Friday, August 15, 2014

Physicians can refer patients to new no-cost YMCA Diabetes Prevention Program



Do you want to help senior patients avoid type 2 diabetes, but aren’t able to ensure they make the appropriate lifestyle changes? 

All it takes is a simple blood test to refer them to the YMCA’s Diabetes Prevention Program, which includes a free year-long membership to the YMCA.


More than 50 percent of people over 65 years old are at risk to develop type 2 diabetes, but many don’t even know they’re at risk. The YMCA’s Diabetes Prevention Program was created to help people who are at high risk of developing diabetes make the necessary adjustments to their diet and exercise routine through personalized coaching.
The best part? All you, as a physician, have to do is order a blood test and then recommend that the patient enrolls in the program. In order to qualify for the program at no cost, a participant must have healthcare coverage through Medicare, be overweight (BMI ≥ 25), and have a hemoglobin A1c value between 5.7 and 6.4 percent or a fasting plasma glucose (mg/dl) between 100 and 125. 
Dallas is one of 17 communities chosen to participate in the initial launch of this project, which is funded by a grant from CMS’ Center for Medicare and Medicaid Innovation. The American Medical Association is working with the YMCA in six cities to pilot programs that will improve access to diabetes prevention coaching, but Dallas is not on that short list.
Mona Roach, MD, is a family physician in Minnesota who was frustrated with the limited program options for patients at risk for diabetes. Although she referred patients to see a dietician or to enroll in a paid program such as Weight Watchers, the cost of those options could be prohibitive. 
“You try to give as much encouragement as you can, but, ultimately, it’s up to the person,” she says. “I could talk to somebody once in the office about it, but then they leave and do what they want.”
Last year, Dr. Roach encouraged two of her patients to participate in the year-long YMCA Diabetes Prevention Program. One of her patients lost 25 pounds through the lifestyle modification program and saw her blood glucose drop nine points.
“The YMCA program really combines the diet and exercise and education elements,” Dr. Roach says. “It’s definitely the best tool we have.”
Linda Funk was one of the first patients in Dallas to enroll.
“Even though I have had weight issues most of my life, my yearly test results were pretty much in the normal category,” she says. “But last fall, my doctor told me that my glucose level was too high and that I was at high risk for developing diabetes.  Type 2 diabetes was suddenly a very real — and frightening — possibility.”
Through enrollment in the YMCA Diabetes Prevention Program, she learned the changes she needed to make in order to avoid diabetes. 
“At each meeting, I received specific suggestions on how to make changes to my life that could delay or even prevent the development of type 2 diabetes,” she says. “The program is not a magic potion — I still had to make the decision to implement those changes — but now, armed with the knowledge and support that I have gained from the weekly meetings, I have been able to turn my outlook around.”

For more information about the YMCA’s Diabetes Prevention Program, including promotional materials you can distribute to your patients, call DCMS at 972-948-3622 or email steven@dallas-cms.org.

Wednesday, August 6, 2014

How Emotions Can Affect Your Practice


by Todd Pollock, MD
2014 DCMS President

I hate complications! I assume this is true for all physicians. Fortunately, as a plastic surgeon, my patients typically are healthy and complications are uncommon. But no matter how careful we are, complications eventually will occur.
Rachel (a pseudonym) was a healthy woman in her mid-40s with two kids and an active lifestyle. She fit squarely into the statistical norm of my patient demographic. Her abdomen showed the typical physical sequelae of having two kids and included a C-section scar. Rachel and her husband were pleasant, upbeat people who worked full-time jobs, exercised regularly and chased their young kids around. I felt an instant rapport with them. She underwent an uncomplicated abdominoplasty and spent one night in the hospital. The next day and at the one-week follow-up, the surgical site looked great from both a postsurgical and an aesthetic standpoint. 
About three weeks out from surgery, Rachel called my office complaining of a severe headache, malaise and a fever of 102° F. I saw her immediately. Despite knowing that I had done the procedure appropriately and that this was an unusual timeframe for a postoperative infection, feelings of fear and guilt settled in my stomach as I took her chart from the door of the patient room. Rachel looked ill, but her surgical site looked appropriate for three weeks post-op and she showed no signs of a surgical site infection. An instant feeling of relief coursed through me. I did sympathize with her and how ill she was, and considered what might be the cause. This occurred near the peak of flu season, and her symptoms fit that bill. I contacted her primary care physician, who agreed. After seeing her, he called and told me that, despite a negative rapid flu test, he believed the symptoms were so classic that he started her on Tamiflu® empirically. Again, I felt relief and a little pride in making the medical diagnosis. 

