Showing posts with label Texas. Show all posts
Showing posts with label Texas. Show all posts
Tuesday, May 10, 2011
Doctor in the House: an interview with author Congressman Michael Burgess, M.D.
When Dr. Michael Burgess gave up delivering babies in favor of kissing them, most physicians thought he was crazy.
After reliving the September 11th World Trade Center nightmare in his head for weeks, the successful obstetrician decided to run for Congress in his Republican district of North Texas against the well-funded and well-named son of then Majority Leader Dick Armey.
Not only did Burgess win, but he has quickly become the thought leader of American medicine in the United States Congress.
In his new best-selling book, Congressman Dr. Burgess retells the story of his first years in the House of Representatives where another nightmare unfolded: the Democratic creation of Obamacare.
His work is entitled Doctor In The House and it contains the prescription necessary to heal the ills of American health care.
In this blog we engage in a spirited discussion with Dr. Burgess. Let us know what you think.
Friday, April 15, 2011
Do physicians make good employees?
There has been a clamor of legislation this past year in many states, including Texas, that would allow for the employment of physicians.
For some readers of this blog that may seem like an odd statement. Texas is one of the few states that still prohibit "corporate practice." This is where physicians work directly for a business entity rather than either working for another physician or physician group.
For Texas and the states that prohibit this practice, the reasoning has always been that this separation helps maintain the clinical autonomy of the doctor-patient relationship. And I would agree with this wholeheartedly.
Having a physician's judgement clouded in any way by the perceived need to make a bottom line is a recipe for disaster. Fortunately, most physicians understand this risk and are masters at handling the tense relationship they might have with their employers.
But the question here isn't whether physicians should be employed, but will they make good employees?
Most people would define a "good employee" as one that shows up for work on time, provides dedicated service, treats the business like their own and functions well in a team environment.
Most of the physician friends that I know all show up to work on time.
And most physicians I know treat the business like their own -- if they are the owner.
And as for team play? Well, let's just say that coed basket ball games in medical school were tense at times. Team play isn't something that is necessarily a reviewed credential in medical school applications.
As a former hospital based medical director, I've seen physician groups owned by health care systems have a turnover near 25%. And with the cost of recruiting a physician close to $250K including startup costs, first year salary guarantees and signing bonus -- that's absurd.
Physicians that are hired fall into two basic groups. They are right out of school, owe $200K in school loans and are uncomfortable in the current environment with starting a new practice from scratch. They have no experience with this model anyway -- most of their teachers are already working in an employed relationship at a medical school or hospital. Their exposure to business is only through these providers.
Or, the physicians are frustrated with private practice: the alarming increase in overhead, growth in liability risks, the long hours, lack of good call coverage and the continual decline in reimbursement. They are seeking employed relationships primarily so they can continue to do what they are called to do. They want to see patients and continue to practice medicine and let someone else worry about the business.
See the commonality here? Both groups don't want to worry about the business.
Hiring employees that "don't want to worry" about the business seems like a recipe for disaster for me.
For now hospitals and health care systems can pay a premium to hire doctors. They are funded under a payment scheme that allows them to have either profits (for profit hospitals) or margin (non profit hospitals) that can be redirected to hire doctors to refer to their hospital so they can make more profits and more margin.
But, for many systems, this doesn't work long term.
Here's an example: Dr. Welby has practiced for years in a community as a family practice doctor. He is well known, works 80 hours a week, has a nurse, two office staff, and a small office that is paid for and hasn't been updated since the 70's -- including the magazines.
Despite this frugal existence he is financially challenged because of the escalating benefit costs for his employees, higher malpractice premiums, and he can't remember the last time he received a rate increase from any payer. Most of his patients are Medicare; twice in the last year he wasn't paid at all because Congress didn't fund the health care for older Americans.
He's tired and looking for help.
In rolls Sister Daughter Felicia Hospital System -- they are a not-for-profit health care system (not-for-profit means they don't pay taxes and "System" is a word right from Modern Healthcare: makes you seem like a big health care team -- read on). They have a physician run medical group that they own, but don't directly control. Well, let's just say they do control the budget for the doctor group. And it always runs at a loss, so the hospital system is perpetually in a position of having to "bail out" the group and define budgetary goals and direction. So there is some control.
