Who Should Control Healthcare?

The American Academy of Emergency Medicine (AAEM) is urging stiffer enforcement of decades-old statutes that prohibit the ownership of medical practices by corporations not owned by licensed doctors (1). These century-old laws and regulations were meant to fight the commercialization of medicine, maintain the independence of physicians, and prioritize the doctor-patient relationship over the interests of investors and shareholders (2). Thirty-three states (click to see list of states that prohibit corporate ownership) plus the District of Columbia have rules on their books against the so-called corporate practice of medicine. In Arizona ownership by nonprofit entities is permitted, however as most of us know, nonprofit healthcare organizations are nonprofit in name only. Furthermore, over the years, companies have successfully sidestepped bans on owning medical practices by buying or establishing local staffing groups that are nominally owned by doctors and restricting the physicians so they have no direct control.

Those campaigning for stiffer enforcement of the laws say that physician-staffing firms owned by private equity investors are the guiltiest offenders. Private equity-backed staffing companies manage a quarter of the nation’s emergency rooms (2). The two largest are Nashville-based Envision Healthcare, owned by investment giant KKR & Co., and Knoxville-based TeamHealth, owned by Blackstone. Court filings in multiple states, including California, Missouri, Texas, and Tennessee, have called out Envision and TeamHealth for allegedly using doctor groups as straw men to sidestep corporate practice laws (2).

Physicians and consumer advocates around the country are anticipating a California lawsuit against Envision. The trial is scheduled to start in January 2024 in Federal court. The case involves Placentia-Linda Hospital in northern Orange County, where the plaintiff physician group lost its ER management contract to Envision. The complaint  by Milwaukee-based American Academy of Emergency Medicine Physician Group alleges that Envision uses the same business model at numerous hospitals around the Nation. Furthermore, the complaint alleges that Envision uses shell business structures to retain de facto ownership of ER staffing groups, and it is asking the court to declare them illegal. “We’re not asking them to pay money, and we will not accept being paid to drop the case,” said David Millstein, lead attorney for the plaintiff. “We are simply asking the court to ban this practice model.” Although Envision filed for Chapter 11 bankruptcy, AAEM has vowed to pursue the lawsuit (3,4).

The plaintiff — along with many doctors, nurses and consumer advocates, as well as some lawmakers — hopes that success in the case will spur regulators and prosecutors in other states to take corporate medicine prohibitions more seriously. The corporate practice of medicine has “a very interesting and not a very flattering history” said Barak Richman, a law professor at Duke University (2). This is a gross understatement in my opinion. The physicians, nurses, and technicians are not responsible for poorer care at higher prices that we now see. Businessmen are responsible by squeezing caregivers and patients for every penny, a practice some call “hyperfinancialization”(5). It is not surprising charging as much as possible while delivering minimal care has evolved. Businessmen in healthcare maximize profits in these situations, especially when they can avoid any responsibility for the healthcare delivered. Rather, a system of “quality assurance” has evolved which is more concerned with controlling caregivers than quality (6).

If not businessmen, then who should control healthcare? Doctors are alleged to be poor businessmen. If by this it is meant that physicians are more likely to try and deliver the best healthcare at the best price rather than bill the maximum for minimal care, I would hope most of physicians would plead guilty. Most physicians are concerned about delivering quality healthcare at reasonable prices. I suspect that the rumor that doctors are poor businessmen was started by business interests for their own financial gratification.

Not all doctors are qualified to lead healthcare. Some are straw managers which will do whatever their business supervisors tell them to do. Physician leaders practicing medical administration should be held to the same high standards that doctors are held in care of patients. Therefore, some degree of local control must be kept. Those of us who advocate for better healthcare can hope the courts enforce existing laws where applicable. We also need to take action in supporting each other for the good of medicine and the health of our patients. However, we also need to do a better job policing ourselves. Those ordering unnecessary or questionable diagnostic testing or treatments need to be called out. If successful, the Envision Case could prompt legislators, regulators and prosecutors in other states to focus attention on clinical practice of medicine prohibitions in their own states and take up arms against potential violations or reinvigorate prohibitions of clinical practice with new legislation and/or regulation.

Richard A. Robbins MD

Editor, SWJPCCS

References

1. American Academy of Emergency Medicine. Emergency Medicine and the Physician Practice Management Industry: History, Overview, and Current Problems. Available at: https://www.aaem.org/publications/key-issues/corporate-practice/emergency-medicine-and-the-physician-practice-management-industry-history-overview-and-current-problems/ (accessed 8/23/23).
2. Wolfson B. ER Doctors Call Private Equity Staffing Practices Illegal, Seek to Ban Them. Kaiser Health News. December 22, 2022. Available at: https://www.virginiamercury.com/author/kaiser-health-news/ (accessed 8/23/23).
3. Condon A, Thomas N. From private equity to bankruptcy: Envision's last 5 years. May 18, 2023. Available at: https://www.beckershospitalreview.com/finance/from-private-equity-to-bankruptcy-envisions-last-5-years.html (accessed 8/23/23).
4. Holland & Knight Law. Federal Bankruptcy Court Stays Envision Healthcare Litigation in California. August 3, 2023. Available at: https://www.hklaw.com/en/insights/publications/2023/08/federal-bankruptcy-court-stays-envision-healthcare-litigation (accessed 8/23/23).
5. Robbins RA. Who are the medically poor and who will care for them? Southwest J Pulm Crit Care. 2019;19(6):158-62. [CrossRef]
6. Robbins RA. The Potential Dangers of Quality Assurance, Physician Credentialing and Solutions for Their Improvement. Southwest J Pulm Crit Care Sleep. 2022;25(4):52-58. [CrossRef]

Cite as: Robbins RA. Who Should Control Healthcare? Southwest J Pulm Crit Care Sleep. 2023;27(3):33-35. doi: https://doi.org/10.13175/swjpccs039-23 PDF

Book Review: One Hundred Prayers: God's answer to prayer in a COVID ICU

By Anthony Eckshar MD

One Hundred Prayers: God's answer to prayer in a Covid ICU
amazon.com

The book is a very moving and spell-binding collection of the encounters between patients and physicians during the worst of the COVID-19 epidemic and Dr. Eckshar’s prayers for each of them. A devout person can read this as a prayer devotional; however, it is much more - an authentic account of what doctors and nurses go through working in the ICU. This book might help encourage people who are searching for faith, especially those who face severe illnesses in themselves or a loved one. It may also encourage doctors, nurses and other healthcare workers who might have been burned out working during the pandemic. Its main message is that faith, compassion, and the scientific method must co-exist. It is also a great review of the history of COVID pandemic from the trenches of patient care in the ICU. For nonmedical people it  should provide a clue to how doctors and nurses think. Hopefully, this book will lift everyone up and instill deep admiration and respect for the ICU doctors and nurses, and perhaps teach you a little something about faith.

Richard A. Robbins MD

Editor, SWJPCCS

Cite as: Robbins RA. Book Review: One Hundred Prayers: God's answer to prayer in a Covid ICU. Sodsuthwest J Pulm Crit Care Sleep. 2023;27(1):14. doi: https://doi.org/10.13175/swjpccs032-23 PDF

How Much Should Healthcare CEO’s, Physicians and Nurses Be Paid?

In 2019 the Southwest Journal published an editorial that stated one cause for the rising costs in healthcare was chief executive officer (CEO) compensation (1). Based on 2017 salaries, Peter Fine from Banner Health was the highest paid healthcare CEO in the country with compensation of $25.5 million. In comparison, the CEO of Mayo Clinic Arizona was paid a paltry $1.8 million (2). We decided to do a follow-up, and found that after a dip during the first year of the COVID-19 pandemic, Mayo raises resumed in 2021. Mayo’s CEO, Dr. Gianrico Farrugia, was paid $3.48 million in 2021 up from $2.74 million in 2020 (3). Dr. Richard Gray, CEO of the Mayo Arizona campus, was paid $1.78 million in 2021, up 26% from the previous year. I shared these numbers with a couple of the Mayo Clinic faculty who were surprised by the amount of compensation their executives were receiving.