Complications
My boosted spirit was short-lived. The next morning, Rachel showed up at my office looking similarly ill, but her abdomen was markedly swollen, fluctuant and bright red from pubis to umbilicus. My feelings of fear and guilt from the previous day returned; I felt as if I’d been punched in the gut. Ever-so-briefly, my head fogged and my expression showed my shock. Luckily, she didn’t notice, as she was recumbent and staring blankly at the ceiling in a febrile haze. I recovered quickly and got her to the operating room. Upon opening the incision, I was met with a sea of foul-smelling pus, a cavernous wound and the terrifying degree of devitalized tissue. My feelings overwhelmed me and my head swam. I paused briefly to collect myself and forced down my emotions as I had been trained. 
After two returns to the OR for further debridement, the better part of a week in the hospital for twice-a-day painful dressing changes, two months of very close follow-up, and a revision of the scar, I can tell you that the end result was positive. Surprisingly, the final result was aesthetically as if the infection had never happened. Isn’t Mother Nature amazing? Possibly even more surprising, I had a happy patient singing my praises and an abundance of lessons learned. Most of these lessons were not regarding medical care (despite reviewing every detail in my head hundreds of times), but were about my emotions and how they affected my delivery of that care.
The feelings of physicians as they journey through their careers, from medical student to seasoned physician, was the subject of the 28th annual Conference of the Professions held in May and hosted by DCMS. This annual conference brings together members of the area’s medical, legal and theological professions to explore shared challenges. The host rotates among the professions; other groups participating were UT Southwestern Medical School, Dallas Bar Association, SMU Dedman School of Law, SMU Maguire Center for Public Responsibility, and SMU Perkins School of Theology. 
This year’s topic, “Agony and Ecstasy: How Your Emotions Affect Practice,” was presented by Danielle Ofri, MD, PhD, an internist at NYU by day and a prolific author by night. Her area of interest is the emotions of physicians, which she analyzes and covers extensively in her most recent book, “What Doctors Feel; How Emotions Affect the Practice of Medicine.” This book is an excellent read and I highly recommend it to all practicing physicians. It opened my eyes to the complex backdrop of emotions that engulfs us through our medical practices, and helped explain the myriad of feelings, experiences and issues we physicians share.  

Empathy is Central 
Classical medical education has emphasized that physicians must remove emotion to avoid clouding their judgment. Renowned medical educator William Osler, MD, in an address to the University of Pennsylvania 1889 medical school graduating class, stressed that “a certain measure of insensibility is not only an advantage but a positive necessity in the exercise of a calm judgment.” Yet, as humans, all of our interactions are encased in a milieu of emotion. Modern-day psychology has shown that we cannot separate cognition from emotion. The quality of the care we deliver can be affected in a positive or negative way based on if and how we choose to understand and process these emotions. I guess even old Osler recognized this as he wrote later in his career that “it is much more important to know what sort of patient has a disease than what sort of disease a patient has.”
The physician’s emotional understanding of the patient’s perception of his or her illness describes empathy, something we all discussed in our med school application essays and display to varying degrees in our practices. Dr. Ofri defines empathy as “recognizing and appreciating a patient’s suffering.” This seems central to the practice of medicine, and yet demonstrations of empathy can vary widely among physicians. The Jefferson Scale of Empathy has shown that a patient’s perception of his doctor’s empathy can have effects beyond their personal relationship. Remarkably, treatment outcomes have been linked to physician empathy. Improved controls of patient blood sugar and cholesterol as well as better oncologic outcomes all have been linked to physicians who have higher degrees of empathy. Empathy is the element that creates the subtle difference between curing and healing a patient. A cookbook algorithm, so common in medicine today, may be able to cure a patient; only an empathetic physician can heal one. I could have cured my patient’s infection with the proper medical protocol alone, but I suppose that my empathy was what made her a happy patient in the end.
The roller coaster of emotions that we experience in our medical practices affects, consciously or subconsciously, our decision making and treatment choices. My teachers echoed this. The wise Dr. Robert McClelland said that we spend our careers learning through academic sources and base our practices on our last patient. I suppose that is the “art” part of medicine. But that also is our emotions over riding our intellect.
The late and beloved Dr. Gary Purdue said that every rule in the Parkland Burn Unit has a resident’s name and the mistake he or she made attached to it. (I know the rule that has my name attached, but that is for another day.) He was saying that we learn from our mistakes, and we make adjustments or rules in our practices based on those mistakes.  
A 2000 Institute of Medicine report estimated that each year medical errors result in between 44,000 and 98,000 preventable deaths and 1 million excess injuries. These numbers have been disputed, but it shouldn’t surprise anyone that errors in medicine occur. After all, we are human and, thus, fallible. But it is the emotions that surround these errors and how we handle those emotions that make us better or worse physicians in our future interactions. Studies have shown that doctors retain strong emotions many years after a negative incident. This can surface as behavioral issues (from being generally ill-tempered to disruptive), burnout (leaving practice early), as well as drug and alcohol abuse.

