Inpatient Practice Medical Economics

Is A Nurse Practitioner Cost-Effective?

One of the most common requests that I get this time of year is for a doctor or a service to ask for hospital support for a nurse practitioner or physician assistant. In each instance, you have to do an analysis to determine if adding an NP or PA for inpatient management is financially worth it. In Ohio, although PAs and NPs have different training, they have similar scopes of practice and are often used interchangeably. So in this post, when I refer to nurse practitioners, it can also mean physician assistants.

In most situations, you want to ensure that by using an NP, that you are at least breaking even with the cost of the NP by the revenue generated by the NP. In Ohio, NPs can write prescriptions and bill independently. In the hospital, there are two ways that NPs can provide care with regular daily visits. (1) They can do a “shared visit” so that they do part of the encounter and documentation and the physician does part of the encounter and also does part of the documentation – in this case, the reimbursement is 100% of the physician’s reimbursement. (2) They can do an independent visit in which case the physician does not need to see the patient or document anything – these are reimbursed at 85% of the physician’s reimbursement.

NPs can either be hired by the hospital or hired by the physician. The key difference is that if they are hired by the hospital, then they are a hospital employee and as such, none of their documentation can be used for the physician’s note in order to bill a daily hospital visit. Therefore, if a physician wants an NP to help with daily rounds and note writing, then the physician has to hire the NP. Otherwise, it is a Stark violation. This primarily applies to medical admission patients – since surgeons get paid by a global fee for a given surgery, they are not required to have the same degree of individual documentation for billing daily encounters and so documentation by a hospital-employed NP doesn’t affect the physician’s reimbursement for the surgery. For hospital-employed NPs, there are creative ways that the physician can lease a portion of the NP’s time from the hospital but the NP would still need to generate enough income to pay for the portion of time that the physician leases.

In our hospital, there is a bylaw that requires that a patient has to be seen by a physician daily. Therefore, having an NP on an admitting service limits them to doing shared visits – they cannot see patients independently without a physician also seeing that patient. However, on a consult service, the NP can see a patient without the physician also seeing the patients, since the admitting physician is also seeing/documenting a daily visit on that patient. Therefore, an NP on a consult service can either do shared visits or independent visits.

Lets take the situation when the NP is on a consult service and is seeing patients independently. The average NP salary is $100,000; add in 25% benefits and that comes to $125,000. NPs tend to usually work closer to a 40-hour work week so let’s say they see inpatients Monday through Friday and the physician covering the weekend sees all of the patients the NP was following during the weekdays. We will further assume that the NP works 46 weeks a year (4 weeks vacation and 2 weeks of holidays over the course of the year).

Therefore, the salary/benefits cost of the NP is $2,717 per worked week or $544 per worked day. In order to break even on the cost of that NP, the NP would need to generate $544 of revenue per day after expenses. In a private practice, there are relatively fewer overhead expenses but in an academic practice, there are a bunch of expenses, for example: Dean’s tax, departmental expenses, divisional expenses, malpractice, billing/administrative expenses, etc. All told these typically run about 21%. So, taking into account overhead, the NP would need to bring in $688 per worked day to fully break even.

In most practices, the physician will see the initial consult on a patient and the NP will see the return visits to that patient – a consult is usually a request for the learned opinion of an experienced specialist who has spent additional years of training to become an expert in an area of medicine and so the physician usually does the initial visit and lays out an impression and plan for that admission. So, we’ll assume that the NP is seeing only return visits and bills, on average, level 2 returns (CPT 99232) – Medicare pays $71 for this level of visits; adjusting this for the 85% reimbursement received by NPs for independent visits, this equates to $60 per encounter (a little less for Medicaid and a little more for commercial insurance). Therefore, based on Medicare reimbursement, the NP would need to see 11.5 inpatient return visits per day in order to pay for his/her salary. That would work out to about 40 minutes per return visit encounter which is very achievable (assuming that the consult service is large enough to support this volume of return visits).

Physicians have higher salaries than NPs and thus the cost per hour of a physician’s time is greater than the cost per hour of an NP’s time. Therefore, NPs can be cost effective when doing very time-intensive activities such as palliative medicine, smoking cessation counseling, diabetic education, etc. Also, you have to take into account what the physician will be doing if they don’t see the return consult visits. If the gastroenterologist will be able to do more colonoscopies or the cardiologist will be able to read more stress tests, then you can afford to lose money on an NP’s salary and still come out ahead because you are able to do a lot more of a more highly reimbursed activity than you otherwise would.

So, putting all of this together, what can we conclude:

  1. NPs need to see an average of 11.5 return visits per workday in order to break even financially.
  2. It can be cost-effective for an NP to see fewer than 11.5 return visits per day on procedure-oriented services such as surgery, cardiology, or gastroenterology since the NP frees up the physician to do more procedures that pay more per hour than return hospital visits.
  3. The practice’s payor mix affects the number of visits necessary to pay the NP’s salary – a practice with little Medicaid and a lot of commercial insurance may only need the NP to see 9-10 visits per day whereas a practice with a lot of Medicaid may need the NP to see 13-14 visits per day.
  4. It is financially more advantageous to have NPs do time-intensive activities (such as counseling, arranging follow-up testing, etc.) instead of having physicians do these.
  5. It is financially more advantageous to have NPs see uninsured/charity care patients since the cost of the NP’s time is less than the cost of the physician’s time.

If the NP is doing a shared visit (either with the admitting service physician or a consult physician), then the number of return visits needed to cover the NP’s salary is less – 9.7 per day. However, since the physician still needs to see each of these patients and do a component of the progress note documentation for each of these patients, that physician’s time now needs to be considered since all of the revenue from those 9.7 encounters will be going to cover the NP’s salary.