Mayo Clinic posted $1.2 billion in net operating income in 2021 (3). More recently, the system reported net operating income of $157 million for the third quarter of 2022 with an operating margin of 3.8 percent. Compensation for Mayo Clinic executives is set by the Mayo Clinic Salary & Benefits Committee and endorsed by the Mayo Clinic Board of Trustees Compensation Committee. Mayo claims not to be a profit-sharing institution and that pay is not linked to doing anything more or less for the patient than what is needed. It is unclear how CEO compensation in the millions fits with this patient care philosophy.

I did a preliminary survey of physicians in the Phoenix area of how much healthcare CEOs should be paid. Not surprisingly, most of these physicians thought that CEOs should be physicians like they are at the Mayo Clinic. Opinions on CEO compensation were all over the board. However, the best answer, in my opinion, came from a retired ID physician. He thought CEOs should be well compensated but should be paid less than senior physicians. His reasoning was that patients come to the Mayo Clinic or other healthcare organizations not because of the CEO, but because of Mayo’s physicians. Lawyers have this figured this out. One of my closest friends is an administrative partner for a large (over 100 lawyers) law firm in Phoenix. He said he is well compensated but paid less than his senior partners. The reasoning was much the same. Clients come not because of his administrative skills, but because of the lawyers. However, he was quick to point out that managing partners do deserve some compensation for their lost income in not practicing law. The compensation committee in these cases is the senior partners.

Some would argue that certain physicians are over-paid. I would agree. Current fee-for-service payment rates for physician visits trace back to the origins of Blue Cross Blue Shield (BC/BS) insurance in the 1930s. At that time, BC/BS rates were set to pay generously for hospitalizations and operations. Payments for so-called “cognitive services” were lower. In the 1960’s Medicare adopted the BC/BS payment model. This disparity has been perpetuated through “Relative Value Units”. Despite recognition by the Medicare Payment Advisory Commission (MedPAC) of the adverse effects of inadequate payment to some physicians, especially primary care, only limited progress has been made toward correction of the disparity (4). This may be due, at least in part, to treatment of total payment for physicians as a zero-sum game in which decision making is dominated by non–primary care physicians through mechanisms such as the Relative Value Scale Update Committee (RUC) (5). This translates to hospitals, procedure-oriented specialties, and especially some surgical subspecialties compensated in excess compared to more cognitive specialties.

When BC/BS was founded in 1929, one goal of the American healthcare Association (AHA) and the American College of Surgeons was to eliminate the “Doctor’s Hospitals”. These physician-run hospitals were sometimes substandard. However, little progress in eliminating them was made until establishment of Medicare and Medicaid in 1965. Many of the “Doctor’s Hospitals” did not meet criteria for Medicare certification. Lack of Medicare and Medicaid payments essentially closed their doors. However, the doctor run hospitals are now making a comeback through surgical centers. Although the AHA has questioned their quality, most have matched or exceeded the quality metrics used by the Joint Commission or other groups and often score better than hospitals in head-to-head comparisons (6). Doctors who run such centers deserve some payment for their administrative efforts.

Nurse practitioners (NPs) and physician assistants (PAs) serve a vital role in patient care. They deserve to be well paid. However, their education and responsibility are generally less than physicians. For example, 1000 clinical hours are required for nurse practitioner certification which represented about 10 weeks of my internship or about 13 weeks under the current 80-hour work week limit. Similarly, PAs are required to only complete 1600 hours of clinical training. In contrast, physicians complete family practice, internal medicine, or pediatric residencies which require a minimum of 3 years, with most subspecialities requiring an additional 3+ years. Surgical residencies are usually 5 years. Furthermore, there appears to me more risk assumed by a physician. In 2019 there were only 420 malpractice suits filed against nurse practitioners and PAs compared to over 20,000 total medical malpractice suits (7).

Nurses are the backbone of any healthcare organization. Although they usually have less education than physicians, NPs, or PAs, nursing is intense and stressful with nurses assuming a large responsibility and delivering the most beside care. Because patients are close at hand, nurses often make independent care decisions. In Arizona, nurse compensation averaged about $78,330 in 2019 (8). Not surprisingly it is considerably higher in California where the cost of living is higher compensation and averages $113,240. Recently, more nurses are working as traveling nurses, or filling a staffing shortage at a hospital or healthcare facility on a temporary basis. Prior to COVID-19 many nurses were dissatisfied with healthcare working conditions (8). This suggests that nurses may be seeking other employment options that provide them with more control over where and when they work (9). Travel nursing provides these options at a higher pay.

The causes of the overcompensation of CEOs at the expense of historically undercompensating some nurses and physicians have been salary and benefits committees set up under a corporate structure. Under the present system of healthcare governance an executive board appointed or heavily influenced by a CEO appoints a board which appoints a salary and benefits committee. The later committee in turn sets salary and benefits for the organization including the executives. A compensation committee consisting of physician and nursing leaders could more realistically evaluate an individual’s value to a healthcare organization. However, it seems likely that such a change will require mandates from healthcare certifying organizations. Healthcare executives are unlikely to readily relinquish the present system which has rewarded them so generously. Therefore, physicians need to lobby various organizations such as the Joint Commission, the Relative Value Scale Update Committee (RUC), ACGME, etc. for a compensation system which examines administrative efficiency and addresses areas of administrative complexity that add costs to the health care system without improving accessibility or value. This is in contrast to the present system of rewarding those who serve a for-profit corporate structure rather than improving healthcare in a not-for-profit system.

Richard A. Robbins MD

Editor, SWJPCCS

References

1. Robbins RA. CEO compensation-one reason healthcare costs so much. Southwest J Pulm Crit Care. 2019;19(2):76-8. [CrossRef]
2. Innes S. This Arizona nonprofit health system CEO topped the salary list at $25.5 million in 2017. Arizona Republic, October 23, 2019. Available at: https://pnhp.org/news/this-arizona-nonprofit-health-system-ceo-topped-the-salary-list-at-25-5-million-in-2017/ (accessed 1/16/23).
3. Gamble M. Mayo Clinic defends executive raises. Becker’s healthcare Review. Dec. 8, 2022. Available at: https://www.beckers healthcarereview.com/compensation-issues/mayo-clinic-defends-executive-raises.html ((1/17/23).
4. MedPac. March 2022 Report to the Congress: Medicare Payment Policy. March 2022. Available at: https://www.medpac.gov/document/march-2022-report-to-the-congress-medicare-payment-policy/ (accessed 2/4/23).
5. Magill MK. Time to Do the Right Thing: End Fee-for-Service for Primary Care. Ann Fam Med. 2016 Sep;14(5):400-1. [CrossRef] [PubMed]
6. Pham N, Donovan M. The Economic and Social Benefits of Physician-Led Hospitals. ADP Analytics. September 2022. Available at: https://ndpanalytics.com/wp-content/uploads/PHA-Economic-Impact-Report-092022-Final-R1.pdf (accessed 2/3/23).
7. Chesney S. Do Nurse Practitioners Really Get Sued? Berxi. Aug 16, 2021. Available at: https://www.berxi.com/resources/articles/do-nurse-practitioners-get-sued/ (accessed 2/3/23).
8. 2U Inc. Nurse Salary. Available at: https://nursinglicensemap.com/resources/nurse-salary/ (accessed 2/3/23).
9. Yang YT, Mason DJ. COVID-19’s Impact On Nursing Shortages, The Rise Of Travel Nurses, And Price Gouging. Health Affairs Forefront. January 28, 2022. Available at: https://www.berxi.com/resources/articles/do-nurse-practitioners-get-sued/https://www.healthaffairs.org/do/10.1377/forefront.20220125.695159/ (accessed 2/3/23).