Overcoming Imperfection
Review of errors is important in our growth as physicians. But, how we review errors can have a greater effect on us than we may realize. The old-school M&M probably did more harm than good. Dr. Ofri says that we experience two inherent and distinct emotions in a poor patient outcome — guilt and shame. Guilt is associated with a particular incident and resolves as the issue resolves. She says that shame, however, is an emotional reaction to the experience of failing to live up to one’s image of oneself. Shame means that we have to accept ourselves as imperfect, and humility is not a common characteristic of the stereotypical doctor. However, if our failings are driven in too hard, we may lose confidence. Although a more temperate intervention and review of an error can reinforce the lesson and make for a more careful and better physician, harsh treatment can be very destructive. For instance, many excellent physicians never emotionally recover from the harsh insult of a lawsuit, even when absolved of wrongdoing.
Our daily practice of medicine is immersed in a complex web of emotions — empathy, fear, shame, joy. And while animals may act on instinct alone and machines purely on data, humans cannot help but be affected by emotions. This especially is true in the physician-patient relationship where often we are involved in the most intimate parts of our patients’ lives: births, deaths, life-changing diagnoses, and even complications of our own treatments. Understanding the effects, both positive and negative, that our emotions play is important in how we practice, how our patients perceive us, and how they respond to our care. In the simple words of Dr. Francis Peabody, “The secret of the care of the patient is in caring for the patient.”

This post originally appeared in the President's Page of the August 2014 Dallas Medical Journal.

Wednesday, July 23, 2014


The Sunshine Act: Is it just another attack on the physician's character?

I’m concerned about what is happening to the image of physicians in this country. Throughout history, physicians have enjoyed a stellar reputation as noble, trustworthy and selfless professionals who champion their patients. Although times have changed over the millennia since Hippocrates, I see the embodiment of this spirit in my colleagues every day. Of course, like all human endeavors, we have our share of those who work on the fringe, who use their position and the trust instilled in them to take advantage of the system or the individual. That, too, I have witnessed.

I contend that these make up only a fraction of the profession and truly are outliers; however, several recent instances have spotlighted this fringe element of medicine, painting physicians as a whole in a negative light and trampling our good reputation. These things, initiated by our government, have come in the form of statements, regulations, policies, and laws which, intended or not, all potentially damage the image of the physician by implying our across-the-board complicit dishonesty, greed and abuse of the healthcare system.

I don’t know if this is the absolute genesis or just when I began to take note. In the summer of 2009, President Obama was working overtime to drum up support for his signature healthcare reform bill. He traveled across the country speaking multiple times a day to groups large and small. His passion was palpable and he was clearly well-prepared. At a press conference in late July 2009, the president told the press corps: “Right now, doctors — a lot of times — are forced to make decisions based on the fee payment schedule that’s out there. Your child has a bad sore throat or repeated sore throats. The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out.’ ”

What? Did he really just say that? Surely this man, who is basing his legacy on reforming the healthcare system of the United States, knows better. Surely he has competent advisers. He must have misspoken in the heat of the moment. But less than one month later, at a town hall meeting in Portsmouth, NH, the president went in for another jab. After detailing the medical treatment of a diabetic patient, which he states “might reimburse a pittance,” he said, “But if that same diabetic ends up getting their foot amputated, that’s $30,000, $40,000, $50,000 — immediately the surgeon is reimbursed.”

There are so many things wrong with that statement, starting with whether internists are letting diabetics get worse for the financial benefit of their surgical colleagues and progressing through a series of increasingly absurd statements to the side-splitter that “immediately the surgeon is reimbursed.” This is from the mouth of the president of the United States, with all of his resources and all of his advisers and all of his presumed knowledge of this system he is determined to completely redesign. Why would he say something so damaging to the trust between doctor and patient?