February 5, 2017

Medical Economics Medical Education

The Hidden Time Cost Of Being A Doctor

It takes a lot of time to become a doctor. And once you become a doctor it takes a lot of time to keep being a doctor. The amount of regulatory requirements per year are staggering. These add up to time costs and every doctor has to pay these time costs, regardless of the number of patients that you see. As you will see in this post, these costs add up quickly and result in those doctors who do a lot of teaching, research, or administration spending a disproportionate amount of their time meeting these requirements.

Protected time (for research, administration, or teaching) is highly sought and highly prized in academic medicine. It has to be – the only way to get promoted and get a salary increase is to do something other than clinical care of patients. There is the obvious cost of these activities: they don’t pay very well so if a physician is going to make anywhere close to a full-time clinician’s salary, then someone else has to contribute money. But there are hidden costs – those that no one ever talks about but that can eat away at your physicians’ productivity and suck the life out of an academic department.

They’re the fixed time costs that we all pay in order to do our regular jobs. Whether you are a 100% clinical FTE (i.e., a physician who only takes care of patients) or a 25% clinical FTE (i.e., someone who only spends 1 out of 4 working hours taking care of patients), you have to do these regular activities in order to maintain licensure and medical staff privileges. And they can add up… a lot. Let’s take a look at some of the more common of these:

  1. Continuing medical education. In Ohio, we have to do 50 hours per year of CME to maintain our medical license.
  2. ACLS (Advanced Cardiac Life Support). Required for many specialties; for others, ATLS (Advanced Trauma Life Support), or PALS (Pediatric Advanced Life Support) may be required. Preparation and classwork is about 10 hours every 2 years.
  3. CITI (Collaborative Institutional Training initiative). This is required for any physician who is involved in human subject research. Because this includes enrollment in trials and not just being a funded researcher, many/most academic physicians have to keep their CITI certificate up to date just to be able to assist clinical researchers by referring patients into clinical trials. It takes about 12 hours to do the program and it has to be renewed every 3 years.
  4. Department faculty meetings. At our University, these are mandatory and held quarterly – 4 hours per year.
  5. Division faculty meetings. In our division, these are mandatory and held monthly – 12 hours per year.
  6. Electronic medical record training. Initially, this takes about 10-20 hours. However, once you are facile with it, you just need to get trained on the periodic software updates – about 1 hour per year.
  7. Compliance training. At our hospital, we have a mandatory 2 hours per year for billing/coding compliance training to ensure that we are documenting our services and billing correctly.
  8. Hospital training. At Ohio State, these fall under “CBL” (Computer Based Learning) modules. These cover everything from what to do in a fire, to how to read a hazardous materials label, to the hospital’s sexual harassment policy. They vary from year to year but typically, it is about 10 hours per year.
  9. Hospital committees. I attend an enormous number of committee meetings but I get paid to attend them as a medical director. However, no one fully escapes committees and most physicians find themselves on a couple. I’ll estimate 15 hours a year.
  10. “Justify your existence forms”. These are part of the annual review that every academic physician has to fill out to document their annual clinical/research/publication/teaching/administrative productivity and describe how they have spent all of their time over the past year. Included in this category is the “promotion and tenure dossier” that all academic physicians have to complete periodically as they move toward promotion to associate professor to full professor. In our institution, if a physician is in the so-called clinical track, even full professors have to fill these out every 2-5 years in order to have their university contracts renewed. If you include the required face-to-face meeting with the division director or department chairman, the process requires about 6 hours per year.
  11. Emails. I get 50-100 a day – most physicians don’t get quite this many. Many of these are mass emails to all physicians. Some are worthy of reading (like weekly hospital news briefs) but a lot are garbage (like people who hit the “respond to all” button on every congratulatory email sent by a chairman to recognize a notable achievement by one of the faculty members). You have to at least open all of them and skim the first few sentences to see if you need to read the rest or if you can just click the delete button on your email program. Probably about 50 hours per year on average.
  12. Licensure forms. Medical license, DEA license, etc. Plan on 1 hour a year on average to fill these out.
  13. Surveys. We get surveyed constantly – from the College, from the hospital, from the department, from outside agencies. Most physicians don’t answer most of them because there are just too many. But some are inescapable – figure 2 hours per year.
  14. Board certification maintenance of certification. This includes required “MOC modules” that some boards require physicians to do every year and also includes the renewal board examination test (every 8-10 years depending on the specific board) as well as studying in order to pass the board exam. Although some of these activities can double for continuing medical education requirements, some can’t so figure an overall average is about 5 hours per year that can’t be included in CME.
  15. Employee health. This includes the time it takes to get your annual flu shot and the time it takes to do the annual infection control learning module, among other employee health & epidemiology requirements. Overall, 2 hours per year.

So, add all of this up and you get approximately 169 hours per year that every physician has to spend doing required activities just to be able to see a single patient or to see a thousand patients. Given that most physicians work about 56 hours per week, this equates to 3 weeks of time over the course of a year. Let’s assume a physician works 48 weeks a year (off 3 weeks for vacation and 1 week for the sum of all holidays for a year). A 100% clinical FTE would need to spend 3 weeks doing all of their required activities resulting in 45 weeks of patient care per year. A 25% clinical FTE (for example, someone who spends 75% of their time doing research or administration) would have 36 weeks per year doing research/administration leaving 12 weeks per year left over to do clinical activities. However, because that physician would need to spend 3 weeks of time on all of the above activities, they would only really be seeing patients for 9 weeks per year.

The reality is that most of us end up doing most of these activities during the evening or on weekends. But they still represent a huge fixed time cost to any academic physician. As a result, you can potentially get more clinical work from one 100% clinical FTE than you do from four 25% clinical FTEs.