Cite as: Robbins RA. How Much Should Healthcare CEO’s, Physicians and Nurses Be Paid? Southwest J Pulm Crit Care Sleep. 2023;26(2):24-27. doi: https://doi.org/10.13175/swjpccs007-23 PDF

CMS Rule Would Kick “Problematic” Doctors Out of Medicare/Medicaid

Last week CMS announced that beginning January 1, 2020, they assumed a new power to bar clinicians' participation if agency officials can cite potential harm to patients based on specific incidents (1). CMS created this new authority through the 2020 Medicare physician fee schedule. CMS claimed that it had no pathway to address "demonstrated cases of patient harm" in cases where clinicians maintain their licenses (2).

The rule drew criticism from multiple physician groups with none supporting it. The Alliance of Specialty Medicine said CMS has been using "vague and subjective" criteria to evaluate physicians for some time. The new revocation authority "just compounds the problem," the Alliance told Medscape Medical News (2).

In drafting the final version of the rule, CMS rejected many suggestions offered in comments about the revocation authority. The AMA pointed out that CMS hid such a major change in the annual physician fee schedule under the opioid treatment program section (2). The Association of American Medical Colleges (AAMC) said CMS should defer to state medical boards and other state oversight entities regarding issues associated with protecting beneficiaries from patient harm (2). In the final rule, CMS argued that it needs the new revocation authority due to cases where "problematic" behavior persists despite detection by state boards.

During the past week two examples of CMS’ bureaucratic nature were observed in my practice. First, I was told from a durable medical equipment provider that a new CMS requirement was that when reordering patient continuous positive airway pressure (CPAP) supplies that I would need to check, initial and date each item from a long list of supplies whether it was ordered or not. Second, an asthma patient was referred to me that was using daily albuterol. I recommended a long-acting beta agonist/corticosteroid combination but was told that the patient must fail corticosteroids alone before prescribing the more expensive combination therapy. Nearly every physician and many patients have seen some nameless and faceless clerk at CMS give them the “ol’ run around”. CMS’ argument that they are improving quality and protecting patients would be more believable if these and the many other instances of bureaucratic overreach were rare rather than common. 

Many “quality” programs have been thrust on clinicians in the past without any demonstrable improvement in healthcare for patients (3). Rather quickly these programs morph from a quality program to a hammer used to control clinicians and suppress dissent. In seems likely that CMS’ new self-assumed authority will be the same. If CMS wishes to improve care, they should deal with examples such as those above and many more instances of time wasting paper work and poor care that they mandate. Two recommendations to reduce these poor decisions are: 1. List the name of the licensed practitioner responsible for each CMS decision; and 2. Establish an efficient appeals process not controlled by CMS. These would reduce the instances of poor, anonymous decision makers hiding behind the anonymity of the CMS bureaucracy and could go a long way in improving patient care.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Centers for Medicare and Medicaid Services. November, 2019. Available at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24086.pdf (accessed 11/9/19). Scheduled to be published in the Federal Register on 11/15/2019 and available online at https://federalregister.gov/d/2019-24086.
2. Young KD. CMS sharpens weapon to kick 'problematic' docs out of Medicare. Medscape Medical News. November 7, 2019. Available at: https://www.medscape.com/viewarticle/920994?nlid=132505_5461&src=wnl_dne_191108_mscpedit&uac=9273DT&impID=2159379&faf=1 (accessed 11/9/19).
3. Robbins RA. The unfulfilled promise of the quality movement. Southwest J Pulm Crit Care. 2014;8(1):50-63. [CrossRef]

Cite as: Robbins RA. CMS rule would kick “problematic” doctors out of Medicare/Medicaid. Southwest J Pulm Crit Care. 2019;19(5):146-7. doi: https://doi.org/10.13175/swjpcc066-19 PDF 

Blue Shield of California Announces Help for Independent Doctors-A Warning

An article today in Modern Healthcare announced that Blue Shield of California is launching a new program to help physician practices remain independent while giving them tools needed to succeed in value-based care arrangements (1). The program touts that it will offer independent doctors and practices tools to improve patient health outcomes while making it easier for them to focus on care instead of administrative tasks.

Blue Shield said it plans to support physicians in moving toward value-based care by investing in their practices. Investments could range from different types of affiliations to even employing the doctors in select situations. The announcement points out that independent physicians appear to be a dying breed. Furthermore, when independent physicians join an integrated healthcare system, costs increase (2).

On the surface this announcement sounds positive but the article raises a number of concerns. First, Blue Shield California is a for-profit company which had its not-for-profit status revoked by the state of California in 2014. Blue Shield California has also been known for being less than forthcoming with details regarding their business. Second, it is unclear what type of access Blue Shield plans to gain to physicians’ practices and patient files. Third, in many instances, quality measures have been nothing more than a series of meaningless metrics whose performance have not benefited patients. However, performance of these metrics has benefited healthcare executives’ bonuses.  Blue Cross and Blue Shield pays bonuses which on average are greater than 65% of the executive’s base salary. 20-25% of the bonuses are dependent on “quality” as defined by Blue Shield.

As with any dealings with insurance companies or integrated healthcare systems, physicians should be wary. What is the cost to patients and physicians? Will the company be charging for software installation and maintenance? What role will the insurance company have in determining value measures and what access will they have to patient data? Will any contractual agreement be easily canceled or will it be prolonged with the physician paying for the installation and use of any software? Will there be a noncompete clause forcing physicians to move if they decide to leave the agreement? These and other questions need to be addressed prior to any physicians signing on this or any similar agreements. Physicians considering any agreement or contract are encouraged to have them reviewed by lawyers familiar with healthcare to determine the potential pitfalls.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Livingston S.  Blue Shield of Calif. aims to help independent doctors with value-based care. Modern Healthcare. August 29, 2019. Available at: https://www.modernhealthcare.com/payment/blue-shield-calif-aims-help-independent-doctors-value-based-care (accessed 8/29/19).
2. Baker LC, Bundorf MK, Kessler DP. Vertical integration: hospital ownership of physician practices is associated with higher prices and spending. Health Aff (Millwood). 2014 May;33(5):756-63. [CrossRef] [PubMed]
3. Blue Shield of California. 2017 executive compensation summary. Available at: file:///C:/Users/Rick/Downloads/2017-Executive-Compensation-Summary-Final%20(1).pdf (accessed 8/29/19).

Cite as: Robbins RA. Blue Shield of California announces help for independent doctors-a warning. Southwest J Pulm Crit Care. 2019;19(2):85-6. doi: https://doi.org/10.13175/swjpcc058-19 PDF 

The Implications of Increasing Physician Hospital Employment

Several years ago, Dr. Jack had a popular, solo internal medicine practice in Phoenix. However, over a period of about 15-20 years, the profitability of Jack’s private practice dwindled and he was working 60+ hours per week to keep his head above water. This is not what he planned in his mid-50’s when he hoped to be settling into a comfortable lifestyle in anticipation of retirement. Jack eventually closed his practice and took a job as a hospital-employed physician. Jack’s story has become all too common. The majority of physicians are now hospital-employed (1).

The increase in hospital-employed physicians raises at least 2 questions: 1. How can a busy private practice not be profitable? and 2. Is it good to have most physicians hospital-employed? Like Jack, it seems most physicians seek hospital employment for financial and lifestyle reasons. But how can a primary care practice like Jack’s not be profitable when the cost of healthcare has risen so markedly?

