Tuesday, September 3, 2019

Robbing Peter to pay Paul in Academic Medicine


"To robbe Petyr & geve it Poule, it were non almesse but gret synne.
("To rob Peter and give it Paul, it were not alms but great sin.")
Jacob's well: an English treatise on the cleansing of man's conscience, circa 1450


Measuring Clinical Effort

An increasing trend in American medicine is that clinicians (specifically Physicians) are expected to take EMR work home and take care of patient issues after hours on a daily basis.  This is rarely the case for the majority of other professions.  As the recent New York Times editorial points out, the system is taking advantage of our professionalism and altruism. (https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html). Not surprisingly, in an academic enterprise, calculation of clinical effort is more complex than in a non-academic enterprise.  Clinical effort, in my opinion, is defined as including all patient care activities, including EMR charting and responding to homework issues (EPIC inbasket).

We should develop systems to allow all clinical documentation to be done by the end of business, daily.  Clinicians taking work home and spending time away from family and other life obligations to document in the EMR are at high risk for burnout and decreased productivity. Pajama time and weekend charting are a major source of burnout and clinician dissatisfaction. 

From various sources, enlightened non-academic enterprises include EMR documentation time into their work days and allow time for clinicians to address EMR and homework issues.  They also employ clinician extenders to triage homework so only the relevant issues are presented for their review.  In enlightened practices, a clinician that is 100% clinical (5 full days of direct patient care per week) actually has half day to a full day built into their templates to address homework issues.  I will explore this topic further in another post, but before I get there, let’s discuss the crux of the issue for academic physicians.

Robbing Peter to pay Paul

In the academic arena, all too frequently, homework spills into the other half of our mission, the “academic time” which is comprised of all activities that are not direct patient care related (non patient care education / research / administrative service).  What complicates the equation is the education component, which can fall into both buckets. Clinicians that spend four days a week in clinic spend the bulk of their academic day responding to homework issues, thus negating their ability to be productive on their academic time.

Academic centers also “rob Peter to pay Paul” when it comes to allocating conference and academic travel.  Clinicians that are out for conferences are forced to make up clinics on administrative days to prevent a fall in RVUs.  As such, the academic mission suffers further. Conversely, in the private practice world, clinicians work 5 days a week (without a significant administrative component) simply accept time lost to conference and CME as the cost of doing business, and as such, lower revenue and RVU targets.  Loss of revenue is mitigated by income and business tax deductions for the conference.
Additionally, those in private practice that have administrative duties in the practice or local hospital are compensated as such.  For many in academic medicine, administrative service is simply part of the expectation of service.  Many of us enter academic medicine precisely to serve in a variety of roles.  The conflicts start to arise when one component spills into the other.

In the majority of academic institutions, conference and CME time, is taken away from academic time.  The clinician is not on campus to take care of their education / research / administrative duties, and is actually “working” full time at the conference.

For the typical work week in the academic setting, a month has 20 business days.
A clinician at 80% clinical is defined as working 80% of their time in a clinical role, so 16 days a month of direct patient care.

If a clinician is 80% clinical and goes for a four day conference, then they are expected to make up those 4 days, so the following month of 20 business days, they are swapping their four academic days to make up for their missed clinics, so they end up being 100% clinical for that month.  The average for the two months then becomes: 16 days direct patient care + 20 days direct patient care = 36 direct patient care days / 40 business days = 90% clinical effort.

As you can see, we have robbed Peter (Academic) to pay Paul (Clinical Care) and the clinician is now no longer at 80% clinical, but 90% (the great sin!)

Therefore, it is imperative that we consider CME/Conference time as a subtraction from the denominator of available business days.

My attempt at a solution:

I have had the following schema in place since 2015 as Section Chief of the Consultative Medicine service:

We have three major buckets, on any given business day, you are either in a
  1. Clinical Role: Direct patient Care +/- Patient Care education duties
  2. Non Clinical Role: Academic / Administrative / Non Patient care education duties
  3. Away: Not at work in the hospital or your office, vacation, Family Medical Leave (special case), conference, jury duty, etc.

