richard[WINTERS]md

CMS Proposed Medicare Payment Changes in 2010

CMS's proposed change in Emergency Medicine reimbursement by Medicare is +2% for 2010. This includes changes in work, malpractice and practice expense RVUs. It represents a survey of all services in the specialty (eg procedures, E&M). This does not include the proposed -21.5% conversion factor adjustment which may (or more likely will not) occur.

Bigger news is the hit proposed for other specialists:

• Cardiology: -11%
• Interventional Radiology: -10%
• Nuclear Medicine: -13%
• Radiation Oncology: -19%

Primary Care would do better:

• Internal Medicine: +6%
• Family Practice: +8%

Additionally, the payment for the professional component of diagnostic testing facilities: -24%

Look at page 716 of the pdf at this link for the full list: http://www.federalregister.gov/OFRUpload/OFRData/2009-15835_PI.pdf

(via Jacob Goldstein at the Wall Street Journal Health Blog)

Would CMS Allow Concierge Emergency Departments?

I recently wrote about Concierge Emergency Departments. There are challenges to such a model.

Scalpel, who blogged about free-standing EDs in Texas last year, commented:

"The concept won't work unless Medicare and Medicaid are excluded because you can't balance bill."

Can we separate care from amenities? We can't balance bill on care, but can we charge for amenities? Patients visiting the ED can purchase food from the cafeteria. They can also purchase bottled water from a vending machine in our lobby. I don't believe this violates any CMS billing standards. Even though, some patients have coins for the vending machine and others do not. Do regulations prohibit charging for a private fancy chair versus a standard waiting room chair?

Those waiting in a non-private area need to receive the same level of care. Comfort scores and pain scores could be difficult to separate. How would we audit and defend the differences?

Peter from Medical Pistache commented:

"An individual may need to visit the ER once every 5 years perhaps. Few would be willing to pay a yearly subscription for services unlikely to be needed every year."

A subscription model is one model. Segmentation of services by price and per visit would provide more service options. You can get first class, business, or coach seats on a flight. Different prices and levels of service, yet all include a chair in the sky that transports you from point A to point B.

Emergency departments generate 119.2 million visits per year. That is 227 visits per minute. An extra $1 here, or $10, or $100 there could add up to significant revenue for hospitals. Service profit could be applied to help pay for the care of all patients.

Thanks to KevinMD and GruntDoc (two of my daily reads) for their referrals.

The Fainting Physician

I never thought I could be a doctor. I used to faint at the sight of anything medical.

I was 13 years old. Our class was attending a birds and the bees talk. I sat with 50 other kids on the steps of a mini-amphitheater. The teacher pointed to the large plastic uterus. Tunnel-vision, weak all over... My teenage survival instincts told me to pretend to sleep on the steps. The other pre-syncopal teens with heads bowed evidently had a similar inner voice.

As an orderly in a local hospital I watched a well-intentioned nurse insert a urinary catheter. The world became a tunnel, I soaked with sweat and the chair on wheels ran away as I grappled to sit. Suddenly I was the focus of attention. Where was I?

We dissected a placenta in medical school. I hobbled in my black-out fog to the more private bathroom.

As a resident emergency physician I was peeling fruit and accidentally created a 3 mm cut in the web space of my left hand. I gently explored my dinky incision. I awoke on the kitchen floor. Then I ate the apple.

I no longer pass out at the site of anatomy, pathology and procedure. Some switch turned on (or off). Medicine moved from the emotional "passing out" section of my brain…to the logical, analytic "red blood cells have no nuclei and mitochondria is inherited from the mother" part of my brain. I forget that these things used to be gross. I have extended periods of consciousness.

Concierge Emergency Department

Is it possible for there to be a bed for every emergency department patient? Quiet individual rooms. Entertainment kiosks. Private bathrooms. Couches for family and guests. There is demand for this level of service.

The number of patients presenting to emergency departments outnumber the beds available. Nationally, ED visits went up 32% from 1996 to 2006. ED visits in my hospital have gone up 35% since 2001. We can't build 35% bigger EDs. We can't squeeze in 35% more ED beds. We don't have the funds.

We improve processes. We see more patients in less space, in less time, with less people, and they are often satisfied.

Many patients go to the ED and never see an ED bed. They see the physician and nurse in an intake area. Blood is drawn, x-rays are ordered, and medications are given. They sit in results waiting areas for their tests and treatment to be complete. They are discharged home. Only the sickest patients get a bed.

Some patients want more service. Some would be willing to pay for that service. Others see that service as a waste of their money.