This past April, we saw the fed’s public release of raw, unverified Medicare physician payment data that showed tens of billions of dollars paid out to physicians. No explanation was given of the work that was done for those payments. This incited a media dog-pile that focused on a tiny fraction of physicians who collect millions of dollars, creating an air of suspicion without justification. Never mind the meager reimbursements for the work we performed or the flawed (SGR) system for determining payments that Congress refuses to permanently fix. Despite the nobly declared intention of rooting out fraud and abuse, this data dump seemed to serve no real purpose other than to paint physicians as greedy and to foster ill will. 

Brace yourselves, as the next salvo soon will be cast across the bows of medicine in the form of the Physician Payments Sunshine Act under the National Physician Payment Transparency Program.

The Sunshine Act, a part of the Affordable Care Act, requires manufacturers of pharmaceuticals, medical devices, medical agents, and supplies to report “payments or other transfers of value” greater than $10 (or $100 aggregate annually) to the Center for Medicare and Medicaid Services. The payments will be posted on an Open Payments website to let the sun shine on possible conflicts of interest. Those in the medical industry have been required to track these payment and so-called “transfers of value” to physicians since Aug. 1, 2013. These include consulting fees, honoraria, food, education, research, royalties, grants, and current or prospective ownership to physicians or their relatives. Physicians need not do a thing. Just sit back and take it.

As of January, physicians could begin registering with CMS for the ability to review, in advance of publication, the payments they allegedly have received over the year. There will be a 60-day review period prior to the Sept. 30 publication date. That is 45 days to review the information and 15 days to correct any errors. The physicians must work directly with the manufacturers to correct any inaccuracies. CMS washes its hands of any verification or corrections. If the dispute isn’t settled by the publication date, the payment in dispute is published anyway but with an asterisk. Despite being electronic, the data will be revised only once a year — so, whatever goes up on the website, you, the physician, owns for that year.

I tried to register on the CMS website, and I believe that CMS hired the same company that created healthcare.gov. I spent more than an hour trying to find the physician registration after meandering through page after page. Once I found the registration page, it was not a problem. So, for those of you who have stuck with me through this diatribe, here is my gift to you: https://portal.cms.gov. It took two attempts and cost me a few handfuls of hair, but I did it. When you register, be sure to have plenty of time and Propecia. 

These government actions raise several questions:

What effect will this Sunshine Act have on physicians? 
It’s hard to say. For a while, we’ll think twice before letting a drug rep into the office with a box of donuts. The Act may slow the dissemination of information on new drugs and devices. Front-page newspaper stories will feature physicians who are bringing in big bucks from the medical industry. But in the end, implementation of The Sunshine Act simply will be another waste of taxpayer dollars, another bureaucratic hurdle for manufacturers that will add to the cost of drugs and medical devices, and another sucker-punch to the eye of medicine. A more fruitful effort would be implementation of a Congressional Sunshine Act, but we all know that will never happen.

Why would there be an image campaign against doctors? 
The vast majority of physicians are honest, but a small number are not. These certainly are outliers, so must Congress think only of these outliers as it legislates? It is clear that the federal government wants deeper involvement in health care, and some people have suggested that in order for the government to justify involvement in an area not specifically within its duties, it must demonstrate a need, such as protection of the public (see Michael Crichton’s book, “State of Fear”). Perhaps the vilification of physicians is a tactic to gin up public concern and thus support government’s deeper involvement in health care. Certainly the complex and ever-changing rules and regulations of Medicare, OSHA, HIPAA, and the looming ICD-10 are making it more difficult for physicians to walk the straight and narrow, and making each of us just one step away from a breach.

How should physicians respond to these actions? 
We must continue to keep in contact with our state and federal legislators, and encourage them to press for elimination of those laws and regulations that have little real value and are costly and destructive. We must support the efforts of our physician advocacy groups, such as the TMA. We must do our best to keep up and comply with this ever-changing sea of regulations. We must maintain good relationships with our colleagues because together we stand and apart we will, no doubt, fall. We must continue to practice good and ethical medicine. But most importantly, we must continue to maintain close relationships with our patients so they will know us as we truly are and will see through the smoke-screen.

This post originally appeared in the President's Page of the July 2014 Dallas Medical Journal.