For the typical work week in the academic setting, a month has 20 business days.  We actually break out each day into 2 sessions and have half day administrative and half day clinical care roles and do the math based on 40 business sessions a month.  For the purposes of this thought piece, I am simplifying.

A clinician at 80% clinical is defined as working 80% of their time in a clinical role, so 16 days a month of direct patient care:

Clinical Care Days / Business Days = Numerator / Denominator = 16 days / 20 days = 80%

A clinician at 60% clinical is defines as working 60% of their time in a clinical role, so 12 days a month of direct patient care:

Clinical Care Days / Business Days = Numerator / Denominator = 12 days / 20 days = 60%

My calculations:

Numerator = Number of business days per month in clinical role.
Denominator = Number of AVAILABLE Business days in a month.  (Business days – Away days)

It’s crucial to remember that clinical effort is the same if a clinician is away from the institution for vacation time.

If the clinician has 5 days of vacation, the number of available business days drops to 15 days in that month.  The 80% clinician is responsible for 80% of AVAILABLE business days: 15 x 0.80 = 12 business days of direct patient care.

The same applies for conferences and CME:

In the above example: 3 days of conference + 2 days of vacation = 5 days AWAY
Numerator = # of business days in a clinical role.

Denominator = Number of business days in a month MINUS number days away
So 12 / (20-5) = 80%

In my current practice model, no one is 60%/80%/90% each month on the dot, there are variances month to month, but the goal is to make it as close to goal as possible on a rolling quarterly basis.  In other words, at the end of each quarter, you should be close to goal, and I make manual adjustments to the next quarter to make it work out.  Any clinician that is within 5% of goal at the end of the fiscal year is considered to be on target.

Systemic and transparent use of the calculation allows us to maintain the integrity of academic enterprise.  All too often, clinicians in an academic environment are asked to sacrifice teaching / research / administrative work in pursuit of the RVU benchmark.  As a result, academic RVU benchmarks, in my opinion are over estimated.  The clinician who is forced to add on extra clinics to make up for academic conference time or vacation is actually “squeezing” more RVUs into the 80% bucket and as such inflated numbers are being reported to bench-marking organizations such as AAMC and MGMA.

At this point, health care administrators and physician leaders reading this are about to storm the barricades and make various arguments about the need for increased clinical throughput, not less.  My point is that we should be increasing clinical throughput (efficiency) for providers while they are in their clinical roles, not relying on them to make up for missed clinics by sacrificing the academic component.

Thoughts appreciated!

Wednesday, November 9, 2016

There's some good in this world...

Authors note: Originally published on 11/9/2016.  I took this post down in January 2017 because I was informed that it was detrimental to my career. After this weekend's events in Charlottesville, VA.  I will be leaving it up. Career consequences pale in comparison to to the death of Heather Heyer and those who were physically beaten by American Nazis while our President stood by doing nothing.


I have been trying to wrap my mind around what happened in the last 24 hours. A highly qualified woman lost to a racist, misogynistic, bombastic, hateful man with no credentials. All the lessons that my wife and I try to teach our children are clearly for naught for large swath of America (CNN's Van Jones said it best).

For my white friends:

You will never be looked upon with suspicion by Federal agents or the Police. I saw my 9 year old daughter humiliated by the TSA for Flying While Brown and I could not do anything about it without being arrested. (She saw a father that failed to protect her in a scary situation).

You will never experience the fear of being a 8 year old beat up in a bathroom in 1979 by kids calling you a "camel jockey" and the school authorities blowing it off as "boys will be boys" (locker room talk?).
In the last 24 hours two Muslim woman students have been assaulted by punks yelling "Trump"

My daughter is brown skinned and she is scared. My son is brown skin and he is scared.

Donald Trump has normalized public hate against minorities and people of color, and the thin veil of public decorum has been ripped away. The change that people on my side of the skin tone barrier I see is that it now acceptable to voice and act on your deepest darkest thoughts and it will be excusable because the President of the United States enables it.

Can you please explain to me why this is okay? Day 1 in Trump's America

I thought of turning to scripture or faith for solace, but that somehow rings hollow when 80% of Evangelicals voted for DJT. Somehow, the Hindu/Buddhist concept of detachment just does not apply fully.