This might occur safely if we ensure that:

• The sickest patients get a bed.
• Care is not delayed for anyone.
• Although extra service may be purchased, care is equal.

For a fee, families or individuals could become members of the Concierge Emergency Department. They might want:

• A private room.
• Couches and chairs for family.
• Wireless or wired internet connections.
• Flat screen television with movies and video games.
• Food and drinks.
• The hospital's nursing and ancillary service stars.
• Member events and dinners where they get to meet the board, executives and physicians.
• Answers to outpatient questions and appointments with hospital-based preferred physicians.

Many of the tactics used by concierge primary care physicians, hotels, and frequent flier clubs may be adopted by hospitals and hospital based physicians. The fee could be paid annually or at a higher level at the time of service. A source of cash flow for hospitals.

Is it possible to separate service level from quality of care?

Be Great

My 3 yo daughter tripped in the kitchen.
A quick recovery.
A stumble. Not a fall.
She shouts, "Dad, you made me trip!"

I was in the other room.

Similar statements occur at work. From adults.
From patients. From healthcare workers.
Amplifying as we get busy.

We hold admitted patients in the emergency department. All of our beds are full. The ambulances keep arriving. Paramedics with gurneys full of sick patients form a line that extends down the hall. The waiting room is packed with patients waiting to be seen. Every bed in the hospital is full. The patients are ill. The staff is fatigued.

Enter the language of the victim. The blame.

Why are they doing this to me?
Why can't I do this?
Why don't they do this?
That's what's wrong with this job, with this department, with this individual.

Reimbursement is decreasing. Costs are rising. The economy is contracting at the level of the world, country, state, county and individual. Hospitals are starved for cash flow.  This portends intensification of the above scenario.

More sick patients. Less physical resources. Less payment.

Now is the time to rise above.

How can I add value?
How can we make this work?
What am I grateful for?

It is not the time to blame others.
It is not the time to eat our own.

Look at your values.
What is your mission?
Be great.

Hip Dislocations: The Captain Morgan

Joint reductions are one of my favorite emergency department procedures.

The pathology is obvious to both the patient and the physician.
The treatment is clear. Put the bone back in joint.
The success of the procedure is evident. The joint is back in normal alignment.

Some joint reductions are easier than others.
Fingers are very easy.
Shoulders are not difficult, not easy, but almost always successful.
Hips can be challenging. Sometimes they refuse to get reacquainted with their joint.

Hip reductions are one of those procedures that can injure the physician. One method involves standing on the gurney and yanking the leg. This can result in a tweaked back, a pulled groin muscle, and the occasional somersault off the gurney. Not elegant.

My favorite method is less gorilla, more investment banker circa 2008. You know, leveraged. You can pull with all your might or you can think like a 3000 BC Egyptian building a pyramid.

The technique I use is called the Captain Morgan.

Use brevital (not rum) or another concoction to get the perfect level of sedation.

Adopt the stance of the pirate and use your knee as the fulcrum to lever the hip back into place.

 

It doesn't work 100% of the time. But nothing does. There are 300 lb athletes where the hip pops in, and there are 90 y old ladies where no procedure short of paralysis and intubation will work.

Greg Hendey, one of my mentors, gives an excellent talk on orthopedic reductions. Here is a direct link to the pdf of his lecture at the American College of Emergency Physician's Scientific Assembly. The line drawing is from that handout.

Who Decides Physician Payments

Medicare pays physicians based on Relative Value Units (RVUs). RVUs are set based on the recommendation of the American Medical Association's RVS Update Committee.

This picture represents the makeup of the specialty societies that sit on that committee.


Not many votes for Primary Care.

Show Me The Policy

It is not uncommon in medicine to be told that you cannot do something because it goes against policy.

"CMS has a policy against that."
"OSHA says we can't do that there."
"DHS says that we have to have this ratio."

These statements are very powerful. They are discussion stoppers. They can be process improvement barriers.

I've found that the best defense to these statements is to ask in an inquisitive and polite manner:

"Can you show me that policy?"

Sometimes they can.

The Science of Waiting: Variability

Why are you waiting?
It might be due to variability.

Assume your physician's walk-in clinic can see 10 patients each hour.

The clinic in this case is the server. It's service rate is 10 patients/hour. You, the patient, are the customer.

What affect does the arrival rate of other patients have on whether you are seen in a timely manner?

During the hour you arrive, 11 other patients also arrive to be seen. Will there be waiting at the end of that hour?


Yes. There will be waiting.
The clinic can only see 10 patients in an hour, not 12.

How about a different scenario? What happens if 7 other patients arrive during the hour you get to the clinic?