Tuesday, May 27, 2014

Is North Texas prepared for a disaster with mass casualties?


by Todd Pollock, MD, 2014 President

“Hope for the best; prepare for the worst.”
—Roger L’Estrange, 1702

Hurricane Katrina formed over the Bahamas on Aug. 23, 2005, and strengthened to a Category 5 hurricane in the warm gulf waters before striking New Orleans on Aug. 29. The city survived the initial assault, but death and destruction followed the catastrophic failures of key levees. The hurricane left 1,833 people dead and untold numbers of people injured, despite the city’s mandatory evacuation and prearranged evacuation centers, such as the Superdome, that housed more than 25,000 people who could not evacuate. The world watched helplessly on cable news as the tragedy played out.
In April 2009, an outbreak of influenza began in Veracruz, Mexico (later research points to ground zero possibly being in Asia), and Mexican authorities tried to contain the spread. Their efforts were unsuccessful and a worldwide pandemic ensued. This H1N1 influenza, similar to the virus responsible for the 1918 pandemic, mutated to kill not just the weak but also the previously healthy and strong by causing pneumonia and ARDS in a small but significant number of its victims. When the virus finally relented, more than 284,500 deaths were confirmed. However, likely more than 500,000 people had died, based on estimates that included deaths that were not confirmed by laboratory testing or were in people who did not have access to medical care. 
On April 15, 2013, at 2:49 p.m., two pressure-cooker bombs exploded near the finish line of the Boston Marathon. Three people were killed and 264 were injured in the blast set by two Russian-born brothers with extremist Islamic beliefs thought to be in retribution for US military involvement in Afghanistan and Iraq. A subsequent plot to attack Times Square was uncovered in the bombing investigation.
A little more than a month later, on May 20, 2013, tornados touched down west of Newcastle, Okla., at 2:56 p.m. and headed east, striking Moore, Okla. (pop. 57,000). Staying on the ground for 39 minutes, the tornado created a path of destruction 17 miles long and nearly 2 miles wide. With wind speeds of more than 210 mph, the EF5 tornado caused incredible damage. The National Weather Service had issued a tornado watch for the area at 1:10 p.m. and upgraded it to a warning at 2:40 p.m. It struck Moore proper around 3 p.m., giving this seasoned tornado-alley town more than 30 minutes to prepare. Despite this, 24 people were killed and 377 were injured.
Whether a warning is issued weeks, days or hours before an event, or not at all, many challenges exist in the organized and ethical distribution of first aid, triage and medical care; prevention of secondary infections; and utilization of limited resources.
Physicians have to make tough decisions in the heat of a crisis. Without planning or predetermined guidance, decision-making becomes even more daunting.
The North Texas Mass Critical Care Task Force was formed to address this. This regional collaboration is led by physicians and includes public health leaders, hospitals, ethicists, clergy, legal professionals, emergency management professionals, and elected leaders. The mission of the task force is the adoption and implementation of nationally recognized clinical guidelines for healthcare providers to use uniformly across North Texas in the event of an overwhelming disaster.

Beginnings
Efforts began in 2009 when the Dallas County Medical Society’s Community Emergency Response Committee asked the DCMS board for permission to address this issue. Under the chairmanship of John Carlo, MD, the committee began its work by focusing on the efforts of Robert Fine, MD, and the Baylor Health Care System, which had adopted a systemwide set of clinical guidelines based on the Institute of Medicine’s recommendations.
Soon after the committee started its work, DCMS became aware of the efforts of the Tarrant County Academy of Medicine Ethics Consortium, which had been working since 2006 to address ethical issues that might arise during a widespread infectious outbreak that strains healthcare resources. This led DCMS and the Tarrant County Medical Society to create the regional task force with Drs. Carlo and Fine, and two physician leaders from the Tarrant County Medical Society, Drs. Sandra Parker and Kendra Belfi, as the four cochairs.

Where the System is Vulnerable
The task force focused on two choke points in the critical care system — indications for emergency care/hospital admission and for ventilator allocation. Having consistent guidelines for these areas would better distribute the scarce resources and ensure the maximum number of survivors. Unfortunately, the state was nowhere near offering statewide guidelines, and task force organizers decided the group should not delay its work.
Fairness and consistency must be the ethical basis of any framework that allocates treatment in the face of limited resources. Therefore, the task force developed a decision-tree algorithm that protects patients by ensuring all are treated equally, regardless of considerations such as economic, social or political status.
The algorithm also protects the physicians who must make the difficult decisions.
In the aftermath of Katrina,
physicians were second-guessed and allegations of mistreatment, malpractice and even murder made headlines. Uniform guidelines give providers a well thought-out, predetermined and ethically based algorithm to follow to avoid Monday-morning quarterbacking.

The North Texas Mass Critical Care Task Force was guided by four goals:
to ensure maximum survival of individuals,
to ensure appropriate treatment is provided fairly and consistently,
to identify “best practices” in the use of the limited resources, and
to recruit the necessary leadership.

