You Are as Smart As Your Patients – General Surgery News May 2015
As surgeons, we have always lived in the self-contained medical community bubble where our image depends predominantly on our personal and social relationships with our peers and referring physicians, and where our hospital status emanates from the volume of procedures we command, assuming a reasonable safety profile. Patients have always been handed down our recommendations as the only path to better health.
This physician-centric world belongs to the past, and the future one being charted in front of our eyes is governed by new rules that use words like “patient experience,” “engagement,” “patient-centered” and “value-based.”
This new world, outlined by the language of health care reform, was born out of the exorbitant cost of the status quo, a cost that was not matched with the quality that other less expensive systems provided.
The 2009 white paper by Thomson Reuters’s Robert Kelley, outlining where the $700 billion yearly waste in the U.S. health care system is spent, was a pivotal document for the lawmakers writing the Accountable Care Act (ACA). It is a must-read document for every physician who feels that we are subjected to an outside intrusion into the sacred physician–patient relationship (http://www.ncrponline.org/PDFs/2009/Thomson_Reuters_White_Paper_on_Healthcare_Waste.pdf).
When it comes to surgery, it is all about the 30% unnecessary procedures and how to improve on that ominous number; and yes, it is 30%! The first response by the system trying to reduce the excess and cost was to reduce reimbursement, but that led to more operative procedures and unnecessary care, since we all have heard and used the statement, “you now have to see more patients and work harder to make the same money!”
Every single dollar spent in health care follows an “encounter,” which ends with a physician “order” and the cost related to the treatment prescribed, and this is where the 30% excess cost is generated. That certainly does not mean that 30% of physicians’ recommendations are self-serving, and a deeper look into how we physicians handle decision making and how we communicate it to patients explains how the problem is caused, and proposes a natural solution. This solution is embodied by the new buzzword, “patient-centric medicine.”
As the old saying goes: “In the eyes of the carpenter whose only tool is a hammer, the whole world looks like a nail.” For many medical conditions for which there is more than one medically accepted treatment option, the medical literature is inconclusive or physicians disagree about which option is better. These conditions are referred to as “preference-sensitive” and include the care of nonemergent heart conditions, spine and joint surgery, many cancer treatments, cesarean delivery and many vascular surgical conditions. In a physician-centric model, we physicians are trained to decide for the patient. That decision is filtered by the bias and experience of the doctor, his medical community allegiances and, obviously, financial interests. The hallmarks of preference-sensitive care are geographic variation and a trend that favors the expensive treatments. As an example, a patient with a heart condition could be twice more likely to get open-heart surgery in one city or four times more likely to get a coronary stent in another, while he is unlikely to be informed that medical therapy could be as effective as both for his condition.
What is obvious is that the physician making the decision is more likely to pick an option that works for him or her rather than one that fits with the personal choice and values of the patient, as long as both are defensible and within the “standard of care.” As a matter of fact, the Cochrane review of decision aid support suggests that providing the patient with decision support tools, such as pamphlets or videos, leads to significantly less elective operations with higher patient satisfaction with the decision-making process and care, and no worsening of outcomes (Cochrane Database Syst Rev 2014 Jan 28;1:CD001431. doi: 10.1002/14651858.CD001431.pub4.).
The conclusion is that educating the patient will lead to a happier, more satisfied one, a patient who will also cost us less to attend to. The ACA thus mandates that we implement “shared decision-making,” which translates into the process of informing the patient about the existence of a choice, and rather than choosing for him, providing him with the tools to make that choice. Unfortunately, the acceptance of this change in paradigm has been slow in the medical community and more needs to be done (N Engl J Med 2013;368:6-8).
Although the ACA tells us where we need to be, it is not clear about how we should go there. Why would a surgeon want to engage in shared decision making, a process that costs time and resources and can lead to fewer operations? Where is the carrot?
The carrot is the fact that if you engage in patient education that leads to fewer operations, you will get paid more for the operations that you do, and this is how it works: Your patient is now given surveys that measure his experience in his visits with you. The most commonly used family of surveys, the Consumer Assessment of Health Providers and Systems (CAHPS), asks patients questions about whether you provided them with educational material, gave them time to ask questions, listened to them, made them feel you were in a hurry, and other questions about your practice such as waiting time, staff professionalism and others. The responses to these surveys, now used routinely by payors, will place you in a tier according to your patients’ aggregate experience. These tiers are the main tool that your organization or you have to negotiate payments, and the higher your patient experience score is, the more you get paid to do what you do.