That's a total of 8 patients in one hour. Again, the clinic service rate is 10 patients per hour. Will there be waiting?

It depends.

Are the patients arriving at exactly 7.5 minutes apart (60 minutes / 8 patients)?

If so, then there will be no waiting. But how often does that occur? Isn't it more likely that patients arrive at a variable rate?

If patients arrive at a variable rate will any of the patients wait?

Yes.

Think about it.

Can the receptionist process 4 people at once?
Can the nurse care for a batch of people at once?
Can the phlebotomist draw the blood on a batch of many patients at once?
Will rooms be occupied as other patients wait to move to the next step in the process?
Will you wait to get a room?

The most efficient processes can crumble as you increase the number of customers and the variability of arrival rate. Plan for variability.

The Science of Waiting: The Server

A queue is a line.

We are queueing specialists. We create lines and we wait in queue.

We wait for the:

• physician to write the order.
• clerk to enter the order.
• nurse to execute the order.
• patient to be ready to get tested.
• lab to process the order.
• physician to see the result.
• etc.

A whole series of queues. Each one dependent on the previous.
A delay at one step results in waits at later steps. Additive delays.

Every step relies on the server to process the customer.

The server can be a thing (blood analysis machine, bed, CT scanner) or it can be a person (tech, nurse, housekeeping, physician, registration clerk).

The customer can also be a thing (lab sample, dirty bed) or a person (patient, family member, nurse).

Each server can only process a specific number of customers during a specific amount of time. Additional customers wait.

Do we have the right number of servers?
Can we eliminate steps?

Seductive Detail

I've been making a mistake during some of my lectures.

I like to emotionally engage the audience. I like to make them laugh. Sometimes I tell stories as a break between content as a sort of cognitive release. Add a little spice. But am I defeating my ability to educate effectively?

Telling stories as part of a lecture can be a great way to effectively teach. However, I need to choose the stories wisely. Highly detailed tangents, while interesting, may hurt the audience's ability to learn my key points.

Cognitive load theorists believe that the brain has a limited ability to process new information at any point in time. Seductive detail is information that is interesting but not necessarily relevant to the key points. New research supports the idea that seductive detail draws cognitive processing power away from learning the main points. In fact, the more interesting the tangent, the more it impaired a deep understanding of the key points. Our brains can only process so much new material in limited time.

Am I giving too much irrelevant detail?
Does my story distract from the key points?

Simplify the Process

What is the probability of a patient visiting the emergency department not encountering an error of process?

Registration functions perfectly.
Labs are ordered correctly and return on time.
Vital signs, medications, transports, x-rays, exams…all performed without error.

Each step of each of these processes has its possibility of error. Every handoff of a task to another person has it's own risk of mistake.

Take the example of ordering and getting the results of an ankle xray.

Assume that getting an ankle xray takes 20 steps (it likely takes many more).
See the patient…
write the order for the xray on the correct ankle…
put the order in the clerks box…
have the clerk enter it correctly…
etc…

Let's say the accuracy of each of these steps is 98%.

In addition, the process of getting an ankle xray involves 5 different handoffs of information. The clerk, the radiology tech, the nurse, the radiologist, and the emergency physician are all exchanging information.

Let's assume that each of these handoffs has an accuracy rate of 95%.

Rolled throughput yield measures the predicted probability that an ankle xray will be ordered and completed error free.

Calculating the rolled throughput yield shows us that the probability of an error free ankle xray process is:

(0.98)²⁰ x (0.95)⁵ = only 52%

What happens if we reduce steps in the process?

We decrease the process from 20 steps to 8 steps.
Instead of 5 handoffs of information we have 3.

Now the probability of an error free ankle xray process is:

(0.98)⁸ x (0.95)³ = 73%

Every step and every handoff of information decreases the probability of an error free process.

An error the majority of the time does not result in a bad outcome for the patient. (eg "Can you re-fax that order?") However, it increases the time it takes to get through the system. It increases the frustration experienced by all involved.

Simplify the process.

Bacon Bandages

Available at Archie McPhee.
They have steak too.

Pattern of Patient Interactions

The same physician.
The same patient.
The same quality of care.
The same amount of time spent with the patient.
But there is a difference.

Visit 1: The physician spends all of her time seeing the patient at the beginning of the patient's visit.
Visit 2: The physician spends all of her time seeing the patient at the end of the patient's visit.
Visit 3: The physician divides her time seeing the patient into three separate interactions during the patient's visit.

After which visit will the patient be happiest?

Tour de Hospital: Don't show your sweat.

I sometimes sweat at work.

Capped, masked and gowned procedures under hot lights.
A difficult negotiation with a consultant.
Hungry. Must eat.
All certain to make me sweat.