These guidelines are intended for use in Dallas, Tarrant, Denton, and Collin counties, and are to be activated only upon the governor’s declaration of a state of emergency. They do not trump individual physician judgment, but rather provide a well-reasoned and uniform framework for clinical decision-making and resource allocation in the fog of a disaster.
Draft Guidelines
After years of work, the task force has developed both adult and pediatric guidelines which provide a protocol for triage of patients, and make the best use of hospital and ICU resources that can be overwhelmed in a disaster. This draft has been approved by all involved county medical societies, hospital systems and county health departments, and the state has sent a letter of support. The protocols are based on three levels of incident severity or triage levels. Level 1 is early in a disaster or pandemic and is more preparatory in nature; Level 3  is worst-case scenario in which the strictest measures are implemented.
To ensure that the greatest number of patients survive, a modified Sequential Organ Failure Assessment (SOFA) scoring system — an objective and evidence-based formula — is used to determine an individual’s survivability. This score considers pulmonary, renal, hepatic, cardiac, and neurologic indicators to generate a score of 0–24. This score determines algorithmically the priority for hospital admission and for ventilator use, if indicated. Patients are considered low priority for hospital admission and/or mechanical ventilation if they have a low severity of illness (SOFA = 0) and thus a high chance of survival without treatment. Patients also are considered low priority for hospital admission and ventilator use if they are too severely ill (SOFA > 11) with a low chance of survival even with aggressive intervention. The most intense interventions are focused on those with the greatest clinical need and with the highest chance of survival with intervention. Every patient who needs care will receive care, although that care may strictly be palliative. The recommendations vary based on the triage level.

Your Guidelines, Your Voice
These guidelines, while fairly complete, continue to evolve and remain open for changes based on feedback and new ideas. It would be ideal if the Legislature passed safe-harbor protections for people who follow these guidelines. Unfortunately, challenges in regionalized legislation make this unlikely, and we must await a statewide plan before legislation will be considered. The Texas Department of State Health Services has notified the task force that it intends to create a statewide plan over the next two years and has invited us to participate in its development.
Feedback from physicians is most critical because we are the ones who must follow these guidelines. We must understand the basis of the guidelines and be comfortable that they are in the best interest of our community. Our patients will turn to us for answers when disaster strikes and medical care is sought, and we must be familiar enough with these guidelines to properly advise them and speak with a unified voice.
The draft guidelines, background material and minutes from task force meetings are available at www.dallas-cms.org/community_health/mcc/tfmcc.cfm.
It is important that your voices are heard before disaster strikes. Please look over the guidelines and contact Connie Webster, senior vice president of operations, at 214.413.1426 or connie@dallas-cms.org if you have questions or suggestions. Let’s hope that we never have to face a crisis of the magnitude that would stress our abundant healthcare resources. But if we do, we can rest a little easier knowing that we have prepared for the worst.

Thursday, April 17, 2014

DCMS President Responds to CMS Data Dump


In a stated effort to be “more transparent” and “help patients make informed decisions about the care they receive,” the Center for Medicare & Medicaid Services (CMS) has released information on its payments to physician. This made the headlines of every news show and newspaper last week. Headlines reveal staggering dollar amounts paid out to the physicians who serve the elderly and disabled, and highlighted a handful of physicians who collected millions. Conventional wisdom amongst physicians is to avoid the topic of compensation, but this information release and the headlines that followed necessitate a response to inject some balance and perspective.

Is this raw payment data helpful to the public in making informed health care decisions? It is highly unlikely and is more likely to deceive and inflame the public. To start, the number of physicians who collected millions of dollars from Medicare — the focus of the headlines — is represents less than 0.4% of physicians in the U.S., with a similar percentage in Texas. And, the dollar amount a physician collects tells nothing about that physician’s net income, quality of the care they provide, or whether there is any waste, fraud or abuse associated with those payments. The vast majority of physicians collects much smaller amounts and is in fact poorly compensated for the work they do by these government insurance programs.