To understand why a practice can be busy but not necessarily profitable we need to follow the money. First, reimbursement for private practice has decreased in real dollars (Figure 1) (2). 

Figure 1. Inflation and Medicare physician fee schedule (MPFS) growth in percent from 2006-2017 (2).

Private practice physician reimbursement is the only major cost center that the Centers and Medicaid Services (CMS) has singled out for asymmetrical negative annual fee schedule adjustments. The other major cost centers—hospital inpatient and outpatient, ambulatory surgical centers, and clinical laboratories—all had fee schedule adjustments that were nearly equal to and typically greater than inflation (2). Of course, private insurance companies follow CMS’ lead and so reimbursement to private practice physicians dramatically decreased (3).

In addition, increased requirements for documentation and paperwork were imposed by CMS and quickly picked up by private insurers. These required more physician time and/or the hiring of additional personnel. In addition, there were increasing annoyances and burdens placed on physicians to review and sign forms and prescriptions which already been electronically submitted. Often these annoyances were so the durable medical equipment provider, pharmacy, etc. could be reimbursed. These later burdens now take up to one-sixth of a physicians’ time, decrease office efficiency, and not surprisingly, greatly decrease physician job satisfaction (4).

The second question is whether hospital-employed physicians is a good thing for patients. Although hospitals have argued that hospital-based physicians provide better care, patient outcomes appear to be no different (5). Hospitals have engaged in a number of practices resulting in physicians being financially squeezed. The American Hospital Association (AHA) has lobbied CMS and Congress for payments that are much higher than independent physicians’ offices, assuring hospital profitability. However, under the Trump administration, CMS proposed to pay the same rate for services delivered at off-campus hospital outpatient departments and independent doctors' offices (called site neutrality) (6). This would result in about a 60% cut to the hospitals for these services (7). Not surprisingly, hospitals complained and lobbied Congress to rescind the rule (7). Later the AHA sued CMS challenging the "serious reductions to Medicare payment rates" as executive overreach (8). The case is currently pending before the courts.

Hospitals have also engaged in a number of practices to limit competition from physicians’ offices. First, several have employed a non-compete clause as a condition of obtaining staff privileges. These clauses mean that should a physician leave a hospital, the physician is unable to reestablish a practice within a specified distance of the hospital (often within a radius of 50 miles) (9). Of course, in a metropolitan area this means the physician has to leave the city, or in the case of a large hospital chain, the physician may have difficulty finding areas to practice even in the same state. Second, with the “hospitalist movement” many hospitals have seized on the opportunity to essentially self-refer. That is, the hospitals schedule follow-up appointments with primary care or other physicians employed by the hospitals.

A study documents that healthcare costs for four common procedures rose with increasing hospital physician employment (10). A 49% increase in hospital-employed physicians led to CMS paying $2.7 billion more for diagnostic cardiac catheterizations, echocardiograms, arthrocentesis and colonoscopies delivered in hospital outpatient settings than it would for treatment in independent facilities. CMS beneficiaries footed an additional $411 million.

Although many decry a fee-for-service healthcare system as being too expensive, the increase in hospital-employed physicians seems to only have increased healthcare costs. Action by CMS is needed not only for site neutrality but also a number of other areas to ensure health competition in healthcare.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Kane CK. Updated data on physician practice arrangements: For the first time, fewer physicians are owners than employees. Policy Research Perspectives. American Medical Association. 2019. Available at: https://www.ama-assn.org/system/files/2019-05/prp-fewer-owners-benchmark-survey-2018.pdf (accessed 5/11/19).
2. Cherf J. Unsustainable physician reimbursement rates. AAOS Now. October, 2017. Available at: https://www.aaos.org/AAOSNow/2017/Oct/Cover/cover01/ (accessed 5/11/19).
3. Clemens J, Gottlieb JD. In the shadow of a giant: Medicare's influence on private physician payments. J Polit Econ. 2017 Feb;125(1):1-39. [CrossRef] [PubMed]
4. Woolhandler S, Himmelstein DU. Administrative work consumes one-sixth of U.S. physicians' working hours and lowers their career satisfaction. Int J Health Serv. 2014;44(4):635-42. [CrossRef] [PubMed]
5. Short MN, Ho V. Weighing the effects of vertical integration versus market concentration on hospital quality. Med Care Res Rev. 2019 Feb 9:1077558719828938. [CrossRef] [PubMed]
6. Robbins RA. CMS decreases clinic visit payments to hospital-employed physicians and expands decreases in drug payments 340b cuts. Southwest J Pulm Crit Care. 2018;17(5):136. [CrossRef]
7. Luthi S, Dickson V. Medicare's site-neutral pay plan targeted in hospitals' lobbying. Modern Healthcare. September 25, 2018. Available at: https://www.modernhealthcare.com/article/20180925/TRANSFORMATION04/180929928/medicare-s-site-neutral-pay-plan-targeted-in-hospitals-lobbying (accessed May 11, 2019).
8. Luthi S. Hospitals sue over site-neutral payment policy. Modern Healthcare. December 04, 2018. Available at: https://www.modernhealthcare.com/article/20181204/NEWS/181209973/hospitals-sue-over-site-neutral-payment-policy (accessed May 11, 2019).
9. Darves B. Restrictive covenants: A look at what’s fair, what’s legal and everything in between, Today’s Hospitalist. April 2006. Available at: https://www.todayshospitalist.com/restrictive-covenants-a-look-at-whats-fair-whats-legal-and-everything-in-between/ (accessed May 11, 2019).
10. Kacik A. Hospital-employed physicians drain Medicare. Modern Healthcare. November 14, 2017. Available at: https://www.modernhealthcare.com/article/20171114/NEWS/171119942/hospital-employed-physicians-drain-medicare (accessed May 11, 2019).

Cite as: Robbins RA. The implications of increasing physician hospital employment. Southwest J Pulm Crit Care. 2019;18(5):141-3. doi: https://doi.org/10.13175/swjpcc025-19 PDF 

The Highest Paid Clerk

Physicians are the highest paid clerks in healthcare, but we only have ourselves to blame. At one time charts were often unavailable or illegible and x-rays or outside medical records were often missing. How we longed to have searchable records available. Now we have them but digital medicine has come at a cost. For every hour physicians spend with patients nearly two hours are spent with the electronic healthcare record (EHR) (1). Nurses in the hospital spend nearly as much time with the EHR (2). If a picture is worth a thousand words, the drawing by a 7-year-old depicting her visit to the doctor may say it best with the doctor staring at a computer with his back to the patient (Figure 1).

Figure 1. Drawing by a 7-year-old of her visit to the doctor (3).

The EHR has done some very positive things. It has reduced medication errors; it assembles laboratory and imaging information; it allows visualization of X-rays; the notes are always legible; and although introduction of an EHR results in an initial increase in mortality, there appears to be an eventual reduction (3,4). However, EHRs were not built to enhance patient care but to augment billing. Despite the effort that goes into collecting and recording data, much of the data is unseen or ignored (3). Our daily progress notes have become cut-and-paste spam monsters that are mostly irrelevant and nearly impossible to interpret. The diagnoses can be difficult to locate, the documentation for the diagnosis is often incomprehensible, and the plan is unintelligible. Of course, billings have increased but not due to improved care, but because of the electronic gobbledygook that serves as a record. 