February 1, 2017

Electronic Medical Records

Using 50 Words To Express A 6-Word Thought

My college freshman English professor told me: “You are not writing for yourself, you are writing for your reader. Always put the reader first.” It is a great message… and one that electronic medical records (EMRs) have made us totally forget. That professor would once a week have us critique an article by a particular reporter for the Cincinnati Enquirer – our job was to completely tear it apart from the perspective of the reader. If he could get a hold of a single progress note from our hospital’s electronic medical record, he would have a enough material for an entire semester.

In a previous post, I mentioned that there are fundamentally 3 reasons to have a progress note:

  1. To communicate with other healthcare providers
  2. To provide documentation for medial-legal purposes
  3. To provide documentation for billing purposes

Electronic medical records make it really easy for us to document for billing but as a communication tool to other healthcare providers, they often fall woefully short. Our hospital uses the electronic medical record program, Epic. It is an incredibly powerful program that allows us to import all kinds of information into a progress note: lab test results, vital signs, past medical history, vaccination records, etc. As a physician, you can go wild with documentation – you can generate a 10-page note full of data just for an office visit note for a patient who comes in to get ear wax removed.

I’m on both the sending and the receiving end of electronic medical record progress notes. From other hospitals, I’ll get printed copies of notes mailed to me – pages and pages of data for a single office visit with a doctor who is co-managing the patient with me. From our own hospital, I’ll get notes from a colleague in a different specialty routed to my electronic medical record “Inbasket” and I’ll need to scroll through mounds of regurgitated data just to find the physician’s impression and plan.

But here’s the thing. If I’m treating the a person’s COPD, I don’t really need to know nor care about what their chloride level was in 2011 or the results of their last 6 normal EKGs. If I need that information, I can go to the lab or EKG section of the electronic medical record and I don’t need that information clogging up a progress note sent to me by another specialist seeing the patient for an unrelated problem.

The electronic medical record is a great documentation tool but we make it a poor communication tool.

Fear has taught us that more is better. If we include everything in the patient’s chart in our progress note, then surely we’ll get all of the right elements to withstand a Medicare billing audit. And shouldn’t we include every lab test the patient has had in the past 3 years just in case the person reading the note wants to see them? As a referring physician, I don’t really care about reading a consultant’s 11-point review of systems and re-statement of the patient’s family history since I already know this information and it is just a click away on the EMR if I need it. When it comes to really communicating in an EMR, less is usually more.

Don’t make the reader have to work to read your note.

There is a reason that we speak in sentences and that books are written using sentences. It is the most efficient way that we process the communications that are given to us. Tables and lists can help support the sentences but it takes a lot of time and brain energy to analyze tables and lists and in an EMR, most of them are just unnecessary fluff for the reader. When I get a communication from another doctor, what I really want to know is what their impression of the patient’s disease is and what they plan on doing about it. Sometimes that impression and plan is at the beginning of a long note of otherwise tabular documentation garbage, sometimes it is at the end, and sometimes it is in the middle – causing us to scroll up and down the notes trying to find out the information that we really want to know. The reader shouldn’t look at reading the progress note as a chore. The absolute best communications I get are from one of our surgeons who sends me a 1-paragraph letter saying what he thinks the patient’s problem is and what he is going to do about it. He communicates more in 2 sentences than most routed EMR notes communicate in 6 pages.

An inpatient progress note is often a communication to the outpatient physician.

My return outpatient visits are scheduled every 15 minutes. That means that when I see a patient in the office after a hospitalization, I have 15 minutes to review the record, talk to the patient, do an examination, order tests and medications, and complete my office note. I don’t have 7 or 8 minutes to spare to hunt through the recent inpatient chart to figure out what was going on with the patient and what I need to specifically follow up on. So I go to the last pulmonary consult note in the inpatient chart to see what pulmonary problem the patient was in with and what I need to be focusing on. If the patient needs a follow-up chest x-ray, or pulmonary function tests, or a decision about when to stop a pulmonary medication, I’m expecting that note to have that information. In this sense, the inpatient progress notes are not just a communication to the other physicians and practitioners seeing the patient in the hospital, they are also a communication with the outpatient physicians to insure a smooth transition from inpatient to outpatient care. Often, I’m both the pulmonary consultant in the hospital and the outpatient pulmonologist for a given patient and in this situation, my inpatient notes are notes to me and the nurse practitioner that I work with.

Don’t use a $25 word in a 25¢ sentence.

William F. Buckley was the conservative host of the TV show Firing Line and was famous for using 5 syllable words that he would pull from deep in the bowels of the English dictionary. He sounded extremely learned and intelligent but the average person couldn’t understand half of what he said. He used his extensive vocabulary like a weapon in political debates. That is great for entertainment but terrible for trying to communicate critical medical information to a wide audience of healthcare providers who will be reading your note. So don’t describe a person as macrosmatic, valetudinarian, or pauciloquent in an EMR note just because it showed up this morning on your “word of the day” app – no one else knows what it means any more than you did yesterday.

January 27, 2017

Electronic Medical Records

The PATH Audit That Almost Was

There are fundamentally 3 reasons to have a progress note:

  1. To communicate with other healthcare providers
  2. To provide documentation for medial-legal purposes
  3. To provide documentation for billing purposes

In the 1980’s, communication with other healthcare providers reigned king. We marked up medical student H&Ps with red ink if they didn’t have perfect grammar and we carefully dictated referral letters and then edited them before sending them out. Nobody cared about billing documentation back then – it just wasn’t important. All of that changed on June 21, 1996, when the Office of the Inspector General announced the PATH audits – “Physicians At Teaching Hospitals”. Although designed to be a way to protect Medicare against billing fraud, the PATH audits turned into the medical billing equivalent of the Spanish Inquisition. Federal Inspectors would do probing chart reviews of physicians at academic medical centers and if they found charts that didn’t have the right documentation elements, they would swoop in and do a massive audit of all of the physicians, often resulting in fines of 10’s of millions of dollars.