They meet with Dr. Welby, show him their electronic health record, how they achieve quality metrics in virtually every measure of health improvement, how U.S. News and World Report thinks they are a Top 100 hospital, and how they will take care of the front desk operations and provide staff. And, oh by the way, they have a new medical office building that has a gym, day care, and even a Starbuck's.
To make things better for Dr. Welby they'll even buy out his practice by purchasing his accounts receivable (there aren't that many), take all of his records, and give him a guaranteed salary for a year and a signing bonus. All he has to do is sign here and start to work.
Now Dr. Welby will have the agreement looked over by a lawyer -- the same guy who did his home refinance and his divorce. The hospital will say that "it's the same agreement that we all sign" and then will grin -- they have Fulbright and Jaworski on their side.
There is back slapping, and maybe even champagne if its a Catholic hospital system, and everyone enjoys the moment and the win.
All will be good for a few months. The staff will not like the move with all the new processes and procedures and uniformity. The patients will not like it because they have to pay to park, will get bills they may not be familiar with and there will like be some changes in health insurance coverage.
The doctor won't like it all either: certain drugs won't be on formulary, there will be an electronic medical record to learn that will "hurt my work flow," and there won't be the complete control of the practice that he's used too.
But there are benefits. It is likely that he will slow down his daily schedule by 25 to 30 percent, there will be less importance on admitting his patients to the hospital ("I'll let the hospitalist do that"), and when it comes to doing procedures it will just mean more work and more risk of weekend responsibilities.
The hospital system will overlay a whole new set of overhead for the physician ranging from new office space (read: more cost/foot), "indirect costs or overhead" that is difficult to explain (but includes many things the physician never purchased before like legal retainers, marketing, telecommunications infrastructure, bill boards, JCAHO, nurse managers, case managers, coding and compliance staff, float nurses, retreats and meetings, helicopters -- you get the picture), and staff whose benefit and salary structure is the same as that of the hospital and is richer and more expensive.
So fast forward one year later.
The hospital is not happy because the physician's practice is losing money -- actually bleeding money. Patient volume is lower and revenue is stark. They don't understand why the physician isn't working harder. They are now going to roll him into an income distribution formula where part of his compensation will be based on volume and the rest on "performance measures." The result will likely be lower pay.
He's not happy with the lower pay and pushes back. He claims its the hospital system's fault: all that higher overhead, not collecting his payments, not billing his claims right, and he can't read, understand, or have access to the right financials. "And what about that indirect costs -- what's that?!?"
So one of three things will happen. He will either leave, and the hospital will have to recruit a replacement. He will stay and conform somewhat but continue to publicly gripe about the system and be disruptive and not a team player. Or, he will conform to the hospital model and all will be well.
The hospital will be in little position to do anything about the overhead issue. But, most systems will work with the physician for awhile, supporting the practice, because they don't want to be seen as "running someone off."
What's the solution?
Certainly models that allow the physician to maintain some autonomy and responsibility for their own practice will help some. Convincing the physician of the long term benefits of some of the good things the hospital has to offer (such as quality improvement and infrastructure) and getting buy-in will be good for all involved. Convincing the hospital that the physician needs to be included under the tent and as a part of the team will also be part of the solution.
Congress could go a long way by aggressively creating gain sharing models that allow both sides of the health care team to be paid for improvement in health care value. This would promote team work and alignment.
But in the end, in the current model, do physicians really make good employees? And do hospitals really make good employers?
For some readers of this blog that may seem like an odd statement. Texas is one of the few states that still prohibit "corporate practice." This is where physicians work directly for a business entity rather than either working for another physician or physician group.
For Texas and the states that prohibit this practice, the reasoning has always been that this separation helps maintain the clinical autonomy of the doctor-patient relationship. And I would agree with this wholeheartedly.
Having a physician's judgement clouded in any way by the perceived need to make a bottom line is a recipe for disaster. Fortunately, most physicians understand this risk and are masters at handling the tense relationship they might have with their employers.
But the question here isn't whether physicians should be employed, but will they make good employees?
Most people would define a "good employee" as one that shows up for work on time, provides dedicated service, treats the business like their own and functions well in a team environment.
Most of the physician friends that I know all show up to work on time.