I'm a big cycling fan and an avid cyclist.
July is a great month. The month of the Tour de France.

It's 107F in Fresno and I ride at 2p.
I wear an undershirt and it greatly increases my cooling.
It seems counterintuitive, more clothes in hotter weather.
A good base layer wicks away the sweat and provides a larger surface area to evaporate.

I wear a base layer at work.
I may be sweating, but you wont see it.
No wet shirts.
I stay cool.

I wear the 2007 Craft Pro Cool Base Layer.
There are many good base layers made by other companies.

A Better Patient Introduction: Smile and Handshake

Every time I walk into a room I make it a point to smile.
A gesture that shows happiness, humility, and a desire to please. I'm here to help.

This can be difficult.
I may have just pronounced a patient dead.
I may have just been insulted.
Perhaps the prior patient pointed out my crooked teeth.

If I'm not ready to smile, I wait.
I meet every patient with a smile...and a handshake.

To each person in the room, "Hi! I'm Dr. Winters."
Shake hands.

If they can't shake hands, I grasp their arm.
If they don't have arms, I grasp their shoulder.
If they don't have shoulders, they are likely very ill.

Patients don't come to the emergency department to be triaged.
They don't come to talk to registration.
They are not here to sit on gurneys in half open nightgowns.
They come to see the doctor.

Here I am.

This week smile when you meet every patient.
State your name and shake hands with everyone in the room.

Wash your hands in front of patients.

My family and I are greeted and seated at a table in our local P.F. Changs restaurant. The server notices that the table hasn't been wiped clean. As she wipes the table she says "this wipe has a disinfectant, so it will get really clean."

"Great!" I think. Half the food my 2 year old daughter will be eating will have fallen onto this table.

You may wash your hands in between every patient. Do your patients know this?

Some rooms have sinks. Some rooms don't. Some have alcohol-based hand sanitizing dispensers.

When I use the alcohol-based hand sanitizing dispensers I tell my patients I am "disinfecting my hands." I whisper it nonchalantly...as if I'm talking to myself. Otherwise they think "why is he moisturizing his filthy hands?"

If there is a sink in the room I use it before and after the physical exam.

If there is a sink outside of the room I tell my patient I need to wash my hands. I do this after I take their history, right before I examine them. Then after I leave the room I again wash my hands. If they can't see the sink I make sure they see me drying my hands with the towel.

Sometimes I will also walk to the next patient as I am finishing drying my hands with the same towel. This can save one of the washings. "Ah...look at the doctor drying his clean hands."

It doesn't matter that I know my hands are clean. My patients need to know that my hands are clean.

A Better Patient Introduction: Knock and Name

I'm in my hotel room sitting in my underwear eating cheetos when the maid walks in the door unannounced. She screams. My body covered with powdered cheesy goodness shocks her. She agrees with my colleagues that I truly look my best with a mask and cap in full surgical gown.

It's polite to knock before entering a room. Yet how often do we do this in the hospital?

I've started knocking and stating the patient's name before I enter a room.

Knock. Knock. "Mr. Jones. It's Dr. Winters. May I come in?"

But what to do if there are no doors, only curtains? A quick shake of the curtain does the trick.

Patients are often sitting bare-bottomed on a hard gurney in a cold room. Give some privacy. Let them allow you to enter.

Stating the patient's name verifies that you are seeing the right patient. Bonus points are awarded if you pronounce a difficult name correctly. Have the first person who meets the patient get the name and write the pronunciation phonetically. I have my scribe help me with this.

Knock before you enter the room.
State the patient's name.
Ask permission to enter.

A Better Patient Introduction

At the beginning of each Fresno State basketball game there is a moment of music. Dry ice blows smoke. House lights dim. Spotlights flash. The resonant voice of the announcer shouts "Yourrrr Fresno State Bulldogsss!!!" and the players burst onto the court. The crowd gets on their feet. Everyone cheers.

Why not bring this to the bedside?

Lights down. Dry ice fog. Loud thumping music. My scribe shouts "Yourrrrr Doctor Winterssss!!!" The curtains part. I chestbutt my scribe and give everyone in the room high fives.

Might be effective. Might be awkward. Might kill grandma.

Sports teams understand that the introduction sets the tone for the whole game. A great introduction announces energy and intent. It brings the home team players and crowd together.

I used to walk into a patient's room and say whatever came to mind. Sometimes this brought the patient and myself together, sometimes it was uncomfortable and ineffective.

I've worked to make my introductions more effective.

It is work to change old inefficient ways. However, it makes work more enjoyable.