It was easy for these investigators – Medicare had established billing rules and required that the each progress note contain sufficient elements to justify different levels of billing. So, for example, a given level of billing for a new patient visit had to have at least 3 symptoms, a past medical/social/family history, 9 different systems documented in a review of systems and at least 11 different body parts examined. If the inspectors (who were not physicians) did not find all of those elements, the physician had to pay back the money from that particular bill and was also susceptible to an additional fine for each progress note that didn’t pass muster.

Although there were examples of clear fraud, for example, a surgeon who billed surgical procedures in Minnesota but had credit card receipt documentation that he was in London, England at the time, most of the cases labeled as “fraud” were really just good doctors trying to take care of patients but not documenting every part of their physical exam or forgetting to list all of the patient’s previous surgeries in their H&Ps. There was also a dark side of the PATH audits because they could also be vindictively.

You see, if a person called the Inspector General’s whistleblower hotline and it resulted in an audit of a physician (or better yet, a large academic medical center group practice), then the whistleblower got to keep up to half of all of the fines that the government collected. You could become a multimillionaire simply by calling in the dogs of the Inspector General.

In the late 1990’s, I was the subject of such a vindictive investigation. We had recently cut the salary of some of the physicians in our group because of low productivity and I was in charge of the clinical/financial management of the group. That year, 3 of our physicians left and one particular physician left the University, harboring a lot of anger and resentment, mainly directed to me since I was perceived as the one who cut his salary. So, he called the Inspector General’s whistleblower hotline alleging that I had fraudulently billed millions of dollars to Medicare. Because of the enormous dollar amount alleged, the OIG descended on our hospital’s medical records department and pulled every single progress note, procedure note, and H&P I had written or co-signed over a 3-month period.

It took them months to comb through thousands of my notes and with each note, they had a scorecard that they would check whether or not I had enough review of systems documented and enough body part examinations documented. It must have cost the OIG a small fortune to send investigators to review all of these notes. We hired an attorney to represent me through this process because of the fear that if I didn’t have the right documentation, it could open the door to a dreaded PATH audit that could essentially wipe-out the physician faculty ranks at Ohio State University. After the completion of the audit, here is what they found:

  1. I had over-billed by one level about 5 times (I had to pay back the difference – total was less than $100)
  2. I had under-billed by one or two levels about 25 times (total was about $2,000 but they don’t give you any money back in this situation)
  3. I had a few notes that I had written when billing ventilator management charges (used by pulmonologists rather than the more documentation-intensive return visit charges). Unfortunately, in addition to my notes, my medical students also had notes in the chart that referred to the ventilator settings and ventilator weaning. Because Medicare classifies ventilator management as a procedure and because any procedure done by a medical student, even with full supervision by the attending physicians, cannot be billed to Medicare, they asked for all of the money back for these notes – total about $200. Although I had done all of the actual ventilator analysis and written all of the orders, since the students also documented the ventilator settings, they said that the “procedure” of ventilator management involved medical students so I couldn’t bill it.
  4. I had come into the hospital one night to see a patient with acute respiratory failure in the ICU – I intubated her, put a central line in her, and did a bronchoscopy. In addition to the procedures, I also billed a critical care charge – for this charge, you have to document that you spent at least 31 minutes providing critical care services independent of any procedures. I had my documentation right there – 11:40 PM to 12:25 AM and I had each procedure note timed with a different time either before or after the critical care times. However, the auditors stated that since the time crossed midnight, 20 minutes of the time had to be accounted to one calendar day and 25 minutes to the next calendar day and since neither of the days’ time was >31 minutes, I couldn’t bill any critical care charges and in fact, was not allowed to bill anything. I had to give back $175.

Before this, I had been a documentation freak so my notes were actually very well-documented and so the amount I had to pay back to Medicare was truly trivial. The OIG spent many times that much in salary, hotels, food, and airfare for the inspectors that they sent to Columbus. My ex-partner got nothing as a “whistle-blower” and our University did not get a resultant PATH audit.

Our electronic medical records now make it simple to ensure that each note has the required number of body parts examined and the correct minimum number of systems documented to be reviewed in the review of systems. The PATH audits have gone away because there just isn’t any money in it for the OIG anymore. However, the legacy of the PATH audits is the topic of my next post – the cluttering of physician progress notes with excess documentation by doctors who do electronic medical record documentation overkill to avoid even a chance of not having enough documentation to support a Medicare bill in the event of an audit.

January 23, 2016

Operating Room

Robots In The Hospital – Its Not Like Robots In The Factory

There are a lot of signs that the “great recession” that began in 2008 is over. The unemployment rate is the lowest that it has been in 12 years. Manufacturing output is back to pre-recession 2008 levels and close to a record high. However, manufacturing jobs are not; in fact, America has lost 5 million manufacturing jobs since 2000. The reason isn’t that they’ve been stolen from low wage countries, the reason is robotics.

Over the past 25 years, advances in production robotics has resulted in many of the factory jobs once done by assembly line human workers now being done by robots. They are faster, they are more accurate, they don’t have expensive fringe benefits, they don’t go on strike, and they don’t call in sick. In other words, automation of U.S. factories has reduced production costs and eliminated an enormous number of manufacturing jobs. And those jobs are not coming back. In our factories, robots replace people.