And most physicians I know treat the business like their own -- if they are the owner.
And as for team play? Well, let's just say that coed basket ball games in medical school were tense at times. Team play isn't something that is necessarily a reviewed credential in medical school applications.
As a former hospital based medical director, I've seen physician groups owned by health care systems have a turnover near 25%. And with the cost of recruiting a physician close to $250K including startup costs, first year salary guarantees and signing bonus -- that's absurd.
Physicians that are hired fall into two basic groups. They are right out of school, owe $200K in school loans and are uncomfortable in the current environment with starting a new practice from scratch. They have no experience with this model anyway -- most of their teachers are already working in an employed relationship at a medical school or hospital. Their exposure to business is only through these providers.
Or, the physicians are frustrated with private practice: the alarming increase in overhead, growth in liability risks, the long hours, lack of good call coverage and the continual decline in reimbursement. They are seeking employed relationships primarily so they can continue to do what they are called to do. They want to see patients and continue to practice medicine and let someone else worry about the business.
See the commonality here? Both groups don't want to worry about the business.
Hiring employees that "don't want to worry" about the business seems like a recipe for disaster for me.
For now hospitals and health care systems can pay a premium to hire doctors. They are funded under a payment scheme that allows them to have either profits (for profit hospitals) or margin (non profit hospitals) that can be redirected to hire doctors to refer to their hospital so they can make more profits and more margin.
But, for many systems, this doesn't work long term.
Here's an example: Dr. Welby has practiced for years in a community as a family practice doctor. He is well known, works 80 hours a week, has a nurse, two office staff, and a small office that is paid for and hasn't been updated since the 70's -- including the magazines.
Despite this frugal existence he is financially challenged because of the escalating benefit costs for his employees, higher malpractice premiums, and he can't remember the last time he received a rate increase from any payer. Most of his patients are Medicare; twice in the last year he wasn't paid at all because Congress didn't fund the health care for older Americans.
He's tired and looking for help.
In rolls Sister Daughter Felicia Hospital System -- they are a not-for-profit health care system (not-for-profit means they don't pay taxes and "System" is a word right from Modern Healthcare: makes you seem like a big health care team -- read on). They have a physician run medical group that they own, but don't directly control. Well, let's just say they do control the budget for the doctor group. And it always runs at a loss, so the hospital system is perpetually in a position of having to "bail out" the group and define budgetary goals and direction. So there is some control.
They meet with Dr. Welby, show him their electronic health record, how they achieve quality metrics in virtually every measure of health improvement, how U.S. News and World Report thinks they are a Top 100 hospital, and how they will take care of the front desk operations and provide staff. And, oh by the way, they have a new medical office building that has a gym, day care, and even a Starbuck's.
To make things better for Dr. Welby they'll even buy out his practice by purchasing his accounts receivable (there aren't that many), take all of his records, and give him a guaranteed salary for a year and a signing bonus. All he has to do is sign here and start to work.
Now Dr. Welby will have the agreement looked over by a lawyer -- the same guy who did his home refinance and his divorce. The hospital will say that "it's the same agreement that we all sign" and then will grin -- they have Fulbright and Jaworski on their side.
There is back slapping, and maybe even champagne if its a Catholic hospital system, and everyone enjoys the moment and the win.
All will be good for a few months. The staff will not like the move with all the new processes and procedures and uniformity. The patients will not like it because they have to pay to park, will get bills they may not be familiar with and there will like be some changes in health insurance coverage.
The doctor won't like it all either: certain drugs won't be on formulary, there will be an electronic medical record to learn that will "hurt my work flow," and there won't be the complete control of the practice that he's used too.
But there are benefits. It is likely that he will slow down his daily schedule by 25 to 30 percent, there will be less importance on admitting his patients to the hospital ("I'll let the hospitalist do that"), and when it comes to doing procedures it will just mean more work and more risk of weekend responsibilities.
The hospital system will overlay a whole new set of overhead for the physician ranging from new office space (read: more cost/foot), "indirect costs or overhead" that is difficult to explain (but includes many things the physician never purchased before like legal retainers, marketing, telecommunications infrastructure, bill boards, JCAHO, nurse managers, case managers, coding and compliance staff, float nurses, retreats and meetings, helicopters -- you get the picture), and staff whose benefit and salary structure is the same as that of the hospital and is richer and more expensive.