A close look at the CAHPS survey should make every surgeon aware of what questions his patients will answer about him in the week or two following the visit, and should help him position his approach and that of his staff to improve patient experience, and thus the revenue of the practice (https://cahps.ahrq.gov/surveys-guidance/survey4.0-docs/surgical_eng.pdf).
While the implementation of shared decision making could potentially be seen as a factor that may slow down the flow of patients in a certain day, providing patients with educational material that they can go over at home could actually shorten the visits and make these visits more productive for both the physician and his now informed patient.
In conclusion, you now are as good as your patient’s health education is, and if you can figure out how to do it right in the new world of patient-centric medicine, you could actually make more money by working less!
Vein Center Accreditation Falls Short of Curbing Over-Utilization: More Patient Advocacy is Required – Vein Magazine, Summer Edition
I started my career in 1999. As a board certified surgeon, I had no abiding interest in venous insufficiency. The procedure I used to treat venous insufficiency was vein stripping, which at that time was done in the operating room under general anesthesia. While interviewing for jobs, no practice boasted about how many vein-stripping procedures they performed. Around 2001, I was exposed to percutaneous vein ablation as a less invasive alternative, which I performed in the operating room. The procedure was first billed using the same code for treatment of brain aneurysms, and reimbursement was substantial, considering how easy and fast the treatment was. “Cool” technology coupled with a sizable payment made me, like others, interested in the procedure, until it received a separate code and the payment was reduced when done in the hospital setting; however, the payment increased when performed in an office setting. This was my first exposure to the administrative and financial skills needed to perform office surgery. What followed made the performance of office-based vein procedures a very attractive aspect of a vascular practice. Physicians, like other professionals, followed the money trail, and since medicine is a supply rather than a demand-driven market, physicians managed to find more patients to treat.
Since then, office-based venous procedures have increased substantially, and so have the number of specialists offering these procedures. Since board certified general or vascular surgeons perform vein stripping in a hospital setting, most states and insurance carriers do not require any credentialing beyond a license to practice medicine and to allow and reimburse a physician for a vein ablation in the office setting.
These procedures are now performed by vascular, cardiothoracic and general surgeons, anesthesiologists, internists, obstetricians and dermatologists. A 2015 article in the New York Times reported that vein procedures are responsible for most of the growth in office vascular procedures across the Medicare population, which is on the older spectrum for treatment of such a disease entity.
While to a purist, performing these procedures should be restricted to board certified vascular surgeons or interventional radiologists, it became evident that other specialists can evaluate and treat venous conditions competently, and can refer rare or complicated cases to more specialized colleagues. Because of the obvious disarray in the credentialing, marketing and delivery of care in venous diseases, more than one board and society endorsed guidelines for the treatment of venous conditions. However, despite the establishment of societies and guidelines, the number of cases being performed kept soaring with no proof that many of these procedures are really adding value to the lives of the patients exposed to them.
As a result, the American Venous Forum, the Society for Vascular Surgery, The American Academy of Dermatology, and many others societies, in association with the Intersocietal Accreditation Commission, sponsored the Vein Center accreditation process, which guarantees the consumer a minimal standard of training and policy and procedures related to the workup of the condition and its treatment. This was a great intersocietal collaboration, which certainly adds a layer of safety and standardization to the care provided, but up until this time, the requirement of this certification as a condition for payment is far from uniform.
In addition, we know from the study of practice patterns in many other conditions that regulating the entry into an activity does not limit its overuse and, as such, competent and safe vein centers will not guarantee the transfer of information to the patient in a way that allows an informed decision based on real assumptions rather than fear. Many patients with chronic venous disease access health care not because of the clinical impact of the condition, but because they worry about life or limb threatening consequences including amputation or pulmonary embolization. Unfortunately, many of these patients get treated with procedures that will not protect them or improve their quality of life.
For this reason, the credentialing of a vein center should include clauses related to patient-sharing, now mandated by the health care reform. Advantages of shared decision making allows the patient to access information about risks, complications, effect on quality of life, and background of the treating physician. This information sharing can allow a dialogue about how the disease and the treatments relate to the patient’s preferences and expectations.
Only then will medical societies elevate themselves from the status of professional self-regulatory bodies to the higher one of patient advocacy voluntary associations.
Shared decision making, now mandated by the health care reform, is proven to reduce unwarranted care significantly, while aligning medical care with patients’ expectations and preferences.
Such an activity will seal the brotherhood of physicians treating venous diseases with a moral tie that is as important as the intellectual one of accreditation.