The robots are gaining a foothold in our operating rooms, too. But in the OR, they are not replacing people. The most commonly used surgical robot is the da Vinci system. It runs about $2.5 million per robotic unit. Until last month, our hospital was the only hospital in town without a da Vinci robot but we recently purchased one in order to grow our hernia repair program and our gynecologic surgery program. You see, we compete with our neighboring hospitals to attract surgeons and younger surgeons want access to the robots that they used when they were training as residents and fellows. If you don’t have a robot, the top young surgical recruits are going to go across town to your competitor hospital. Moreover, many patients have a perception that surgeries done with a robot are better than those done solely by hand. Having a surgical robot is no longer a competitive advantage for a hospital, it is a competitive necessity.

You need just as many people in the operating room when you are doing a robotic surgery as you do without a robot. You see, unlike in the factory, where manufacturing robots replace people, in the operating rooms, surgical robots augment people. The surgical robot is not used for “automated surgery” but instead is controlled by the surgeon who sits in a console and controls the arms of the robot. Instead of the surgeons hand holding a scalpel, the robot’s arm holds the scalpel and the surgeon’s hand controls the robot’s arm. With cameras on the end of the robotic arms, this allows the surgeon to get into tight places and use smaller incisions than he/she could with  a regular open procedure. This translates to less post-operative pain and more rapid recovery. It doesn’t necessarily make the surgery faster or less expensive – it just makes the surgery better.

Automation, robotics, and computerization has had huge impact on U.S. manufacturing jobs. But that is just the beginning. The prototypic self-driving cars of today will give way to the self-driving trucks of tomorrow and in 15 years, we as a country will be lamenting the loss of transportation and trucking jobs just as today we lament the loss of manufacturing jobs.

But at least for the foreseeable future, the intrusion of robots into the operating room is not going to translate to a loss of OR jobs. So, if you are a teenager and your career goal was a  union job at the General Motors plant, you need a new goal. And if you think you can go to truck driving school and have a job to last a lifetime, think again. But for the next 15 years, a robot is not going to take your operating room job away.

January 20, 2017

Life In The Hospital

Guilty Until Proven Innocent

A couple of weeks ago, I got one of those calls that you dread as a medical director. I was in the office seeing pulmonary patients and one of the hospital supervisors paged me to tell me that a nurse covering patients on one of the hospital floors smelled alcohol on the breath of one of the doctors. She then asked one of the other nurses if she also smelled alcohol and the second nurse said yes, she also smelled alcohol.

Anyone can report that they suspect a physician is under the influence of alcohol or drugs at work: another physician, a nurse, a patient, a family member, anyone. When that happens, the medical director has to immediately sequester the physician and remain with the physician until the lab director can do testing with a forensic breathalyzer or do urine drug testing, depending on the substance allegedly consumed.

This is a priority that takes priority over other priorities and means that I had to drop what I was doing and go to the hospital to meet the physician in a conference room and keep him under direct visual contact until testing could be completed. As it happened, the lab director was in a hospital in a different county doing an administrative review so it was going to take 2 hours before he arrived. It was a Friday afternoon and I had patients that had driven in from all over Ohio and West Virginia to see me – my office staff had to tell them that I was not able to see them due to a hospital administrative emergency and send them home to be rescheduled.

Around 5:00, the breathalyzer arrived and the results were completely negative. It turns out that he had french onion soup for lunch and just had “onion-breath”. He went back to the nursing units to round on his patients and I got on the phone to apologize to my outpatients who had to drive back to their home towns without seeing the doctor.

This isn’t the first time that this has happened and I’m sure it won’t be the last time. The 2 most recent episodes were triggered by patients who called the hospital’s administrative offices to report that their attending hospitalists were intoxicated in the hospital. In both cases, the physicians were immediately removed from patient care duties and emergent cross-coverage was arranged until the physicians could be breathalyzer and urine tested – in both cases the results were completely negative. In investigating, we found out that in both cases, the patients were demanding opioid pain medications and the hospitalists suspected them of drug seeking opioid abuse. When the hospitalists would not prescribe Percocet, the patients retaliated by reporting the physicians being under the influence. Its a cunning strategy: a drug-seeking patient who gets the reputation of making a doctor’s life miserable if they don’t prescribe narcotics tends to get what he/she wants the next time since the physicians don’t want to have to be sequestered for a couple hours pending drug or alcohol testing. During those 2 hours, some other hospitalist has to cover twice their normal number of patients and at the end of the day, the sequestered hospitalist ends up working 2 hours past their normal shift just to get their work done.

On the other hand, we have had times when physicians have been at work under the influence and so we just can’t take any chances. In order to maintain the integrity of our profession, we have to take each allegation with the highest level of seriousness and we have to immediately remove the physician from patient care responsibilities until we complete the testing. It is unfortunate that some patients with knowledge of this policy take advantage of it in order to get what they want – usually narcotic medications. In this sense, the accused physician is guilty until proven innocent.

January 17, 2017

Medical Economics Physician Finances

Do Happy Doctors Make Less Money?

I was reading over the 2016 Medscape Physician Compensation Report and was struck by some of the results. Every year, Medscape does a survey of physicians about their income, job satisfaction, demographics, etc. Last year, 19,200 physicians, responded to the survey and it unveiled some curious results.

Perhaps not surprisingly, the 6 specialties with the highest incomes were:

  1. Orthopedics ($443,000)
  2. Cardiology ($410,000)
  3. Dermatology ($381,000)
  4. Gastroenterology ($380,000)
  5. Radiology ($375,000)
  6. Urology ($367,000)

Equally unsurprisingly, the 6 specialists with the lowest incomes were:

  1. Pediatrics ($204,000)
  2. Endocrinology ($206,000)
  3. Family medicine ($207,000)
  4. Infectious disease ($215,000)
  5. Allergy ($222,000)
  6. Internal medicine ($222,000)

The real surprise came in the responses to the question “Would you choose to go into medicine again?”. The physicians in specialties that were most likely to respond that if they could do it all over again, they’d still go into medicine as a career were:

  1. Family medicine (73%)
  2. Internal medicine (71%)
  3. Rheumatology (70%)
  4. Pulmonary (69%)
  5. Infectious disease (69%)
  6. Pediatrics (68%)

The the physicians in specialties that were least likely to go into medicine again if they had to do it all over again were:

  1. Plastic surgery (47%)
  2. Radiology (49%)
  3. Orthopedics (49%)
  4. Urology (51%)
  5. Dermatology (53%)
  6. General surgery (54%)

Notice anything striking? The physicians in the lowest paid specialties were most likely to choose a career in medicine if they were just starting out again whereas the physicians in the highest paid specialties were least likely to go into a career in medicine again.