Several other recent examples illustrate that doctors are viewed and being used mainly as clerks. I recently, applied to renew my hospital privileges. This involved completing about a 25-page on-line form to including uploaded documentation of all licenses, board certifications, CME hours, a TB skin test and a DTaP vaccination. For this privilege, not only are medical staff dues paid but a $100 fee needs to accompany the application. Pity the poor physician who goes to several hospitals. In our office every piece of paperwork is scanned into the computer and signed by the physician. This includes the insurance forms, notes from co-managing physicians, the prescriptions that I have written and signed, the pulmonary function tests that I have interpreted and signed, the scored Epworth sleepiness scales that the patient has completed and are included in my note, etc.

A recent court decision may further increase the physician clerical load. The Pennsylvania Supreme Court in a 4-to-3 decision ruled that a physician may not "fulfill through an intermediary the duty to provide sufficient information to obtain a patient's informed consent” (5). What this essentially means is that a physician, presumably the operating surgeon, must obtain an informed consent which usually involves signing a piece of paper. However, signing an informed consent form does not assure informed consent and the form’s main purpose is to protect the hospital or surgical center against litigation by shifting culpability to the surgeon. Now a surgeon must not only inform the patient about the operation but must have a form signed to protect the hospital and discuss every adverse outcome and all alternatives, a clearly impossible task. Will it be long before an unintelligible informed consent is required before prescribing an aspirin?

Many physicians, including myself, have resorted to voice recognition software using a template to generate notes due to increasing documentation requirements. Although this seems to decrease documentation time and increase face-to-face time with the patient, a recent article points out that voice recognition makes mistakes (6). Although there is little doubt that this is true, other documentation methods have their problems such as typographical errors, spelling errors, and omissions in documentation. Hopefully, a hullabaloo will not be made over voice recognition mistakes like was made over copying-and-pasting (7,8). Copy-and-paste errors seem to be mostly trivial and the information they contain is mostly for billing and probably does not need repeating in the medical record in the first place.

Physicians have cowered too long to insurer or hospital interests to avoid being labeled as “disruptive”. Many physicians would be happy to carefully proof every note or spend an hour getting the hospital’s informed consent form signed, but only if adequately compensated. Whining about physician lack of autonomy and increased clerical load either in the doctor’s lounge or in the pages of a medical journal will have no effect. The trend of shifting clerical workload to the healthcare providers will likely continue until either physicians refuse to do these clerical tasks or receive fair compensation for their services.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Verghese A. How tech can turn doctors into clerical workers. NY Times. May 16, 2018. Available at: https://www.nytimes.com/interactive/2018/05/16/magazine/health-issue-what-we-lose-with-data-driven-medicine.html (accessed 7/13/18).
2. Stokowski LA. Electronic nursing documentation: Charting new territory. Medscape. September 12, 2013. Available at: https://www.medscape.com/viewarticle/810573_1 (accessed 7/13/18).
3. Toll E. A piece of my mind. The cost of technology. JAMA. 2012 Jun 20;307(23):2497-8.
4. Lin SC, Jha AK, Adler-Milstein J. Electronic health records associated with lower hospital mortality after systems have time to mature. Health Aff (Millwood). 2018 Jul;37(7):1128-35. [CrossRef] [PubMed]
5. Fernandez Lynch H, Joffe S, Feldman EA. Informed consent and the role of the treating physician. N Engl J Med. 2018 Jun 21;378(25):2433-8. [CrossRef] [PubMed]
6. Zhou L, Blackley SV, Kowalski L, et al. Analysis of errors in dictated clinical documents assisted by speech recognition software and professional transcriptionists.  JAMA Network Open. 2018;1(3):e180530. [CrossRef]
7. Centers for Medicare and Medicaid Services. Electronic Healthcare Provider. December 2015. Available at: https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/docmatters-ehr-providerfactsheet.pdf (accessed 7/13/18).
8. The Joint Commission. Preventing copy-and-paste errors in EHRs. QuickSafety. February 2015. Available at: https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_10.pdf (accessed 7/13/18).

Cite as: Robbins RA. The highest paid clerk. Southwest J Pulm Crit Care. 2018;17(1):32-4. doi: https://doi.org/10.13175/swjpcc089-18 PDF 

Beware the Obsequious Physician Executive (OPIE) but Embrace Dyad Leadership

Obsequious is defined as “obedient or attentive to an excessive or servile degree”. Obsequious comes from the Latin root sequi, meaning "to follow”. An Obsequious PhysIcian Executive (OPIE) is more likely to be servile to the hospital administration than a leader of the medical staff. This is not surprising since they are chosen for a “leadership” position not by the physicians they purportedly lead, but by the hospital administration they serve. OPIEs become the administration’s representative to the physicians and not the physicians’ or patients’ representative to the administration. Their job often becomes keeping the medical staff “in-line” rather that putting the success of the medical center first.

My own views have developed over 40 years of observing OPIE behavior in a multitude of medical centers. Although there are many exceptions, OPIEs often share certain characteristics:

1. Academic failure. OPIEs are usually academic failures. They are the antithesis of the triple threat who excels as a physician, teacher and researcher. In contrast, they excel at nothing and often are obstructionistic of others’ attempts to accomplishment anything meaningful.
2. Advanced degrees not pertaining to medicine. Frustrated by their lack of success, they seek advancement by alternative routes such as nontraditional career paths or obtaining degrees outside of medicine, e.g., a master’s degree in business administration (MBA). Though they will argue that they are just serving a need or advancing their education, more likely they are seeking the easiest path for advancement, especially if their past accomplishments are best described as “modest”. Beware the unaccomplished physician with a MBA.
3. Blame others for failure. Not all ideas, even from good people, are successful. Some are bad ideas destined to failure. When an OPIE’s idea fails, they blame others. Worse yet, they lie about a staff in order to place themselves in a good light. This appears to be one of the root causes of the waiting time scandal at the VA. In contrast, a leader accepts responsibility for failure and proposes a new and hopefully better plan.
4. Bullying. OPIEs often fail to see two sides to any argument and are usually impatient and short-tempered with any who disagree. Rather that attempting to build a consensus, they attempt to bully those who show any resistance.
5. Retaliation. If bullying fails, OPIEs seek retaliation. This can be through various means-often denial of resources. For example, one chief of staff sat for over a year on a request for a Glidescope (a fiberoptic instrument used for intubation) in the intensive care unit and then was faultfinding when a critical care fellow did not use a Glidescope during an unsuccessful intubation intubation. OPIEs might limit clinic space or personnel but then disparage the physicians when patients are not seen quickly enough to meet an administrative guideline. Lastly, if all else fails they may retaliate by invoking quality assurance. Quality is often ill-defined and it is all too easy in this day of “patient protection” to slander a good physician.

One of the latest buzzwords in healthcare is dyad leadership, a term that refers to physician/administrator teams that jointly lead healthcare organizations (1). A recent editorial touted the success of the partnership between Will Mayo MD and Harry Harwick at the Mayo Clinic in Rochester (2). My own positive example comes from Mike Sorrell MD, Charlie Andrews MD, and Bob Baker at the University of Nebraska Medical Center in Omaha. However, simply putting a physician and administrator together in leadership positions does not guarantee organizational success. In fact, if not done correctly, it leads to confusion, resentment, lack of consistent direction and divided organizational factions.