Then I remembered the words of one very wise Hobbit, Samwise Gamgee:
Frodo: I can't do this, Sam.
Sam: I know. It's all wrong. By rights we shouldn't even be here. But we are. It's like in the great stories, Mr. Frodo. The ones that really mattered. Full of darkness and danger they were. And sometimes you didn't want to know the end. Because how could the end be happy?
Sam: How could the world go back to the way it was when so much bad had happened? But in the end, it's only a passing thing, this shadow. Even darkness must pass. A new day will come. And when the sun shines it will shine out the clearer.
Sam: Those were the stories that stayed with you. That meant something. Even if you were too small to understand why. But I think, Mr. Frodo, I do understand. I know now. Folk in those stories had lots of chances of turning back only they didn't. They kept going. Because they were holding on to something.
Frodo: What are we holding on to, Sam? 

Sam: That there's some good in this world, Mr. Frodo. And it's worth fighting for.

Lord of the Rings, The Two Towers, Director: Peter Jackson




Thursday, November 13, 2014

My Tweet went viral, now for the Mea culpa

On the afternoon of Tuesday, 11 November 2014, a small part of the twitterverse exploded.  Dr. Oz of America's Doctor fame asked for questions via Twitter using the hashtag #OzsInBox.  The adage of be careful what you wish for came true, and numerous physicians whom I follow tore into him, quickly making it a trending topic.  Mixed in with 95% tweets meant to tweak his nose and make fun of him where about 5% serious questions.  The majority of tweets were quite hilarious.

Seeing all the fun they were having, I decided to give it a try, and asked a semi serious question after midnight:


I have always wondered why Dr. Oz has not been censured or disciplined for his lack of scientific and medical morality on his TV show by his colleagues at the medical school where he holds the position of Vice Chair of Surgery.  I would like to think that if my institution had a MD that was spouting nonsense about miracle cures and melting fat away, they would be soundly denounced by their colleagues, privately and publicly.  Even if his speech is protected by the Columbia University Faculty Free Speech policy, he has an obligation, as a physician, not to mislead his viewers.

I forgot about it on Wednesday morning and went about my normal duties, occasionally checking twitter to see if someone had posted something funny.

On Thursday morning, my twitter inbox was getting busy.  Several people questioned my professionalism.  They stated that Twitter was not the appropriate platform for calling for a a fellow physician's firing;  especially since I had linked to the Columbia Department of Surgery's twitter account.  Being a relative twitter neophyte, I started answering some of the questions and tweets personally, not realizing that I was being baited by twitter trolls and others. 

Later that morning, my twitter inbox exploded.  The apparent cause was a USA Today article that featured my tweet.  My tweet was later picked up by Salon.com also





My tweet has become the subject of several mini debates about professionalism, and I have decided not to take any further part in them, and hoping it will die a natural death. As of this writing, I am the 4th top ranked mention in regards to this topic.

My Mea Culpa...

 

In hindsight, my tweet probably should have never went out.  In the twitterverse, I have been accused of being mean, unprofessional, greedy, and not being a gentleman etc...

Gentleman

Gentleman is defined by Merriam Webster as: c (1) :  a man who combines gentle birth or rank with chivalrous qualities (2) :  a man whose conduct conforms to a high standard of propriety or correct behavior. 

While I have never met the man personally, I cannot make a judgement of his personal conduct.  A such, I should not have accused him of conduct unbecoming a gentleman.  I was trying to make a humorous play on the phrase "conduct unbecoming of an officer and gentleman."  I certainly think his public conduct leaves much to be desired, but in a polite and civil society, it was low blow, and for that I am sorry.   Like others, I should have mocked the behavior, not the man.

@ColumbiaSurgery

Tagging the Columbia Med Department Surgery's twitter account also was a mistake. I should have used the hashtag #ColumbiaMed or #ColumbiaSurgery or something similar, not their actual twitter handle.  With all the retweets and mentions, I probably inundated their twitter feed and made their social media team have a heart attack.  The @ColumbiaSurgery twitter tag is designed to present the best of what they have to offer, not a platform for ridicule.  In an attempt to make things right, I did post the following apologies earlier on Thursday AM:


For the record, I do apologize to the professionals at Columbia Department of Surgery for involving them.