I’ve been thinking about this and came up with a few possible explanations. First, it could be that the highest paid specialties are the most grueling and stressful leading to greater burn-out. Second, there could be career selection bias if medical students choose specialties based on projected income rather than what they are passionate about. Third, it could be that having more money makes you lament the fact that you don’t have very much time to enjoy it.

However, I’d like to think that there is a fourth explanation. The physicians who were most likely to say that they would choose medicine again were in specialties where there is temporal continuity of the doctor-patient relationship. By that I mean that those physicians tend to have patients that they take care of for years and even decades and develop long-standing bonds with those patients.

In my pulmonary practice, I have patients that I have managed their asthma for 25 years. Patients that I’ve seen regularly since placing airway stents 20 years ago. Patients who are the children of my patients from years past. These are people who when I look at the next day’s office schedule, I look forward to seeing them again. Over time, you become vested in a patient’s health, in their life, and in their family. It is one of the great satisfiers in medical practice.

In recent years, we have been under increased pressure to increase productivity. I’ve often been asked by business leaders to increase my new-to-return patient ratio by seeing more new patients and transferring return patients to advanced practice providers to see to see for follow-up visits. From a short-term revenue standpoint, this makes total sense, because those new patient visits pay better and have a lot of down-stream revenue to the health system. But in the long-term, it is the return patient visits that create the bonds that make physicians say, “If I had to do it all over again, I would”.

For doctors, money can’t buy you job satisfaction but maybe the doctor-patient relationship can.

January 14, 2017

Medical Economics

Medicaid Reduces Emergency Department Use

A couple of months ago, Ohio Senator Sherrod Brown visited our hospital to do a press announcement about legislation that he and Senator John McCain were sponsoring. After the formal event, I spent a few minutes speaking with Senator Brown. I was telling him about how we had seen a decrease in our emergency department visits ever since Ohio enacted Medicaid expansion. He challenged me by saying that the published data did not support the contention that Medicaid expansion reduces ER visits and in fact, some literature suggested just the opposite, that states that participated in Medicaid expansion actually saw an increase in ER visits. My explanation was that our ER was different in that we had an extremely high percentage of uninsured patients prior to Medicaid expansion, our hospital is in what was previously a “primary care desert”, and that since Medicaid expansion, we have greatly increased our primary care footprint in the neighborhood. Senator Brown remained skeptical but the next week, I got a handwritten note from him thanking me for my comments and telling me that it was a good conversation.

I’ll preface this post by letting you know that I’m politically ambidextrous – I’m not registered with either political party and vote for whoever I think is the best candidate for an office, regardless of party affiliation. Over the past 25 years, we have had unbelievably great Senators: John Glenn, Mike DeWine, George Voinovich, Sherrod Brown and Rob Portman. Prior to October, I had never met Senator Brown but I found him highly intelligent and very quick thinking – he won me over.

So, after our meeting, I started questioning my own observations. And then the recent Ohio Medicaid Group VIII Assessment: Report to the General Assembly was released and it validated our hospital’s recent experience.

Ohio’s governor, John Kasich, enacted Medicaid expansion in January 2014. Prior to that time, our hospital’s uninsured rate (for admitted patients) was about 12.5%. That means that we didn’t get paid for 1 out of every 8 patients admitted to our hospital. The uninsured rate in our ER was even worse. It was bad for us as doctors to not get paid for providing medical services, but it was even worse for the patients. Most of them could not afford the medications that were prescribed in the ER and most of them did not have access to primary care physicians for basic preventive care. So, for example, if a patient came into the ER with a severe asthma exacerbation and we stabilized them with nebulizer treatments and some IV steroids, they couldn’t afford the inhaler prescription that they got (average about $300/inhaler) and so they bounced back in a week and then became unemployable because of work absences.

After Medicaid expansion, our hospital’s admitted patient uninsured rate fell to 2.3%. That’s huge. And the percent of poor Ohioans without insurance dropped from 32% to 14%.

However, since 2014, we saw a funny thing in our monthly financial reports. Our emergency department visits started to drop. OSU purchased our hospital in 1999 and we had seen a steady and striking increase in ER visits from 1999 through 2013 – we had projected and budgeted for a continued increase so this was a bit alarming. But although our ER visits fell off, the number of emergency squad arrivals per day were continuing to increase and the number of hospital admissions through the ER continued to increase. This means that we were continuing to see more of the sicker patients but we were seeing fewer of the less sick patients, the so-called “treat and release” patients. My belief had been that we were getting more of these patients into Medicaid coverage so that they could fill their prescriptions and get non-emergent care at less expensive primary care physician locations that they now had access to.

The newly released Ohio Medicaid Group VIII Assessment report now shows that what we have observed is real – that Medicaid expansion has reduced ER visits. For adults between 19 and 44 years old, ER use dropped from 1,557 to 1,279 per 100,000 – an 18% reduction. For adults between 45 and 64 years old, ER use dropped from 1,349 to 877 per 100,000 – a 35% reduction.

