The Clown Car and Health Care Reform

The recent passage of the House of Representatives version of health care reform has got me thinking about the clown cars at the circus. (And no, the joke is not what you’re thinking. That one is waaaay too easy, and I like to feel like I’ve worked for my laughs. Besides, that’s not really a joke, but merely a statement of fact, just like I’ve heard it said that the mother-in-law joke is not really a joke, but a very serious question.) Thoughts of health care reform brought me to the circus because I always wondered who was driving the car. With so many clowns packed into such a small space, there seemed to be no way that a single clown had enough space to work all the controls. And while it seems to be obvious who’s driving health care reform, and who’s trying to stand in its way, it seems much less plain who actually drives the health care system.

(I think the other, subconscious influence on me might have been that I always seem to have a Schoolhouse Rock song percolating about in my head, and lately its’ been “Three Ring Government.” Schoolhouse Rock is why I also know that interjections show EXCITEMENT or EMOTION and are usually set apart from a sentence by an exclamation point, or by a comma when the feeling’s not as strong. It’s also why I know that legislative bills often wander around the Halls of Congress on their little legs in a state of semi-permanent depression.)

(Incidentally, in the course of writing this blog I also did some research into the history of the Clown Car. It turns out that the gag was first performed at the Cole Brother’s Circus in the 1950’s. Opinions vary on how it’s done. Most references say that the car parks over a trapdoor in the floor of the ring that’s covered with hay or straw, and that the wild actions of the disgorged clowns distract the audience from looking down. Others describe a hollow shell with ledges and grab-ons that allow the clowns to hold on and fit themselves in the car. But what I found more interesting was that the term “clown car” is now used to refer to a particularly fertile woman, such as the “Octo-Mom.” No comment needed, I think.)

Under most circumstances, the question of who’s in charge is actually a pretty easy one. It just depends on who you ask and who’s the villain de jour. The folks driving the car can be the evil insurance companies who charge high premiums for great profit and little return. It might be the government who provides too many benefits, too few benefits, or not enough for me and too many for you. It might be lawyers that force doctors to raise costs and shy away from complicated patients by practicing defensive medicine. (I’m still trying to figure out exactly how terms like 4-3, Zone, and Cover 2 apply to clinical practice.) It might be doctors who shun the care the uninsured to line their own pockets. It might be the administrators whose very existence depends on the proliferation of paperwork that takes time and resources away from medical care. It might be the bean counters for whom patients and medical staff are nothing more than cost centers, and who worship at the Altar of Profit, or at Least Solvency, to the idol of the Third-Party Payer. It might be drug companies and makers of medical devices, who coax doctors to prescribe expensive medications and cajole consumers with slick television ads. It might be unscrupulous health care providers and agents fraudulently milking the system. It might be societal expectations themselves that place an emphasis on the use of technology rather than thought and reason, assumptions that demand immediate satisfaction and flawless performance in an inherently inexact art. (I actually have no problem buying into the latter rationale. At a very basic level, I believe that our attitudes towards health are driven not by a particular individual or institution, but reflect, for better or worse, what we expect of society as a whole.)

But figuring out who’s in charge of the health care system is more than an exercise in blame. Thinking hard about the issue rather than relying on the blame game is key to determining where the most effective interventions within the system might be.

A number of years ago I did some part-time work for hospitals as a physician documentation consultant. In essence, my job was to remind doctors to actually write down on the chart the things they were thinking. Physicians work with a lot of commonly understood but unstated assumptions about patient care. For example, if we say that a patient has come to the ED complaining of pressure-like chest pain and shortness of breath on exertion, virtually every ED doc will have the same three or four things on his mental short list of likely causes. But because these thoughts are a given in daily use, we tend not to write things down so there’s no track record of the thought process nor of the work that goes into the cognitive part of care. Entering these thoughts within the medical record provides a much clearer picture of care for utilization review, quality improvement, physician profiling, and risk management activities.

While I’d like to think these are good and valued goals in their own right, the reason I got paid for doing this is because hospital reimbursement Medicare Part A is based on something called a Diagnosis Related Group (DRG). A DRG is a group of diagnosis within the same organ system that share a similar intensity in the use of hospital resources, and therefore are reimbursed at the same level regardless of actual cost to the hospital. The hospital that provides care at less cost than the DRG will reimburse makes money; the facility whose costs exceed the DRG payment suffers a loss.

DRG assignment is based on review of the medical record for the physician’s documentation of the principal diagnosis (the main reason the patient was admitted) and notation of any accompanying complex medical conditions (comorbidities) or complications of care which can drive up the intensity of the provided hospital services. Successfully maximizing reimbursement requires the physician, and no one else, to fully and completely document the clinical status of the patient in the medical record. For example, clinicians are well aware that pneumonia in nursing home patients (especially those with swallowing difficulties after a stroke or who feeding tubes in place) is often due to aspiration of stomach contents into the lungs. Patients with these kinds of pneumonias often stay in the hospital longer, and have more complex medical issues, than other patients with pneumonia from a different cause. But if all you write down in the medical record is a diagnosis of “pneumonia,” the hospital is reimbursed a set amount regardless of the cause. Of you take a further step and document that the patient has “aspiration pneumonia,” payment increases. And if you also note in the record that the patient has concomitant chronic renal failure or uncontrolled diabetes, reimbursement rises again. The key is that the physician has to write down what’s going on. (Those of you “in the know” will recognize that this is a slightly dated and very simplistic explanation of the system, but please bear with me for the sake of argument.)