Unprofessional

This accusation actually bothers me the most. I have always tried to be a professional and collegial with my colleagues.  I am still struggling with the issues raised about physicians criticizing other physicians, privately and publicly.  Many medical blogs refer to not publicly criticizing another physician because it undermines the confidence of our patients.  I certainly don't do that in person, so why would I do it on twitter? My approach in person is to talk to them one on one, and it is usually about a mistake, or something missed that caused an error.  Universally, all physicians take that kind of critique at heart, and vow to do better next time. I certainly do.  One of my favorite phrases is that when it comes to patient safety, I have no ego.  I have called out MDs who I think are gaming the system, but do so in a much more professional way.

Twitter has opened up a new paradigm in terms of professional interaction on all sorts of levels.  It's great during medical conferences to discuss breaking news and controversial studies.  But again, this is using twitter to critique the topic, not the person.  Instead of using my "professional and official" twitter account which is @drsunilksahai, perhaps I should have used my personal private citizen account @sunilkumarsahai to post the tweet.  That way, it would have been me, as a private citizen commenting.  I know I am the same guy, but one account is meant for more medical news and professional interactions, than the other.  That way I can use my personal account to tweet about my cable company, airline snafus, and humorous memes that don't have a natural fit on the professional side.  I'm pretty sure my medical followers don't want to hear about my latest interaction with @att.

However, I am not sure the same can be applied in Dr. Oz's case.  He is not making medical mistakes on patients he treats and has a physician-patient relationship with.  He is promoting pseudoscience to his viewers who have put their trust into him.  I think the two are very different matters.  As of this writing, I don't have a good answer to that.  Other physicians and bloggers do a much better job at criticizing Dr. Oz than I did, so I will leave it to them from now on.

The Tweet I Should Have Tweeted: (updated 11/14 AM)






 



Monday, November 10, 2014

Medical Literature Critique:

My letter to the editor was rejected by JAMA, so I am posting it here.  It apparently did not get enough points to qualify.  With the word restrictions they have in place, it's hard to write a cogent critique in the first place.

The Article in Question:


Conclusion:  In a diverse group of high-risk patients being discharged from the hospital, we found no statistically significant effect of a virtual ward model of care on readmissions or death at either 30 days or 90 days, 6 months, or 1 year after hospital discharge.


My letter to the Editor that was rejected by JAMA editors:

Dear Editor,

I read with interest the research article by Dr. Dhalla and his colleagues (1), including the accompanying editorial by Dr. Boling (2).  The authors noted no reduction in readmissions and death between the two groups.  Dr. Boling contrasts this finding with other studies that cite a reduction in readmissions (3-5).
Several important aspects that might prove insightful were not thoroughly discussed by either author.  First and foremost, the patients were Canadian, the studies cited by Dr. Boling involved patients in the United States.  While there are issues with access to primary physicians in Canada, they are nowhere nearly as bad as the United States, where a virtual ward model may be helpful. Secondly, patients who did not have health insurance and who were discharged outside the local catchment area were excluded.  The patients that were left in the study spoke English, had health insurance, and lived locally.
For this study, the virtual ward model is analogous to having the option of purchasing a platinum service contract when buying a new car. You may either opt for the standard manufacturer’s warranty, or for the fancier service contract with free oil changes, tire rotations, etc... In both groups of warranties (standard discharge verses virtual ward) the same model of cars (patients) will break down at a similar rate, requiring a trip to the mechanic (readmission).
The patient who is discharged from a hospital in Ontario under the standard care model and not feeling well will pick up the phone and call his or her provider. The provider will then act on the patient complaint, virtual ward or not.  In the United States, our patients without insurance or providers have no one to call in the first place.  In this case, the post discharge care (roadside assistance, to continue the analogy) is provided by an intact universal health insurance system; whereas the patients discharged from the hospital in the United Sates are at the mercy of whichever tow truck driver happens to drive by.  The Canadian primary providers may not know what happened in the hospital secondary to issues with communication and electronic health records, but they will act if called by a patient.  In summary, the key difference for the differing outcomes lies in the make and model of the vehicle, not the warranty provided.