43% of Ohioans in Medicaid expansion reported a decrease in unmet health needs and only 8.3% reported an increase in unmet health needs. 48% reported an improvement in their overall health and only 3.5% reported that their health had worsened. The previously unemployed Ohioans reported that it was easier to look for work now that they had Medicaid coverage and those that had a job said that Medicaid made it easier for them to keep their job.

State-wide, 702,000 people are enrolled in Group VIII Medicaid from the Medicaid expansion. In Franklin County, 18.5% of adults under age 65 are enrolled in Medicaid – that is nearly 1 out of every 5 adults. The counties along the Ohio River are even more striking with 25-30% of adults on Medicaid. 

So what does all of this mean? From the hospital’s perspective, Medicaid expansion is keeping patients out of our emergency department. And for most of these patients, that is a good thing. Emergency rooms are for patients with emergencies and not for patients with minor problems that don’t have any other access to healthcare.

Some would argue that Medicaid expansion is excessively expensive and that it needs to be abolished. I would argue that without Medicaid, these same patients would still be getting sick, it is just that they don’t get good treatment for their conditions so rather than being cured of their diseases, their diseases would just smolder – making them perpetually clog up our emergency departments and making them unemployable. When they get sick, our ERs, hospitals, and doctors still have to take care of them on moral, ethical, and legal grounds and so they continue to consume our country’s healthcare resources so we all end up paying for it with higher healthcare costs to everyone else. In the long run, the cost to our society is greater without Medicaid expansion.

January 10, 2017

Life In The Hospital

The Nuns Versus Blue Cross

Anyone who has been to our hospital recognizes it right away. It is circular. If you are driving from the east into Columbus on interstate 70, it rises up in front of you like a giant cylinder on the horizon. Each nursing unit is round and the patient rooms are all on the outside, like slices of a gigantic pie.

OSU East’s tower had a (nearly identical) twin sister building in Columbus, the Christopher Inn which was designed by African-American architect, Leon Ransom and was built by the Elford building company in 1963. For 25 years, it was Columbus’s premier downtown hotel and local famed jazz musician, Bob Allen and his trio played in the bar nightly. On our wedding night in 1983, my wife and I stayed at the Christopher Inn and I vividly remember the two of us walking down the curved stairs to the bar with her wedding dress flowing down the stairs behind her with Bob Allen playing a jazz song. Sadly, The Christopher Inn was demolished in 1988 – although ultramodern in the 1960’s, by 25 years later, it was dated and out of style.

Ohio State University Hospital East first opened as St. Anthony’s Hospital in 1891, built and operated by the Sisters of the Poor of St. Francis. In the 1969, St. Anthony’s Hospital opened its new tower building, also designed by Leon Ransom and constructed by the Elford company.

When the Sisters of the Poor worked with Ransom to draw up the initial architectural plans for their new hospital tower, the Sisters wanted to do something really innovative, namely, make all of the rooms private. Up until that time, the industry standard was semi-private hospital rooms. These were rooms with 2 patients, generally separated by a pull-back curtain. Hospitals contained mostly semi-private rooms with a few “VIP rooms” that were private for only one occupant. Part of the reason for the semi-private rooms was that insurance companies would only pay for a semi-private room since a private room was considered an unnecessary luxury at the time.

But the Sisters really, really wanted to have all private rooms. In that sense, they were innovative and quite forward-thinking. The problem was, when they went to Blue Cross with their plans, the insurance company said that it would not pay for private rooms, only semi-private rooms as was their standard practice for inpatient coverage throughout the country.

So, after a lot of negotiation, the Sisters struck a deal with Blue Cross. The hospital would be allowed to have all private rooms but they would have to be exactly 1/2 the size of a standard semi-private room. In exchange, Blue Cross would pay semi-private room rates for inpatients admitted to the hospital.

Now, we have circular nursing units that have about 30 patient rooms per floor, each room being half the size of a normal semi-private room at other hospitals. Since 1969, a lot has changed in healthcare and now, the industry standard has moved from semi-private to private rooms. Hospitals are scrambling to convert their old 2 patient rooms into 1 patient rooms. Furthermore, hospital rooms now require more monitoring and medical equipment that takes up space.

Also, our patients are bigger than they used to be. In 1960, the average American man weighed 166 pounds but by 2010, the average man weighed 196 pounds. In 1960, the average American woman weighed 140 pounds but by 2010, the average woman weighed 166 pounds. That means that in the past 4 decades, the average man in the United States weighs about 30 pounds more and the average woman weighs 26 pounds more. Bigger people means bigger beds, bigger chairs, and tighter spaces in the rooms designed for the smaller patients of the 1960’s.

At the OSU Medical Center, we have several different hospital buildings. Our newest building is the new James Cancer Hospital, a beautiful 21-story building on Ohio State’s campus that opened in 2014. It has the largest private rooms at 314 sq ft. The Ross Heart Hospital (built in 2004) is the second newest building with private rooms at 302 sq ft. Before that was the original James Cancer Hospital building (now the OSU Brain and Spine hospital building) that originally opened in 1990 with private rooms that are 239 sq ft. Rhodes Hall is one of two buildings of the main University Hospital and opened in 1976 with semi-private rooms that have now largely been converted into 224 sq ft private rooms. Doan Hall is the oldest of the OSU Medical Center buildings still in operation and was built in 1951 – its semi-private rooms have been largely converted to private rooms that are 214 sq ft.

The nuns were way ahead of their time in demanding that hospitals be made of private patient rooms. But now, 40 years later, there are new demands in hospital rooms and in the future, hospital room construction will require even larger rooms to accommodate even larger American patients, more medical & monitoring equipment, and family members whose expectation is to stay overnight with patients. Additionally, as we have more emphasis on eliminating hospital-acquired infections and utilizing contact/airborne/respiratory/enteric isolation precautions, semi-private rooms will become a curiosity of history and private rooms will be the only kind of U.S. hospital patient rooms.