Based on their Mayo Clinic experience, Smoldt and Cortese list five key success factors they believe bring success to a dyad leadership (2):

1. Common core values. Perhaps the most important factor in a successful dyad is that members of the physician/administrator team have the same core values and goals. Furthermore, these need to be consistent with the staffs' values and goals. Smoldt and Cortese (2) point out that at Mayo Clinic the core value of “the needs of the patient come first” is deeply imbedded. The staff of an organization will primarily deduce leadership core values from their daily actions. Administrative bonuses or increased reimbursement are not necessarily common core values, and if emphasized over patient care, the dyad is doomed to failure.
2. Willingness to work together toward a common mission and vision. In a medical center, if the administrative leadership and staff can work together toward a vision, it is more likely to be achieved. If leadership becomes too territorial or engages in OPIE behavior, the ideal of leveraging each other’s strengths will be lost. If the staff perceives that the dyad is emphasizing their personal goals and finances over institutional success, the staff will be unwilling to work with or support the dyad.
3. Clear and transparent communication with each other and the organization. To gain the most from dyad leadership, each member of the team should leverage and build on the strengths of the other. The more time the individuals spend together as a leadership team and with staff at a medical center, the more frequent and open the communication will be. If over time, communication declines, it is probably a sign that the dyad is not working and is often followed by the OPIE behaviors of bullying, lying and retaliation.
4. Mutual respect. A team works best if its members operate in an atmosphere of mutual respect. If the dyad team does not share or show mutual respect for each other, mutual respect will likely also be lost among the healthcare delivery team. It is especially important for the dyad to remember that respect must be earned, and a big part of earning respect is to show respect for the views and positions of the staff.
5. Complementary competencies. No one organizational leader is good at everything that needs to be done in a medical center. Employing a dyad leadership approach can expand the level of competence in the top leadership. For example, in a physician/administer leadership team, it is not unusual for the administrator to have better financial skills than the physician. It goes without saying that physicians and nurses have better medical skills in their own scope of practice than an administrative/physician dyad.

Integrated delivery of care is an absolute for a successful medical center. OPIE behavior dooms the medical center. Establishing a physician/administrator dyad leadership team with the right administrator and physician can be a good step towards success.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Zismer DK, Brueggemann J. Examining the "dyad" as a management model in integrated health systems. Physician Exec. 2010 Jan-Feb;36(1):14-9. [PubMed]
2. Smoldt RK, Cortese DA. 5 success factors for physician-administrator partnerships. MGMA Connection Plus. September 24, 2015. Available at: http://www.mgma.com/practice-resources/mgma-connection-plus/online-only/2015/september/5-success-factors-for-physician-administrator-partnerships (accessed 10/4/17).

Cite as: Robbins RA. Beware the obsequious physician executive (OPIE) but embrace dyad leadership. Southwest J Pulm Crit Care. 2017;15(4):151-3. doi: https://doi.org/10.13175/swjpcc121-17 PDF

The Unspoken Challenges to the Profession of Medicine

More and more, we are practicing in a challenging environment. Job satisfaction for our profession is at an all-time low, burnout at an all-time high and there exists an alarming depression rate. As a profession, we face no shortage of problems. Our medical student graduates await many hurdles and need to be prepared to deal with increasing educational costs, ACGME duty hour changes, declining interest in primary care, health care reform, declining Medicare reimbursement, assaults to fee for service designs, bundled payments, care for the uninsured, medical malpractice, ABIM recertification, and MOC changes, the electronic health record, among many others.

If you are like most physicians, you have found yourself grappling with patients seeking a particular drug especially when that drug is a controlled substance or an antibiotic. You want your patient’s approval of your care and maybe even avoidance of their anger while providing the appropriate care that is based on your best judgment.  The accrediting bodies like American Board of Medical Specialties and ACGME in overall policies require that those seeking board certification have demonstrated “altruism, accountability, excellence, duty, service, honor, integrity and respect for others” (1). A reaction of anger or disapproval challenges our wish to strive toward achieving goals of being altruistic, knowledgeable, skillful, and dutiful. How does a patient review on various internet sites or hospital administrators’ perspectives address essential elements of medical professionalism? Most of us now work for large organizations (2). So we all have an interest in conforming to their wishes. In fact we do not have independent choice in what we do and probably very few docs practice with independent choice. Whether it be medication formularies, patient satisfaction scores or performance measures that seem geared more to justify institutional financial goals than to truly improve patient care. 

Uncertainty has long characterized the practice of medicine despite advances in technology or biomedical knowledge. Medical professionalism is defined by what we do and how we act, by demonstrating that we are worthy of the trust bestowed upon us by our patients and the public. My friend shared with me “I try to use independent judgment but always take into account how much or what to do for a patient, thinking what would seem acceptable to others at work if the patient went home and died, and my care got reviewed”. More and more we are judged by everyone, and not just our peers. The opinions of non-medical professionals who lack insight are taken into account and some of that has to do with the lack of solidarity to our peers in front of the public which diminishes confidence for the whole profession (3). 

Listening to our patients is the first key step in adding critical insight to our decisions. Long term we are expected to be providing fiscally prudent appropriate care to the public. In an era of ever increasing drug abuse we need to focus on making our decisions and behavior based on patient’s best interests and the publics good and not on current organizational financial goals, health trends or other distractions from our profession.  

Medical professionalism requires subordinating your own interest to the interest of the patient’s and public’s health. We have a duty to do right and to avoid doing wrong in principles of beneficence and nonmaleficence. As an example, our profession has been criticized for both under and over prescribing pain medications and antibiotics. Resisting the current trends or an individual’s unsupported drug request in favor of patient and public’s good is what we need to exercise. We need to exercise accountability not just for ourselves but for our colleagues, including intervening and not abrogating our responsibility early in the slippery slope of such behaviors as being chronically late for over commitments for monetary gain, derogatory comments about institution/hospital that degrade trust in our profession to the public, outbursts of anger and inappropriate work place sexual harassment or alternatively false allegations of such type of behavior (4). The Public trust demands that we make appropriate decisions in face of complex environments and often unscientific pressures for the overall care of patient and public if we are to do our part in maintaining a profession (5). We need to continue to strive toward benefiting our patients and subordinating our interests to best meet the needs of our patients and we should stand our ground to pillars of our profession, otherwise maybe we should amend our thinking to accept the fact that we have become corporate or political factotums and not here for a higher calling. Our voices should be united, altruistic and with medical professionalism to maintain public’s trust. Create goals that will prevent burnout and focus lifestyle expectations that realistic and fulfilling in order to avoid the need to rush through the long queues of patients in the waiting room and its associated dissatisfaction (6).  

F. Brian Boudi, MD

Phoenix Veterans Administration Health Care System

University of Arizona College of Medicine

Phoenix, Arizona

Connie S. Chan, MD

Phoenix Veterans Administration Health Care System

Phoenix, Arizona 

References

1. American Board of Internal Medicine. Project Professionalism. 2013. Available at:  https://medicinainternaucv.files.wordpress.com/2013/02/project-professionalism.pdf (accessed 6/29/17).
2. G Hamel, Zanini M.  More of us are working in big bureaucratic organizations than ever before. Harvard Business Review. July 5, 2016. Available at: https://hbr.org/2016/07/more-of-us-are-working-in-big-bureaucratic-organizations-than-ever-before (accessed 6/29/17). 
3. Pardes H. The future of medical schools and teaching hospitals in the era of managed care. Acad Med. 1997 Feb;72(2):97-102. [CrossRef] [PubMed]
4. Scott KM, Berlec Š, Nash L, Hooker C, Dwyer P, Macneill P, River J, Ivory K. Grace Under Pressure: a drama-based approach to tackling mistreatment of medical students. Med Humanit. 2017 Mar;43(1):68-70. [CrossRef] [PubMed]
5. Relman AS. Education to defend professional values in the new corporate age. Acad Med. 1998 Dec;73(12):1229-33. [CrossRef] [PubMed]
6. Barkil-Oteo A. Have physicians finally joined the working class? KevinMD.com. November 3, 2016. Available at: http://www.kevinmd.com/blog/2016/11/physicians-finally-joined-working-class.html (accessed 6/29/16).