Sunil K Sahai, MD, FAAP, FACP
Associate Professor of Medicine
The University of Texas MD Anderson Cancer Center



1.         Dhalla IA, O’Brien T, Morra D, et al. Effect of a postdischarge virtual ward on readmission or death for high-risk patients: A randomized clinical trial. JAMA. 2014;312(13):1305-12.
2.         Boling PA. Managing posthospital care transitions for older adults: Challenges and opportunities. JAMA. 2014;312(13):1303-4.
3.         Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine. 2006;166(17):1822-8.
4.         Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA. 1999;281(7):613-20.
5.         Shaughnessy PW, Hittle DF, Crisler KS, Powell MC, Richard AA, Kramer AM, et al. Improving Patient Outcomes of Home Health Care: Findings from Two Demonstration Trials of Outcome-Based Quality Improvement. Journal of the American Geriatrics Society. 2002;50(8):1354-64.

Sunday, June 1, 2014

Subsidized Medical Care for International Patients: The Obamacare "Lawfully Present" loophole

Please take the time to read the note at the end of the post - abcdmd

Introduction

The Affordable Care Act contains a loophole that may (will?) destroy profit margins at elite academic hospitals.  In light of dropping reimbursements from insurance companies, many tertiary and referral centers have looked overseas for revenue. Many of these institutions rely on international patients to provide a cushion to the bottom line.  In fact, the member institutions of the Texas Medical Center sponsor a hospitality lounge in Terminal E of the IAH-Houston airport.

Medical Tourism

It is no secret that international patients coming to the United States for medical care pay more than those of us who live and work in the United States. According to a modernhealthcare.com report in 2013:

"The mean charges—or amount billed—for international patients in 2010 was $69,771 compared with $33,079 for all patients."

It is completely fair to charge international patients a premium for healthcare delivered in the United States. Foreign nationals coming to the USA for medical care have not contributed to the medical infrastructure through income and Medicare taxes, so they should pay more. In fact, when an US citizen or permanent resident sponsors a relative to visit or immigrate to the USA, they sign an "affidavit of support" stating that they will reimburse the government in case the immigrant becomes a "public charge."

The Loophole

In the past, before the Affordable Care Act, it was almost impossible for a foreign national coming to the USA for medical care to get US based medical insurance for here for pre-existing medical conditions. It would have been absurd for a private insurance company to sell a policy, and then cover long term cancer or cardiac care costing tens of thousands of dollars a month. However, as of January 1, 2014, the absurdity has become a reality.

Before the ACA of 2010, and January 1, 2014

1. Wealthy foreign national is diagnosed with breast cancer in her home country and wants to come to a cancer hospital in the USA for treatment. She contacts international patient services at the cancer hospital and they agree to see her. She goes to the local US Embassy with her appointment letter and gets a Non-Immigrant Visitor B1 (Business) or B2 (Tourist) Visa good for 6 months. There is no such thing as a "medical visa."

2. Prior to her arrival in the USA, she is required to deposit US $100,000 cash with the cancer hospital against future care and treatment. 

3. She is seen, treatment initiated with surgery, chemotherapy and radiation therapy. If her account runs dry, it needs to be replenished. She goes home in four to six months, cured of cancer. She is billed for services against the deposit account and any excess is refunded to her.

After the ACA of 2010, and January 1, 2014

1. and 2. are the same as above

3. Upon arrival in the USA, she logs onto healthcare.gov and purchases an insurance policy covering cancer care for several hundred dollars a month from the federal or state exchange. There is no way to verify income from overseas, the federal exchange has to give her a policy under the law at subsidized rates due to the fact that pre-existing conditions no longer exist.

4. She is seen, treatment initiated with surgery, chemotherapy and radiation therapy. Any copays are deducted from her $100,000 deposit.

5. Her copays amount to $20,000 over six months, the cancer hospital has to refund the $80,000 and gets the negotiated rate from the insurance company instead.