For me, I have my eyes set on constructing a new patient care tower with 325 sq ft rooms. Now, if I could just find $70 million…

January 7, 2017

Emergency Department

Found Down With A Needle In The Arm

“39 yo female presented in cardiac arrest after being found down with needle in her arm. Multiple epinephrine and Narcan given prior to arrival with no ROSC. Resuscitation continued briefly with PEA on monitor and patient was pronounced dead.” Every week, we review all deaths in the hospital. One of our quality nurses summarizes each case in a couple of sentences. Every 2-3 weeks, there is one similar to this one from last week. The perpetrators: heroin and fentanyl.

We often consider heroin abuse as a problem of modern times. But opioid use has been with us for at least 5,000 years and heroin abuse has been a plague on humanity for more than 100 years. It all started with the ancient Sumerians. They migrated from what is now Iran to settle between the Tigris and Euphrates rivers around 5,000 BC. They had one key advantage over all of the other tribes in the area, in that they learned irrigation techniques to keep their crops from dying during periods of drought. They flourished and by 3,000 BC, they had invented writing and from their writing, we can learn about what crops they grew. For example, we know that they grew barley and about 40% of it went to the brewing of beer. They also grew poppies that they called the “plant of joy”.

By 500 BC, the secret of opium poppy cultivation spread to the Akkadians, the Assyrians, the Egyptians, and then the Greeks. Two thousand years later in 1,500 AD, Europeans had figured out that you can get a stronger effect of opium by smoking it rather than by drinking it and from this was born the opium dens. With fast and sturdy sailing ships, the Europeans were eager trade with China for spice, porcelain, and silk. But Europe needed something to take to China in return and that something was opium.

In 1720, the British East India Company shipped 15 metric tons of opium to China and by 1840, that had increased to 2,555 metric tons. In 1804, morphine was first extracted from opium and it rapidly gained commercial success as an analgesic. In 1874, a chemist in London was experimenting with morphine by mixing it with various acids and he created diacetylmorphine. His work was forgotten and then in 1897, Felix Hoffman, working for the Bayer chemical company accidentally synthesized diacetylmorphine when he was trying to produce codeine. Scientists at Bayer had just invented another drug that they called aspirin and the head of Bayer decided to move forward with diacetylmorphine first because it was felt to have more commercial potential than aspirin. They called their new product heroin and said that it was 10 times more effective then codeine as a cough medicine and more effective than morphine as a pain reliever. They also pushed it as a treatment for asthma, bronchitis, and tuberculosis. In its first year, Bayer produced 1 ton of heroin. It was initially claimed to be completely non-addictive but soon there were heroin addicts world-wide and by 1913, Bayer decided to stop producing the drug.

Today, 80% of the world’s heroin comes from poppies grown in Afghanistan. Here in the United States, most heroin comes from Mexico and Colombia. Mexican heroin production has significantly increased over the past decade, rising from 26 tons in 2013 to an estimated 70 tons in 2015. The reason for the increase is the economics of capitalism in its purest form. First, Drug cartels previously were primarily in the business of cocaine and marijuana importation but with the increase of legalized marijuana production in the United States for recreational and medicinal purposes, the demand for illegal Mexican marijuana fell significantly. Second, coincident with this was the burgeoning appetite of Americans for opioid prescription pain pills resulting in a rather dramatic increase in the American demand for opioids. With a recent nation-wide crackdown on excessive opioid prescriptions, the supply of pills dried up. The reduction in the demand for Mexican marijuana and the increase in demand for opioids resulted in a ramped up production in Mexican heroin as business shifted from cannabinoids to opioids. It is simple supply and demand – the heart of capitalism.

A big part of the cost of heroin is the transportation costs – getting it across the U.S. border. As with any transportation cost, if you can decrease the size of your product, you can reduce your cost to get it to the market. Enter fentanyl. In medicine, we’ve used it as an intravenous anesthetic for many years. It is 50-100 times more potent than heroin. Therefore, by adding fentanyl to heroin, you can dramatically decrease the size and weight of the opioid, thus significantly decreasing transportation costs. So now, we have heroin that is often more than just heroin and will additionally contain fentanyl and its many derivatives, such as carfentanil (which is 100 times more potent than fentanyl)

The net effect of this is that we now have heroin available on the street that is more potent and cheaper than ever before. A single dose of heroin costs about $10-$15 dollars. In comparison, to buy a 40 mg oxycontin tablet on the street will cost about $25-$40. So, heroin is now usually cheaper than prescription pain pills when purchased illegally. As “pill mills” declined, street sales of heroin exploded.

In 2014, 1 out of every 300 Americans used heroin and more than 10,000 Americans died from heroin overdose. And the number keep going up. In 2015, 1,424 Ohioans died from a heroin overdose, an increase from 1,196 in 2014. Fentanyl overdose deaths in Ohio increased from 503 in 2014 to 1,155 in 2015. Last year, Franklin County (Columbus, OH) had 279 drug overdose deaths. Heroin and fentanyl have emerged as the top overdose killers in our state. At the same time, deaths from prescription opioids has fallen.

The Sumerians didn’t die of overdoses from sipping tea made from poppies 5,000 years ago. The Europeans didn’t die from overdoses from smoking opium 300 years ago. And people didn’t die from drinking Felix Hoffman’s newly invented heroin 100 years ago. But today, we have cheap and incredibly powerful heroin and fentanyl derivatives that make it all too easy to overdose and die, for as little as $15 or $20. So, for the near future, a chief complaint of “Found down with needle in her arm” will continue to be a common first line in the emergency room chart and a common epitaph on our nation’s gravestones. Opioid deaths come down to the principles of Economics 101.

January 3, 2017