The reality is that payments from Medicare are meager and barely cover expenses. On average, 61 percent of Medicare’s payment goes towards the treatments’ overall cost —expensive drugs, medical supplies and other expenses of running a business. The problem starts with how Medicare payments are determined. In medicine, unlike other businesses, charges don’t reflect what physicians are ultimately paid for the services they provide. The amount physicians are paid by CMS for a service they perform is derived by a formula adapted by congress in 1997 with the express purpose of controlling costs. These fees have not been increased, despite inflation and increasing medical costs, since its inception. In fact, using this formula, Medicare payments to physicians would have been cut 24.1 percent this year had Congress not stepped in to avert it. This unfair payment formula has been slated for overhaul for over a decade, but instead it was kicked down the road for the 17th time with a short-term patch. The unwillingness to permanently address this important payment issue has caused great concern among physicians, further limiting patient access as physicians often limit the number of new Medicare patients they accept into their practices.
                                                             
CMS admits that this data has limitations as it acknowledges that the information has not been verified, does not account for the disease severity of patients being treated, does not account for overhead costs of the treatments, and cannot possibly asses the quality or, more importantly, the value of care. In fact, due to the potential for inaccuracies and lack of context, this raw data is more likely to mislead the public rather than aid them in making an informed decision about their health care.

Despite this poor reimbursement, most physicians continue to treat the Medicare community out of a deep feeling of commitment to serve their patients. There is almost certainly waste, fraud, and abuse in any system as large and with as much money in play as Medicare. As a taxpayer, when waste is found, I absolutely want CMS to root it out and develop ways to avoid it. When fraud and premeditated abuse are uncovered, I expect it to be prosecuted to highest degree allowed by the law. But, this raw data — unverified and lacking in perspective —has garnered headlines and unfairly portrays the physician as at best, excessively compensated, and at worst, criminal. Rather than focus on the few who collect large sums, this information release should shed light on how inadequately most physicians are compensated under Medicare. Only a more detailed analysis of the typical physician’s Medicare compensation will provide patients and policy makers with a more accurate picture. 

Todd Pollock, MD
Dallas County Medical Society President

Friday, April 11, 2014

Organ Donation — Plan to Give the Gift of Life


by Todd Pollock, MD, 2014 President

On a beautiful Saturday afternoon last September, a good friend of mine laughed and joked with his wife and two daughters as he got on his 1993 Harley Fat Boy to meet a friend for a leisurely ride in the countryside. He was an experienced and cautious rider. When he never arrived back home, his wife found him at Parkland, admitted as a “John Doe” after being struck by a car that entered an intersection against the light. His helmet did not prevent a severe head injury and he incurred several other injuries. 

His wife, confused and in shock, called me for help as I was a doctor, and she knew I had trained at Parkland and may have some insight. My wife, Kasi, and I spent a long night with her in the Parkland ICU waiting room, sitting in as the neurosurgeon explained things, comforting her and helping her understand the medical jargon. After he was stabilized and extensively assessed, physicians determined that his head injury was not survivable. 

A young, healthy, bright man with a beautiful, loving family and a wonderful future was struck down in a second, changing forever the lives of his family and of his many close friends. I can’t remember ever feeling such profound sadness. His wife kept telling me how thankful she was for my help that night, but all I could think about was that I never had felt so helpless and how badly I wanted to do something of substance. 

As physicians, we have experienced these life and death situations, but usually in a more clinical and emotionally tangential way. We give an update to the family, briefly share a moment, and then move on. Certainly, we care and we feel — but we compartmentalize. 

Much later, I realized that what my friend had appreciated was simply our presence — she didn’t have to go through the experience alone. I remember thinking how remarkably clear her thoughts seemed and how gracefully she handled herself through this terrible time. Most remarkably, through the fog of this horrible tragedy, this wonderful woman retained the goodness in her heart to give her husband’s organs for transplantation. She was able to turn what was a devastatingly negative event for her family into one with profoundly positive effects for many other families.

This was an eye-opening experience for me. I have been fortunate to have spent most of my life on the doctor side of the equation. As physicians, we are used to building emotional walls. We marvel at the incredible science of medicine and, in this case, organ transplantation. The storied history goes back centuries — from rudimentary attempts at grafting to Carrell’s pioneering experiments and anastomotic suturing techniques, (fellow plastic surgeon) Joseph Murray’s first renal transplant, and Jean Borel’s discovery of the immunosuppressive properties of cyclosporine isolated from fungus, to name a few. Every step along the way is more fascinating and amazing than the previous. 

But then there is the other side — the human side. These are the lives that must be taken away for this amazing process to take place. These are the people who are touched by the passing of a child, a spouse, a parent, or a friend. This is the situation that physicians experience by virtue of our profession and by the randomness of being on call or working a shift. If we blink and if we don’t stop and smell the coffee, we may miss the honor and privilege we have as physicians to share this important, life-changing moment with our fellow human beings. Also part of this human side are the people whose lives are saved or immensely improved by another’s tragedy. 