Unintended consequences

Why is a foreign national who is here for medical care on a Non-Immigrant Visitor B1 (Business) or B2 (Tourist) Visa allowed to buy subsidized insurance through a federal/state insurance exchange? At my hospital, I have noticed that a handful of patients from overseas have figured out that the loophole exists, and have gotten subsidized health insurance through the federal exchange.

According to the National Immigration Law Center facts page about the ACA (emphasis mine):

"Under the Affordable Care Act of 2010, individuals who are “lawfully present” in the United States will be eligible for new affordable coverage options after January 1, 2014. These options include access to "Pre-Existing Condition Insurance Plans" (PCIPs), to state or federally-run insurance exchanges, and to premium tax credits to help make health insurance more affordable. In their final rules on eligibility to enroll in the exchanges and to apply for premium tax credits, the U.S. Depts. of Health and Human Services and of the Treasury adopted the definition of "lawfully present" adopted by HHS for purposes of the PCIPs."

Who is "lawfully present?"

It's a big category and includes legal immigrants, asylum seekers, etc. The complete list is here at healthcare.gov. The bullet of interest is half way down, an "Individual with Non-Immigrant Status":


Again, from the NILC FAQ PDF on this subject (emphasis mine):

"Nonimmigrant visa holders include tourists, students, and visitors on business, as well as individuals who are permitted to live and work in the U.S. indefinitely. Nonimmigrants may have a status granted under 8 U.S.C. section 1101(a)(15)(A) through (V) or by a treaty such as the one described below. Some categories of nonimmigrant statuses allow the status holder to work and eventually to adjust to lawful permanent residence. Nonimmigrants who violate the terms of their status — for example, by overstaying a tourist visa or working without permission — may lose their nonimmigrant status and be considered undocumented. Nonimmigrants who have not violated the terms of their status are considered “lawfully present.”"

The key point is that a visitor here for medical care is "lawfully present" under the law as a "non-immigrant visa holder", and may purchase health insurance through the exchanges, even if they have a pre-existing condition (such as cancer). I agree that students coming to the USA to study should be allowed to purchase health insurance while they are studying (think of it as an investment in keeping the smartest ones here). I have mixed feelings about those here on business. 

Will this get fixed?

Short answer is no. The Republicans will have a field day tearing apart the ACA, and demanding another useless vote for repeal. The Democrats don't have the votes to make a change in "lawfully present." In this country, reasoned and civil debate ceased to exist years ago. I doubt HHS and CMS even have this on the radar, even though it may probably be fixed by a future rule change in the federal register.

One of my colleagues wryly remarked that China or Russia does not need to hack us or demand payment on our debt in order to bankrupt us, they just need to stop providing medical care there, and send all their people here for medical care and give them the means to sign up on healthcare.gov

What will happen?

People in suits who run elite academic health centers will notice the declining revenue and make the clinician (who is nothing more than a commodity) see more patients. They will congratulate themselves for increasing the volume of overseas patients, and then give themselves bonuses and raises, while the physician's reimbursement drops because the insurance company is losing money. These were the same people that had representation through the American Hospital Association and supported passage of the ACA.  I find it perplexing that the AHA missed this loophole while the legislation was being drafted, as they had a seat at the table.

Here's a thought! Create a new visa category called B3, Medical Visa, and exempt those that get it from getting subsidized coverage under the ACA. I doubt it is going to happen, it's way too logical....


Note: 
I tried to do an extensive amount of research and attempted to find any documentation that would refute my logic above, but have been unable to do so.  I welcome any evidence to the contrary.  I used the information from the National Immigration Law Center's website because it was easy to find and reference.  I did review the Federal Register and items in question, and think my reasoning is sound.

I am in favor of the aims of the Affordable Care Act, but not necessarily in the means that have been used to implement it. I seek only to point out one unintended consequence of the ACA, not to damm the entire legislation. 

I am a believer in social justice and fair play, and I think the presence of the loophole described below violates the intended balance that was envisioned. As a child of immigrants, and a proponent of immigration, I do not want this blog post to be considered in any way, shape or form to be anti-immigrant. I am a believer in medical tourism to the United States, as I do believe we have some of the best physicians in the world. Some of my most rewarding professional experiences have been with my overseas patients. It is a privilege to take care of them.

I welcome your comments - abcdmd