So fast forward one year later.
The hospital is not happy because the physician's practice is losing money -- actually bleeding money. Patient volume is lower and revenue is stark. They don't understand why the physician isn't working harder. They are now going to roll him into an income distribution formula where part of his compensation will be based on volume and the rest on "performance measures." The result will likely be lower pay.
He's not happy with the lower pay and pushes back. He claims its the hospital system's fault: all that higher overhead, not collecting his payments, not billing his claims right, and he can't read, understand, or have access to the right financials. "And what about that indirect costs -- what's that?!?"
So one of three things will happen. He will either leave, and the hospital will have to recruit a replacement. He will stay and conform somewhat but continue to publicly gripe about the system and be disruptive and not a team player. Or, he will conform to the hospital model and all will be well.
The hospital will be in little position to do anything about the overhead issue. But, most systems will work with the physician for awhile, supporting the practice, because they don't want to be seen as "running someone off."
What's the solution?
Certainly models that allow the physician to maintain some autonomy and responsibility for their own practice will help some. Convincing the physician of the long term benefits of some of the good things the hospital has to offer (such as quality improvement and infrastructure) and getting buy-in will be good for all involved. Convincing the hospital that the physician needs to be included under the tent and as a part of the team will also be part of the solution.
Congress could go a long way by aggressively creating gain sharing models that allow both sides of the health care team to be paid for improvement in health care value. This would promote team work and alignment.
But in the end, in the current model, do physicians really make good employees? And do hospitals really make good employers?
Tuesday, February 22, 2011
Re-bamacare: Is health care reform now a problem for Republicans?
The public relations nightmare for the Obama administration's health care plan last year now seems to be a problem for the Republicans.
Republican lawmakers have long wanted more intense reforms of insurance laws that purport to stream line the system, lower cost, and cut out redundancy.
Of course the concern for patients is that the only sure fire way to lower health care costs is to restrict access and therefore lower utilization.
Patient advocates have long been skeptical of Republican promoted health care (read: insurance reforms) because below the surface the bills seem to be reminiscent of old war style cronyism: pandering to the insurance companies and corporate medicine.
True or not, that's not the purpose of my discussion today. This is more about the table turning anti-Obamacare public sentiment that is now being carefully redirected toward these Republican proposals.
Particularly in state legislatures where lawmakers are now struggling to balance state budges with escalating deficits, every possible revenue source or cost cutting move is being critically examined.
On the surface many of these ideas seem plausible -- directly employee physicians so that their prescribing and ordering habits can be controlled.
Given that the most expensive piece of medical equipment in America right now is the pen, this would seem to be on target.
Limit tests or procedures, force the use of quality guidelines and metrics, cross share lab to prevent redundancy, and put physicians smack in the middle of a care management team to increase quality and value for patients.
And to make more money for the corporate entities involved.
The problem is not whether something like these rules need to be implemented -- they do -- the problem is that absent proper oversight and restraint the slippery slope of profits and revenue would suggest that patients might get the short end of the stick.
Just imagine if your physician was told to use a certain drug, a certain provider for a procedure or diagnostic test, a particular institution for your surgery -- your choice would be gone as would that of the physician.
Now certainly we are all going to have give up some health care decision freedom as we move to limit the exponential rise in health care expenditures.
But patients and physicians need the opportunity for some autonomy in the doctor-patient relationship.
Whether it is contractural protections against wrongful termination, protections against adverse hospital decisions, prohibitions against forced admissions, or whistleblower protections, physicians need to maintain some degree of separation from the unintended consequences of corporate America.
Patients need this as well.
What's been fascinating to watch is that in multiple states where Republicans are using the budget shortfall as a steam roller to clear a path for any proposal that seems to save money, the health care changes related to employment and insurance reform seem to be hitting a snag.
Dubbed "____-bamacare" depending on the lawmaker in question, use of this phrase immediately conjures up negative sentiment not only among the public but also among fellow Republicans who might not be so forward educated on the benefits at stake.
This is particularly evident in Texas where Lieutenant Governor David Dewhurst is seeing push back on his proposals to expand corporate control of health care.