The Gift
The two sides of this story — the loss of a life and the giving of a life — are told beautifully by Tara and Todd Storch in their book, “Taylor’s Gift.” They share the story of the loss of their 14-year-old daughter, Taylor, in a skiing accident and the donation of her organs. Through their words you feel the indefinable grief that accompanies the loss of a child, and a view of the hospital and the medical process from a perspective that physicians typically don’t have. As the father of a 13-year-old daughter, it was a tough read and required a lot of Kleenex. 

The Storches also shared the stories of the individuals who received Taylor’s organs. Their emotional and spiritual journey getting to know the recipients depicted how their daughter lives on through them. There was the diabetic cowboy who received Taylor’s kidney and pancreas … the nurse with two young boys who received Taylor’s heart … the young man with renal failure who dreamed of bike riding and who received a kidney … and the young girl with intractable headaches, eye pain and vision loss who was given Taylor’s corneas. But the donations did more than alleviate their medical conditions; they provided the gift of freedom for the recipients to go where they want and accomplish their goals. They received the gift of watching their children grow and the gift of being independent. Organ donation isn’t just the gift of life but the gift of living a complete life. That was Taylor’s gift.

The Numbers
According the US Department of Health and Human Services, more than 113,000 people are on the organ transplant list awaiting a donor, and a person is added to that list every 10 minutes. Over 11,000 of those awaiting transplant are in Texas. And, while nationally 79 people receive an organ transplant each day, 18 people die per day waiting for one. 

In preparation for writing this, I spoke with Todd Storch, who has become an ardent supporter of organ donation. He and his wife started Taylor’s Gift Foundation to educate the public and promote donor registration, asking individuals to register to be an organ donor and “outlive yourself.” He explained the great disconnect between people’s support of organ donation and their registering as a donor. Although nine out of 10 people believe in organ donation, most of those able to register have not done so. Only 7 percent of eligible Texans are registered organ donors. I have been told that due to efforts of the Texas Department of Public Safety through the DMV and groups like Donate Life and Taylor’s Gift, the registration in Texas is now above 20 percent. However, I have not been able to document that statistic. This pales in comparison to a national average of about 40 percent of citizens over 18 years old, ranking Texas an embarrassingly 49th in the country in 2011, according to the Donate Life America Annual Report Card.

He explained some reasons for this disparity. First, it is human nature (at least in our culture) to avoid thoughts and talk of death and our own mortality. Therefore, people tend to put off conversations with family about their wishes and the process of registering as organ donors. Second, misinformation prevails about organ procurement, such as the fear that physicians will not do everything to save a patient’s life if they know the patient is a donor. Many religious misconceptions persist, although most major religions support organ donation. 

Another major factor for Texas’ low registration rate is people’s mistaken belief that they already are registered. In 2007 when Texas moved to an Internet database, the system purged many registrants, so it is critical that you confirm your registration. Each state runs its own registry. In Texas, Donate Life Texas is a nonprofit organization that is contracted by the state to maintain the registry and educate Texans about the benefits of organ donation. (Note: This organization officially is called the Glenda Dawson Donate Life Texas, named after the kidney transplant recipient and state representative who led the effort to create the registry.) You can register or confirm your registration at donatelifetexas.org. It takes only a minute. The state registration lists are shared with and accessible only by the national organ procurement organization, United Network for Organ Sharing (UNOS), which maintains a centralized database. 

When a deceased donor is identified, the hospital contacts Southwest Transplant Alliance, our local organ procurement organization. A transplant coordinator communicates with the UNOS computer network to generate a rank list of potential recipients based on compatibility tests such as blood type, antigen and tissue matching, length of time on the list, degree of urgency (for some organs), immune status, and distance between donor and recipient. A single donor can save as many as eight lives and, with tissue donation, can make life better for a whole lot more.

April is National Donate Life month. You can take just a few simple actions and make a critical difference in so many lives. Take the time to register or confirm your registration. Have that difficult conversation with your family, and educate your friends and patients. 

Todd Storch compares organ donation to life insurance. The contemplation and purchase of life insurance is difficult, but you buy it — not for yourself, but for the benefit of your survivors. Like life insurance, organ donation provides for your survivors, but there are no premiums.

I miss my friend Mike, but I am comforted by the thought of him “outliving himself” through his organs.

Dedicated to my friend Mike May, his family, and the people who are alive and living a better life from his gift. 



This post originally appeared in the President's Page of the April  2014 Dallas Medical Journal.