Cite as: Boudi FB, Chan CS. The unspoken challenges to the profession of medicine. Southwest J Pulm Crit Care. 2017;14(6):222-4. doi: https://doi.org/10.13175/swjpcc085-17 PDF 

Mitigating the “Life-Sucking” Power of the Electronic Health Record

An article in PulmCCM discussed “life-sucking” electronic health care records (EHR) (1). It is in turn based on an article in the Annals of Internal Medicine on the work time spent by physicians (2). The latter, funded by the American Medical Association, observed 57 physicians in internal medicine, family medicine, cardiology, and orthopedics over hundreds of hours. The study revealed that physicians spend almost two hours working on their electronic health record for every one hour of face-to-face patient time. Interestingly, physicians who used a documentation assistant or dictation spent more time with patients (31 and 44%) compared to those with no documentation support (23%).

The PulmCCM goes on to list some of the reasons that the EHR requires so much time:

• The best and brightest minds in software design don't go to work for Epic, Cerner, Allscripts, and whoever the other ones are.
• There's a high barrier to entry for competition now that most major health systems have implemented the big-name systems.
• The vendors can't easily improve the front-end design's user-friendliness (like web pages and consumer software have) because it rests on clunky, proprietary frameworks built in the 1990s and which can't be substantially changed for stability reasons. Think Microsoft Office, but way worse.
• Software designers are congenitally incapable of accepting the reality that a user would be better off the less they use the product, and designing it that way. They think their EHR is super cool, and can't fathom that it actually sucks to use.

Let me add another possibility. Those who demand implementation of the EHR see documentation as being most important because of the bottom line. It if comes at the price of physician efficiency so be it-as long as it does not hurt payment. Physicians are not paid for the required increased documentation much of which is unnecessary, redundant and, in some cases, downright silly (3). Furthermore, the concept that this improves patient outcomes largely seems to be a myth (4). Those manuscripts that report improved “quality” of care usually have examined meaningless surrogate metrics that often have little or even inverse relationships with patient outcomes (3). For example, high patient satisfaction seems to come at the price of increased mortality (5).

What is the solution-charge for the time. As it now stands, there is no downside to demanding pointless documentation. Third party payers can deny payment when something like the rarely beneficial family history is omitted. There should be a charge for seeing and caring for the patient and another “documentation fee” that is based on time. That would mean that a 20 minute office call would not be billed at 20 minutes but at the 1 hour of physician time the visit really consumes. Those physicians who use a documentation assistant or dictation can pay for these services by seeing more patients. Only in this way can the trend of wasting physicians’ most precious resource, their time, be mitigated.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. PulmCCM. Life-sucking power of electronic health records measured, reported, lamented. November 25, 2016. Available at: http://pulmccm.org/main/2016/outpatient-pulmonology-review/life-sucking-power-electronic-health-records-measured-reported-lamented/ (accessed 11/28/16).
2. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016 Sep 6. [Epub ahead of print] [CrossRef] [PubMed]
3. Robbins RA. Brief review: dangers of the electronic medical record. Southwest J Pulm Crit Care. 2015;10(4):184-9. [CrossRef]
4. Yanamadala S, Morrison D, Curtin C, McDonald K, Hernandez-Boussard T. Electronic health records and quality of care: an observational study modeling impact on mortality, readmissions, and complications. Medicine (Baltimore). 2016 May;95(19):e3332. [CrossRef] [PubMed]
5. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med 2012;172:405-11. [CrossRef] [PubMed]

*The views expressed are those of the author and do not reflect the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Cite as: Robbins RA. Mitigating the “life-sucking” power of the electronic health record. Southwest J Pulm Crit Care. 2016;13(5):255-6. doi: https://doi.org/10.13175/swjpcc125-16 PDF

VA Administrators Gaming the System

On 4-23-12 the Department of Veterans Affairs (VA) Office of Inspector General (OIG) issued a report of the accuracy of the Veterans Healthcare Administration (VHA) wait times for mental health services. The report found that “VHA does not have a reliable and accurate method of determining whether they are providing patients timely access to mental health care services. VHA did not provide first-time patients with timely mental health evaluations and existing patients often waited more than 14 days past their desired date of care for their treatment appointment. As a result, performance measures used to report patient’s access to mental health care do not depict the true picture of a patient’s waiting time to see a mental health provider.” (1). The OIG made several recommendations and the VA administration quickly concurred with these recommendations. Only four days earlier the VA announced plans to hire 1900 new mental health staff (2).

This sounded familiar and so a quick search on the internet revealed that about a year ago the United States Court of Appeals for the Ninth Circuit issued a scathing ruling saying that the VA had failed to provide adequate mental health services to Veterans (3). A quick review of the Office of Inspector General’s website revealed multiple instances of similar findings dating back to at least 2002 (4-7). In each instance, unreliable data regarding wait times was cited, VA administration agreed, and no or inadequate action was taken.

Inadequate Numbers of Providers

One of the problems is that inadequate numbers of clinical physicians and nurses are employed by the VA to care for the patients. In his “Prescription for Change”, Dr. Ken Kizer, then VA Undersecretary for Health, made bold changes to the VA system in the mid 1990’s (8). Kizer cut the numbers of hospitals but also the numbers of clinicians while the numbers of patients increased (9). The result was a marked drop in the number of physicians and nurses per VA enrollee (Figure 1).

Figure 1. Nurses (squares) and physicians (diamonds) per 1000 VA enrollees for selected years (10,11).

This data is consistent with a 2011 VA survey that asked VA mental health professionals whether their medical center had adequate mental health staff to meet current veteran demands for care; 71 percent responded no. According to the OIG, VHA’s greatest challenge has been to hire psychiatrists (1). Three of the four sites visited by the OIG had vacant psychiatry positions. One site was trying to replace three psychiatrists who left in the past year. This despite psychiatrists being one of the lowest paid of the medical specialties (12). The VA already has about 1,500 vacancies in mental-health specialties. This prompted Sen. Patty Murray, Chairman of the Senate Committee on Veterans Affairs to ask about the new positions, "How are you going to ensure that 1,600 positions ... don't become 1,600 vacancies?" (13).

Administrative Bonuses

A second problem not identified by the OIG is administrative bonuses. Since 1996, wait times have been one of the hospital administrators’ performance measures on which administrative bonuses are based. According to the OIG these numbers are unreliable and frequently “gamed” (1,4-7). This includes directions from VA supervisors to enter incorrect data shortening wait times (4-7).

At a hearing before the Senate Committee on Veterans' Affairs Linda Halliday from the VA OIG said "They need a culture change. They need to hold facility directors accountable for integrity of the data." (13). VA "greatly distorted" the waiting time for appointments, Halliday said, enabling the department to claim that 95 percent of first-time patients received an evaluation within 14 days when, in reality, fewer than half were seen in that time. Nicholas Tolentino, a former mental-health administrative officer at the VA Medical Center in Manchester, N.H., told the committee that managers pressed the staff to see as many veterans as possible while providing the most minimal services possible. "Ultimately, I could not continue to work at a facility where the well-being of our patients seemed secondary to making the numbers look good," he said.

Although falsifying wait times has been known for years, there has been inadequate action to correct the practice according to the VA OIG. Sen. Murray said the findings show a "rampant gaming of the system." (13). This should not be surprising. Clerical personnel who file the data have their evaluations, and in many cases pay, determined by supervisors who financially benefit from a report of shorter wait times. There appears no apparent penalty for filing falsified data. If penalties did exist, it seems likely that the clerks or clinicians would be the ones to shoulder the blame.