From visiting with hundreds of patients its clear that monkeying with anything to do with a patient's health care choices, particularly now in this post-Obamacare sensitivity, is a risky move.
It is likely that good proposals will also potentially fall on the sword with our President's plan.
Patients seem to be tired of government intervention in health care. They recognize the need for changes in the cost, but they are still not convinced that government or big business is in the best position to make these decisions.
They are probably right.
- Posted using BlogPress from my iPad
Republican lawmakers have long wanted more intense reforms of insurance laws that purport to stream line the system, lower cost, and cut out redundancy.
Of course the concern for patients is that the only sure fire way to lower health care costs is to restrict access and therefore lower utilization.
Patient advocates have long been skeptical of Republican promoted health care (read: insurance reforms) because below the surface the bills seem to be reminiscent of old war style cronyism: pandering to the insurance companies and corporate medicine.
True or not, that's not the purpose of my discussion today. This is more about the table turning anti-Obamacare public sentiment that is now being carefully redirected toward these Republican proposals.
Particularly in state legislatures where lawmakers are now struggling to balance state budges with escalating deficits, every possible revenue source or cost cutting move is being critically examined.
On the surface many of these ideas seem plausible -- directly employee physicians so that their prescribing and ordering habits can be controlled.
Given that the most expensive piece of medical equipment in America right now is the pen, this would seem to be on target.
Limit tests or procedures, force the use of quality guidelines and metrics, cross share lab to prevent redundancy, and put physicians smack in the middle of a care management team to increase quality and value for patients.
And to make more money for the corporate entities involved.
The problem is not whether something like these rules need to be implemented -- they do -- the problem is that absent proper oversight and restraint the slippery slope of profits and revenue would suggest that patients might get the short end of the stick.
Just imagine if your physician was told to use a certain drug, a certain provider for a procedure or diagnostic test, a particular institution for your surgery -- your choice would be gone as would that of the physician.
Now certainly we are all going to have give up some health care decision freedom as we move to limit the exponential rise in health care expenditures.
But patients and physicians need the opportunity for some autonomy in the doctor-patient relationship.
Whether it is contractural protections against wrongful termination, protections against adverse hospital decisions, prohibitions against forced admissions, or whistleblower protections, physicians need to maintain some degree of separation from the unintended consequences of corporate America.
Patients need this as well.
What's been fascinating to watch is that in multiple states where Republicans are using the budget shortfall as a steam roller to clear a path for any proposal that seems to save money, the health care changes related to employment and insurance reform seem to be hitting a snag.
Dubbed "____-bamacare" depending on the lawmaker in question, use of this phrase immediately conjures up negative sentiment not only among the public but also among fellow Republicans who might not be so forward educated on the benefits at stake.
This is particularly evident in Texas where Lieutenant Governor David Dewhurst is seeing push back on his proposals to expand corporate control of health care.
From visiting with hundreds of patients its clear that monkeying with anything to do with a patient's health care choices, particularly now in this post-Obamacare sensitivity, is a risky move.
It is likely that good proposals will also potentially fall on the sword with our President's plan.
Patients seem to be tired of government intervention in health care. They recognize the need for changes in the cost, but they are still not convinced that government or big business is in the best position to make these decisions.
They are probably right.
- Posted using BlogPress from my iPad
Location:Jacksonville, Florida
Wednesday, October 27, 2010
Perry-Palin in 2012? Hillary Clinton in 2012?
As we enter the final weekend of this political season I thought I would take a few moments to suggest some possible scenarios for 2012 that will begin as soon as the last ballot is cast on Tuesday.
Here are some thoughts:
Perry-Palin 2012? Could this be the next Republican dream team? Before I get the laugh lines and hate mail let me make my point.
Both of these individuals have been or are Governors from large states with many similarities. Texas and Alaska have faired much better than their counterparts in the latest recession, have enjoyed a relatively friendly tax environment, have benefited from the increase in energy demand, and, lets face it, represent geographically about a third of the United States.
But more importantly both Rick and Sarah correctly identified early on the upswing of the Tea Party movement and latched on. I think this "movement", I don't really think it qualifies as a Party yet, has surprised almost everyone's expectations about its growth and popularity. I'm not sure where it will end up, but these two mavericks have been riding the wave into this election season.