But what came to me as I was doing this work is that despite the many outside interlopers nibbling at their heels, it seemed like from a day-to-day, operational view, physicians still actually ran the health care system. In the very narrow sense of the work I did, physician documentation drove reimbursement. But what drove the costs was the process of establishing the diagnosis and providing care, all of which are under the expert control of the physician. And I think this concept of the doctor in charge plays out in a larger sense as well. It’s the physician who provides an entry point into the health care system through the office or clinic. It’s the physician who provides the assessment, orders tests, requests consultations, and order drugs and other treatments for acute or chronic medical conditions. It’s the physician who has to balance clinical realities, resource management, consumer demands, and societal expectations while keeping the patient’s welfare first in mind. It’s the physician’s actions (or lack thereof) which drive the medicolegal system. And while physicians are unquestionably subject to, and necessarily react to, all the outside influences upon their practice, the fact remains that nothing gets done, care is not provided, costs are not incurred, paperwork is not completed, without the doctor starting the chain of events.

(I should note that I believe this not because I happen to have an MD after my name, but because it makes intuitive sense. Nothing gets done in health care without a physician either ordering a test or treatment or passively consenting to the demands of others. And as far as the MD goes, I’m of the belief that outside of the hospital, the abbreviation rarely needs to be unveiled. The only indication I have of my degree in the house…my diplomas are somewhere in the garage, because the Residential Cat isn’t easily impressed and The Child considers my educational achievements as minimal compensation for the fact that I have not memorized the plot of every episode of “Chowder” ever aired…is a framed poem called “My Daddy, MD” whose first verse reads, “Whenever Daddy signs his name he always signs MD; so everyone will know, that he belongs to me.” Okay, it’s syrupy, but I like it. Yet I thought it was well over the top…or under the ground...when I was visiting a cemetery once to find that a head stone was engraved with “Richard Barber, MD.” I would think at that point, it probably doesn’t matter. Does heaven really have special, close-in parking lots for doctors?)

So if physicians are driving the clown car, are they necessarily the cause of this mess we call health care in America? I really don’t think so. Driving the clown car over the trap door is probably the most crucial part of pulling off the gag, and the driver has to be able to do his job to the best of his ability despite all the hangers-on who want in on the show. And while the doctor may drive the car, the car itself is provided by the circus, and once the door is open the success of the act depends on the mercy of the rest of the clowns.

So it seems to me that if we really want to reform health care, we need to concentrate on the role of the physician. Here’s an example. I recently read a study that said that only 20% of physicians in the US will accept Medicaid patient into their practice by choice. Another 20% refuse to do so. The remaining 60% see Medicaid patients not by choice, but when they have to, such as when being on call at a hospital. We already know that it’s difficult for Medicaid patients to get into physician’s offices. While it’s true that expanding Medicaid gets more patients “coverage,” what makes anyone think that simply expanding Medicaid means more patients will actually get to see a physician? Or that physicians will flock to see patients on “public option” programs with undefined reimbursement rates, especially when whatever revenue the physician makes from these is offset by higher taxes and by cuts in Medicare rates?

I recognize that this runs very close to the border of saying that doctors are nothing but mercenaries. But if any of us running a small business had widgets to sell, and one group of customers were willing to pay a higher price for the widgets, wouldn’t you preferentially sell to the higher-paying group? Of course you would, and you’d be entirely within your rights to do so. And until we abandon any vestige of the status quo, put all physicians on salary, and have a single payer system, that is the way it will continue to be. (That being said, I think most physicians recognize that part of their charge is to help those in need. I even once heard a cardiologist I personally dislike as a human being…and referring to him as "human" is pushing it…take another doctor to task for refusing an uninsured consult in the hospital. “Ten percent of everything we do ought to be for free," he said. "It’s not like you don’t have food or your kid’s not going to college.” However, there is a world of difference between giving away 10% of your work…your “societal tithe,” as it were…and greater amounts. There are some studies that show ED physicians often give away over half the care they provide. I’d be quite happy to have that time, and money, back.)

So it seems to me that if we really want to achieve health care reform within the current context…and that includes not only expanding insurance coverage, but also getting patients the care they need…we should focus less on the payment plans and more on the physician. We need to find ways to get patients into the physician offices, and to make sure they get the care they need. Unfortunately the simple solutions are not very helpful. For example, I’ve heard people say that physicians should be required to accept Medicaid or unfunded patients into their practice as a requirement of licensure. But how exactly does that work? The burden will clearly fall more on primary care physicians than specialists, which is inherently unequal. And if we already have an epidemic of medical school graduates opting out of primary care to go into high-technology, high-revenue, stable lifestyle specialties, how will this practice impact care in the long run? And enforcement seems to be a problem as well. Will there be “financial police” to audit doctor’s office and decide if they’ve seen enough Medicaid patients or not? And while we might be able to entice physicians by raising reimbursement rates for patients on public assistance, what does that do to the goal of controling costs?

Crafting real solutions based on the key role of the physician requires more than a knee-jerk reaction. It needs to include a realistic assessment of why, despite the strong tradition of service to all, physicians choose to restrict their practices to certain patient groups. (There is more…a lot more…in play than just money.) It needs to include an evaluation of if there are, in fact, enough physicians in the right places and the right specialties to achieve the overall health care goals for the nation. And it needs to identify a set of operational, clinical, and financial incentives designed to entice physicians into providing care for patients who will now be covered by new expansions of Medicaid and “public option” programs, as well as to provide care to that percentage of the population who will remain uninsured.

Send in the clowns.