The Current System is Ineffective

A repeated pattern of the OIG being called to look at wait times, stating they are false, making recommendations, the VA concurring, and nothing being done has been going on for years (1, 3-7). Based on these previous experiences, the VA will likely be unable to hire the numbers of clinicians needed and wait times will continue to be unacceptably long but will be “gamed” to “make the numbers look good”. Pressure will be placed on the remaining clinicians to do more with less. Some will become frustrated and leave the VA. The administrators will continue to receive bonuses for inaccurate short wait times. If past events hold true, in 2-5 years another VA OIG report will be requested. It will restate that the VA falsified the wait times. This will be followed by a brief outcry, but nothing will be done.

The VA OIG apparently has no real power and the VA administrators have no real oversight. The VA OIG continues to make recommendations regarding additional administrative oversight which smacks of putting the fox in charge of the hen house. Furthermore, the ever increasing numbers of administrators likely rob the clinical resources necessary to care for the patients. Decreased clinical expenses have been shown to increase standardized mortality rates, in other words, hiring more administrators at the expense of clinicians likely contributes to excess deaths (14). Although this might seem obvious, when the decrease of physicians and nurses in the VA began in the mid 1990’s there seemed little questioning that the reduction was an “improvement” in care.

Traditional measures such as mortality, morbidity, etc. are slow to change and difficult to measure. In order to demonstrate an “improvement” in care what was done was to replace outcome measures with process measures. Process measures assess the frequency that an intervention is performed.  The problem appears that poor process measures were chosen. The measures included many ineffective measures such as vaccination with the 23 polyvalent pneumococcal vaccine in adult patients and discharge instructions including advice to quit smoking at hospital discharge (15). Many were based on opinion or poorly done trials, and when closely examined, were not associated with better outcomes. Most of the “improvement” appeared to occur in performance of these ineffective measures. However, these measures appeared to be quite popular with the administrators who were paid bonuses for their performance.

Root Causes of the Problems

The root causes go back to Kizer’s Prescription for Change. The VA decreased the numbers of clinicians, but especially specialists, while increasing the numbers of administrators and patients. The result has been what we observe now. Specialists such as psychiatrists are in short supply. They were often replaced by a cadre of physician extenders more intent on satisfying a checklist of ineffective process measures rather than providing real help to the patient. Waiting times lengthened and the administrative solution was cover up the problem by lying about the data.

VA medical centers are now usually run by administrators with no real medical experience. From the director down through their administrative chain of command, many are insufficiently medically trained to supervise a medical center. These administrators could not be expected to make good administrative decisions especially when clinicians have no meaningful input (10).

The present system is not transparent. My colleagues and I had to go through a FOIA request to obtain data on the numbers of physicians and nurses presented above. Even when data is known, the integrity of the data may be called into question as illustrated by the data with the wait times. 

The falsification of the wait times illustrates the lack of effective oversight. VA administration appears to be the problem and hiring more administrators who report to the same administrators will not solve the problem as suggested by the VA OIG (3-7). What is needed is a system where problems such as alteration of wait times can be identified on the local level and quickly corrected.

Solutions to the Problems

The first and most important solution is to provide meaningful oversight by at the local level by someone knowledgeable in healthcare. Currently, no system is in place to assure that administrators are accountable.  Despite concurring with the multitude of VA OIG’s recommendations, VA central office and the Veterans Integrated Service Networks have not been effective at correcting the problem of falsified data. In fact, their bonuses also depend on the data looking good. Locally, there exists a system of patient advocates and compliance officers but they report to the same administrators that they should be overseeing. The present system is not working. Therefore, I propose a new solution, the concept of the physician ombudsman. The ombudsman would be answerable to the VA OIG’s office. The various compliance officers, patient advocates, etc. should be reassigned to work for the ombudsman and not for the very people that they should be scrutinizing.

The physician ombudsman should be a part-time clinician, say 20% at a minimum. The latter is important in maintaining local clinical knowledge and identifying falsified clinical data. One of the faults of the present VA OIG system is that when they look at a complaint, they seem to have difficulty in identifying the source of the problem (16). Local knowledge would likely help and clinical experience would be invaluable. For example, it would be hard to say waiting times are short when the clinician ombudsman has difficulty referring a patient to a specialist at the VA or even booking a new or returning patient into their own clinic.

The overseeing ombudsman needs to have real oversight power, otherwise we have a repeat of the present system where problems are identified but nothing is done. Administrators should be privileged similar to clinicians. Administrators should undergo credentialing and review. This should be done by the physician ombudsman’s office.  Furthermore, the physician ombudsman should have the capacity to suspend administrative privileges and decisions that are potentially dangerous. For example, cutting the nursing staffing to dangerous levels in order to balance a budget might be an example of a situation where an ombudsman could rescind the action.

The paying of administrative bonuses for clinical work done by clinicians should stop. Administrators do not have the necessary medical training to supervise clinicians, and furthermore, do nothing to improve efficiency or clinically benefit Veterans (14). The present system only encourages further expansion of an already bloated administration (17). Administrators hire more administrators to reduce their workload. However, since they now supervise more people, they argue for an increase in pay. If a bonus must be paid, why not pay for something over which the administrators have real control, such as administrative efficiency (18). Perhaps this will stop the spiraling administrative costs that have been occurring in healthcare (17).

These suggestions are only some of the steps that could be taken to improve the chronic falsification of data by administrators with a financial conflict of interest. The present system appears to be ineffective and unlikely to change in the absence of action outside the VA. Otherwise, the repeating cycle of the OIG being called to look at wait times, noting that they are gamed, and nothing being done will continue.

Richard A. Robbins, M.D.*

Editor, Southwest Journal of Pulmonary

            and Critical Care

References

1. http://www.va.gov/oig/pubs/VAOIG-12-00900-168.pdf  (accessed 4-26-12).
2. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2302 (accessed 4-26-12).
3. http://www.ca9.uscourts.gov/datastore/opinions/2011/07/12/08-16728.pdf (accessed 4-26-12).
4. http://www.va.gov/oig/52/reports/2003/VAOIG-02-02129-95.pdf (accessed 4-26-12).
5. http://www.va.gov/oig/54/reports/VAOIG-05-03028-145.pdf (accessed 4-26-12).
6. http://www.va.gov/oig/54/reports/VAOIG-05-03028-145.pdf (accessed 4-26-12).
7. http://www.va.gov/oig/52/reports/2007/VAOIG-07-00616-199.pdf (accessed 4-26-12).
8. www.va.gov/HEALTHPOLICYPLANNING/rxweb.pdf (accessed 4-26-12).
9. http://veterans.house.gov/107th-congress-hearing-archives (accessed 3/18/2012).
10. Robbins RA. Profiles in medical courage: of mice, maggots and Steve Klotz. Southwest J Pulm Crit Care 2012;4:71-7.
11. Robbins RA. Unpublished observations obtained from the Department of Veterans Affairs by FOIA request.
12. http://www.medscape.com/features/slideshow/compensation/2012/psychiatry (accessed 4-26-12).
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14. Robbins RA, Gerkin R, Singarajah CU. Correlation between patient outcomes and clinical costs in the VA healthcare system. Southwest J Pulm Crit Care 2012;4:94-100.
15. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med 2005;353:1860-1 [letter].
16. Robbins RA. Mismanagement at the VA: where's the problem? Southwest J Pulm Crit Care 2011;3:151-3.
17. Woolhandler S, Campbell T, Himmelstein DU. Health care administration in the United States and Canada: micromanagement, macro costs. Int J Health Serv 2004;34:65-78.
18. Gao J, Moran E, Almenoff PL, Render ML, Campbell J, Jha AK. Variations in efficiency and the relationship to quality of care in the Veterans health system. Health Aff (Millwood) 2011;30:655-63.

*The author is a former VA physician who retired July 2, 2011 after 31 years.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.

Reference as: Robbins RA. VA administrators gaming the system. Southwest J Pulm Crit Care 2012;4:149-54. (Click here for a PDF version of the editorial)