND Corp. found that "Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction."

In addition to the burden of mandated electronic-record entry, doctors also face board recertification in the various medical specialties that has become time-consuming, expensive, imposing and a convenient method for our specialty societies and boards to make money.

Meanwhile, our Medicare and Medicaid reimbursements have significantly declined, let alone kept up with inflation. In orthopedic surgery, for example, Medicare reimbursement for a total knee replacement decreased by about 68% between 1992 and 2010, based on the value of 1992 dollars. How can this be? Don't doctors have control over what they charge for their services? For the most part, no. Our medical documentation is pored over and insurers and government then determine the appropriate level of reimbursement.

I don't know about other physicians but I am tired—tired of the mandates, tired of outside interference, tired of anything that unnecessarily interferes with the way I practice medicine. No other profession would put up with this kind of scrutiny and coercion from outside forces. The legal profession would not. The labor unions would not. We as physicians continue to plod along and take care of our patients while those on the outside continue to intrude and interfere with the practice of medicine.

We could change the paradigm. We could as a group elect not to take any insurance, not to accept Medicare—many doctors are already taking these steps—and not to roll over time and time again. We have let nearly everyone trespass on the practice of medicine. Are we better for it? Has it improved quality? Do we have more of a voice at the table or less? Are we as physicians happier or more disgruntled then two years ago? Five years ago? Ten years ago?

At 58, I'll likely be retired in 10 years along with most physicians of my generation. Once we're gone, who will speak up for our profession and the individual physician in the trenches? The politicians? Our medical societies? Our hospital administrators? I think not. Now is the time for physicians to say enough is enough.

Dr. Craviotto is an orthopedic surgeon in Santa Barbara, Calif., and a fellow of the American Academy of Orthopedic Surgeons.