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The Happy Hospitalist

Posted Sep 18 2008 11:16am

This is an update to an earlier post on the Happy Hospitalist -- we are working double time, putting the final touches on the next "WS3" release of the Wellsphere site ... filled with amazing new features and expanded health communities... stay tuned for an announcement very soon!

Here is a recent posting I found interesting from the Happy Hospitalist, an anonymous hospital-based physician who is a member of the Health Bloggers Network.
My Theory of Game fixing

by The Happy Hospitalist ..

Often times, we as hospitalists , end up in the middle of battles that take place between patient and specialist outside the the hospital walls. We occasionally get these types of patients across all specialties. GI. Cardiology. Pulmonary. Surgery. These are patients that are fired from their respective specialists for what ever reason. Noncompliance. Annoyance. Talking too much. Failure to pay. Failure to follow up. Being an ass. Personality disorders. It doesn't matter. Any doctor can fire any patient at any time for no reason at all. They must give the patient due notice, usually 30 days, to find another physician. But as far as I know, there is no legal obligation for forced servitude once a patient-doctor relationship is severed.

A patient may come into the ED with medical complaints and get admitted to the hospitalist service. On occasion we well find out that these patients have an issue that is related to a procedure or a surgery or a medical condition that a specialist has previously managed. But what's a hospitalist to do when the issue can only be resolved by procedural intervention by the specialist. And the specialist has fired them. And other consultants won't touch them with a 10 foot pole.

At my hospital, the only obligation to see a patient is by way of the ED. If a patient is in the ED and they need a surgeon or a specialist, and that specialist is on call, our hospital bylaws state they must see the patient. But, once that patient leaves the ED and is admitted to the floor, no consultant is required to see any patient, ever, for any reason. Even if they are on call in the ED.

This policy has occasionally caused extreme difficulty in caring for patients for which I am not trained to manage. Fixing orthopaedic fractures was not part of my training. Correcting gastric outlet obstructions from gastric bypass was not in my training. Stopping a GI bleed with cautery probe was not part of my training.

Unfortunately, on too many occasions, I have been placed in the middle of situations where I am of no good to the patient. They need services that I can't provide. We provide a great service to many of our specialists by admitting patients with primary specialty problems in the setting of multiple medical conditions. And I'm OK with doing that because I know that patient would otherwise get eight consultants and a gazillion tests ordered through the polyconsult process.

However, it also means we become the abused. I have since started my own policy of having any patient that I know needs a primary service that I am not trained to provide, to have the specialist called from the ED. It alleviates hours and hours of busy work and phone calls by me playing tag with passive aggressive doctor personalities. It is the only way I can have my patient get the appropriate services they need, by those able to provide them. I know a surgeon would be none to thrilled about operating on a patient who's original surgery was done years ago. The mantra of I operate, I own apparently doesn't hold true in today's surgical training.

It seems like a lot of the problems of duty, respect, ownership and obligation between doctor and patient left the playing field when Medicare instituted their price control measures of the 1990's, which have in fact done nothing to control prices at all. Medicare used to pay usual and customary fees. But Medicare claimed they were rising too fast. But the current system hasn't solved anything. In fact, I would argue it has accelerated the cost by increasing referrals and imaging in time constrained office visits. The current system has forced the well off to pay less and the not so well off to pay nothing. It seems like doctors lack of ownership left the formula of of the doctor-patient relationship when Medicare changed the rules.

I would suspect that physicians were far more likely to provide pro bono work to those less fortunate when they received a price they felt was respectable for their services. Now that Medicare has destroyed the payment formula, doctors feel less and less obliged to provide free care. And more obliged to leave the ED's in droves to the comforts of their own clinics and specialty hospitals, by invitation only. To close their clinics to Medicare and Medicaid and feel no moral obligation to provide care. I suspect that if they were able to recuperate their fees on the backs of those able to pay, they would be much more likely to put up with the abusers, the noncompliant , the poor who are left out to the cold and use the ED as their primary service of care.

The entire culture of care was destroyed by Medicare's meddling in the 1990's. Because the rates are set by the government with obscure formulas based on faulty data and backroom politics of the elite few, the rationality of business economies have left the building. And what we have today is a direct result of that destruction. Instead of a one way street in creating a price structure, it is now entirely autocratic and functions like a dictatorship, I believe there exists a potential solution to the problem of the fixed price formulas which have created incentives in all the wrong places. I believe there should be an open access silent auction bidding process for the fees set by physicians and insurance companies. Medicare should role into town once every two years with a silent auction to set rates. Providers bid on the CPT rate schedule for the next two years. The lowest CPT bid gets to set that CPT rate for all other providers within that regional district. But here's the kicker. The winning provider gets a 25% bonus for that procedural code for ONE OF THOSE TWO YEARS, as a reward for coming in with the lowest bid. This is a WIN-WIN solution,filled game theory solutions.

You see, the incentive to come in with the lowest bid is a 25% mark up for your group for that CPT code, for that first year. But coming in below cost would be discouraged as the hit to the bottom line in year two may be unbearable. My theory would suggest that all doctors would try and provide the lowest bid they could handle, based on their business model, in order to capture the 25% bonus year, but not bid too low to lose money in year two. Large groups would certainly be at an advantage with a lower cost structure, but that's OK. Competition often creates business of scale, and if large groups can provide the same service cheaper,that's the way it should be. If your competition can provide the service for cheaper, they should win the right to get the bonus for that year. A silent auction process would guarantee anonymity as those with the lowest bid would not be encouraged to tell others as they would risk losing the 25% bonus. This would encourage all doctors offices to provide a fee schedule that was both rational reasonable and customary, but also give them the opportunity for that 25% bonus for that first year. Every doctor would have the opportunity to opt in or out based on the final fee schedule and how capable they would be financially to provide those rates. If that doctor's office is unable to accept that rate, they opt out until the next round. The same goes for all other insurance companies. The lack of access by the poor, the hurried offices, the fragmentation, the lack of communication, it's all Medicare's fault. And I bet it would all disappear when everybody is in a WIN-WIN situation.

This type of game theory would also encourage doctors to enter under served areas as the competition to their fee schedule would certainly cause a rise in fees. It's all market based. And the market always gets it right, eventually.
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Dr.Geoff's editorial note: My apologies to the anonymous happy hospitalist for an earlier version of this post that incorrectly identified him as Dr. J. Gurley
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