Both have also been able to run as "non-incumbents". This has been easy for Palin (read: jobless), but despite the anti-incumbent rage sweeping the country, Perry has been able to be the outsider in the current Texas governor's race. He has successfully painted his opponent as being part of the "problem" by using his mediocre performance as Houston mayor as the whipping post.
Will I vote for this team? Not sure, but it will make for an interesting discussion as we move into next year and both are not running for President. Right.
Now think about this: Hillary Clinton the Democratic nominee? I know this sounds far fetched.
But think about it for a moment. Assuming President Obama is defeated in his bid for reelection, Hillary would face the risk of a four to eight year stint of being on the outside of a Republican administration. (And she would likely be too old to run at the end of an Obama second term.)
So what would happen (assuming the Democrats get trounced in the Congressional elections) if Clinton resigns her post as Secretary of State, moves back home, and now jobless -- turns into the Palin-type evangelist of change and returns to the Democratic principles that she campaigned on (and remember, almost won).
She could certainly make the argument that the wrong choice was made in selecting Obama and he has moved way outside the mandate for American that swept the D's into power.
If she could somehow manage to recreate the mid-term rehabilitated mode of her husband Bill during his first term (move slightly to the center, fiscal responsibility, make the country's problems those of the Republicans), she might offer hope to the Democratic Party.
Particularly if there isn't a valid Republican nominee (read #1).
Plus, what an exciting political season. We haven't had a sitting President with a primary challenge in a long time.
I know everyone just can't wait to start this circus all over again.
- Posted using BlogPress from my iPad
Here are some thoughts:
Perry-Palin 2012? Could this be the next Republican dream team? Before I get the laugh lines and hate mail let me make my point.
Both of these individuals have been or are Governors from large states with many similarities. Texas and Alaska have faired much better than their counterparts in the latest recession, have enjoyed a relatively friendly tax environment, have benefited from the increase in energy demand, and, lets face it, represent geographically about a third of the United States.
But more importantly both Rick and Sarah correctly identified early on the upswing of the Tea Party movement and latched on. I think this "movement", I don't really think it qualifies as a Party yet, has surprised almost everyone's expectations about its growth and popularity. I'm not sure where it will end up, but these two mavericks have been riding the wave into this election season.
Both have also been able to run as "non-incumbents". This has been easy for Palin (read: jobless), but despite the anti-incumbent rage sweeping the country, Perry has been able to be the outsider in the current Texas governor's race. He has successfully painted his opponent as being part of the "problem" by using his mediocre performance as Houston mayor as the whipping post.
Will I vote for this team? Not sure, but it will make for an interesting discussion as we move into next year and both are not running for President. Right.
Now think about this: Hillary Clinton the Democratic nominee? I know this sounds far fetched.
But think about it for a moment. Assuming President Obama is defeated in his bid for reelection, Hillary would face the risk of a four to eight year stint of being on the outside of a Republican administration. (And she would likely be too old to run at the end of an Obama second term.)
So what would happen (assuming the Democrats get trounced in the Congressional elections) if Clinton resigns her post as Secretary of State, moves back home, and now jobless -- turns into the Palin-type evangelist of change and returns to the Democratic principles that she campaigned on (and remember, almost won).
She could certainly make the argument that the wrong choice was made in selecting Obama and he has moved way outside the mandate for American that swept the D's into power.
If she could somehow manage to recreate the mid-term rehabilitated mode of her husband Bill during his first term (move slightly to the center, fiscal responsibility, make the country's problems those of the Republicans), she might offer hope to the Democratic Party.
Particularly if there isn't a valid Republican nominee (read #1).
Plus, what an exciting political season. We haven't had a sitting President with a primary challenge in a long time.
I know everyone just can't wait to start this circus all over again.
- Posted using BlogPress from my iPad
Thursday, September 16, 2010
Everything is Bigger in Texas
Visit msnbc.com for breaking news, world news, and news about the economy
Saturday, April 17, 2010
Fredricksburg Flowers from Wildseed Farms
Check out this video of the flower photos from our visit today to Fredricksburg's Wildseed Farm:
Create your own video slideshow at animoto.com.
Subscribe to:
Posts (Atom)