Health Care Health Care Reform

When doctors meet with hospital administrators…

The meeting was remarkable. It’s not normal to get nine cardiologists to sit down with this many important hospital people. There was a CEO and CFO, two vice presidents, and a ‘consultant,’ a man who sported a nice suit but said no words. We gathered to discuss major issues in healthcare, things like budgets, pro forma estimates, physician recruitment, declining reimbursement, and yes, the electrophysiology situation.

It goes without saying that I can’t offer details. I can, however, share four big-picture things:

First…This stuff is really hard. Healthcare delivery I mean. It’s hard on people. As a regular observer of inflamed overworked people (AF patients), it was easy for me to spot the tension. It’s in the body language and faces. And this is no surprise. Tension and healthcare delivery go together. The layers of complexity boggle the mind. The only certainty is uncertainty. In that conference room were people I’ve known for more than a decade, friends and colleagues. Many have worked only here. Yes, dollars and cents are important, but self-esteem is attached as well. Ours is not a big or famous hospital, but it’s been a local success for more than 50 years.

Second…There is a major disconnect between a hospital’s financial success and good medical practice. Dr. Atul Gawande and colleagues published a telling study in JAMA last April. His team showed many US hospitals make more when patients have surgical complications. This is crazy, yet it occurs because hospitals are paid for doing things–countable things that can be coded. That’s a problem because doctors who practice minimally disruptive, evidence-based medicine tend to do fewer countable things. There are no codes for wisdom or nuance or compassion. Smart people in health policy know this, and change will come, but turning a boat the size of US healthcare will take years. In the meantime, healthcare people will have to wrestle with a system that reduces the dollar value of good medical practice.

Third…The conflict between quality care and financial success affects recruitment of young doctors. There are tight budgets. Blank checks for all-star doctors are relics of the past. Yet young doctors, especially those skilled in the latest techniques, don’t come cheap. Here we have the age-old problem in which near images impair sight of the long view. Doctors fresh out of training are the bone marrow of a practice. You need them to build that which gives a practice life. But…those who administer healthcare see the facts. Healthcare competition in most American cities turns on other factors: ownership of primary care doctors, valet parking, and satellite offices conveniently placed in the suburbs next to a Starbucks, so people only have to drive 5 minutes rather than 20 minutes to see their doctor. In this system, which is most unlike some very efficient foreign models, doctors look alike on a spreadsheet.

Fourth…I mentioned an electrophysiology situation. I do so, not because electrophysiology is that important to overall budgets, but rather that the situation highlights the concept of value. In January 2013, the Center for Medicare Services (CMS) decreed that many electrophysiology procedure codes would be ‘bundled.’ That’s policy-speak for: we are paying you less to do the same procedure. The letter might read: “Dear [heart rhythm] doctor: You do good work. We appreciate that your procedures improve patients’ lives. We understand it took decades—not twenty hours–to gather the expertise needed. Perhaps you made it look too easy. We simply don’t see the same value.”

The value of healthcare? How people see that surely depends on the position of their lens.

Note that these words are not meant to debate the value of ablation or implanting devices or providing consultation. Doctors are too conflicted to judge our own worth. This is for the American people to decide. I hope we choose wisely. I hope we do a better job valuing healthcare than we did education. It all seems so expensive until…