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One Doctor’s Perspectives on the Evolution of Health Care

Posted on October 15, 2015 I Written By

I had a great exchange with a physician reader recently about HIPAA and it led to this doctor sharing his story with me. He covered a lot of ground including reimbursement challenges and history, conversations about death, integrative medicine, time spent with patients, medical education and much more.

I love first hand, off the cuff perspectives on the history of medicine and how we got where we are today. No doubt there’s always more to the story, but I think perspectives from doctors like the one that follows helps those of us who work in healthcare IT. It wasn’t intended to published, but that’s what I love about it. I hope you enjoy it as well.

I am originally from Manhattan but have lived in the DC area since 78. Ironically, I have never eaten at the government trough. I have a friend I met during my residency in Baltimore. He retired one year short because the overtime was killing him. He has since worked for Uncle Sam in a number of capacities. When he does retire, he will receive three checks…ah, if I had it to do all over again…when in Rome….

In private practice though, having worked in a number of different situations, I have had patients from every 3 letter agency that you can think of. The public has no real idea how crazy our government bureaucracy really is. The amount of waste is inconceivable. I remember laughing the first time I heard the term “beltway bandit.” Now, banditry has stretched far beyond the beltway.

What concerns me most about American Medicine is the fact that it is a business and big business at that. The problem is that it was doomed from its inception, an unholy alliance or marriage between Flexner, who condemned naturally, holistic remedies, and Rockefeller owner of Standard Oil…think organic chemical manipulation….gave birth to a child named Big Pharma and the genesis of the allopathic (against symptom) approach which has brought us to where we are today.

Add to this the change which occurred when slick surgeons forever tilted reimbursement rates to favor procedures rather than cognition. It was simple, a statistical analysis of the then existing ills that had a surgical solution. Realize that since patients would not be paying out of pocket, drive up the reimbursement for the surgeon performing the procedure. The hospitals followed in turn eventually adding cost shifting to the mix. Eventually, the malignancy spread and cognitive physicians came on board only to see their real income drop because of inflation and the procedural slant to reimbursement.

Let me demonstrate this from my own experience. Let me first digress and explain how I evolved to where I am today. My original training was in Infernal Medicine. I did my residency from 86 to 89 at the beginning of the AIDS crisis. When I started there were no patients. The first was a 7-ish year old guy who died from kidney failure who happened to be demented.

this boy’s diagnosis was AIDS dementia. Hmmm…he was not homosexual. He did however have a transfusion as did what became a deluge of patients, often with strange presentations, like the woman who came in complaining that she had difficulty walking. She had a collection of golf sized balls of lymphoma in her brain which developed because HIV destroyed her immune system, again the result of a transfusion. By the time I left, the place had become a war zone. My job became shepherding people during the transition from life to death.

Eventually, this and other experiences led to my becoming a champion of death. We spend more money on medical care in the last six months of our lives than during the entire time prior to that! Of course medicine should strive to preserve life. However, there comes a time when we have to die and prolonging it I think is a crime.

During my residency I developed a routine when an elderly patient came in who was obviously at the end of his or her life. Yet, some family members would demand that “everything be done.” I would escort the entourage to the ICU where I could always point to at least one poor soul intubated with numerous tubes either going in or out of body orifices or cavities. I would tell the group that ultimately, this is what you will make me do to your loved one. As a result, I almost always was able to get permission for a DNR or do not resuscitate order.

Yes, we live longer. However, what is the point if our final years are compromised by chronic degenerative illnesses: diabetes, Alzheimer’s, and arthritis to name a few. Contributing factors are poisoned air, soil mineral depletion resulting in food that is less nutritious, and the countless FDA approved poisons that we ingest with every bite…yes, those names you cannot pronounce.

Sorry for the digression. After residency, I fell into a Medical Directorship of a substance abuse program. Seeing the mess of Addiction Medicine, the eclectic, empiricist that I am, led me in 1990 to the South Bronx where I spent a few weeks with Dr. Michael Smith of Haight Ashbury fame, learning auricular acupuncture to treat addiction.

This turned into a year long course in Acupuncture. Thus began a journey that took me from conventional western medicine modalities to biofeedback, audio-visual entertainment, cranio electrical stimulation, nutrition, hypnosis, herbal medicine, chiropractic, off label use of pharmaceuticals, a stint as Medical Services Director for the Life Extension Foundation, stuff now under the rubric of complimentary or integrative medicine.

​Now to that point regarding cognitive/procedural differences. I spent almost three years working in an undeserved area in rural TN. ​I had already broadened my skills by working in Urgent Care Centers. In addition to the diagnostic skills of an internist, I was now doing family medicine including pediatrics, gynecology, as well as many Urgent Care procedures. However, to better serve my patients I needed to do more. I added more cardiology service by doing my own stress tests and echocardiograms. (This required training.) An opportunity arose where I could learn to do upper and lower endoscopies. These procedures are generally done by GI docs. I could never get privileges to do these procedures in a major metropolitan area because there are so many specialists. However, in an undeserved area it is a different story. Of course initially, just as I would have done had I trained in GI, I initially did my cases with the assistance and guidance of a GI doc.

Here is the point regarding reimbursement. In my TN private practice I spent at least an hour with all my new older patients. (Eventually, my initial visits would become three hours.) Medicare would reimburse me around $90. With a 50 percent overhead, I was making $50 an hour. However, when you consider all the time that I spent on paperwork, phone calls to or about patients for which I was not reimbursed, it is even less, far less.

However, when I did a colonoscopy and removed a polyp, while I don’t remember exactly how much Medicare and other carriers reimbursed me because it has changed so much over time, but for around a half hour’s worth of work, I received on average between 3 and 5 hundred dollars. The point is that reimbursement has always favored procedural over cognitive medicine. The problem is that everything is backwards. The word doctor comes from the Latin, docere, to teach. That is exactly how I came to see a large part of my role as a physician. The idea is to prevent disease, essentially to put myself out of business which seems counter intuitive. During my time studying acupuncture I had heard, although I was never able to find references to support it, that Chinese physicians at one time were paid only when the patient was well.

When Stark II was passed, all my alternative colleagues who were doing certain things for which insurance would not reimburse, found that they had to drop out of Medicare and other insurance carriers. Combined with the fact that I was seeing very complicated patients and holistic approach, I found that I needed around 3 hours to do an initial history and exam. This was 1995 when I was a beta site for a DOS based EMR which was pretty sophisticated. Personally, I think any less time constitutes malpractice.

I also realized that the American Business model does not select for the right people to become physicians. The truth of the matter is that the best physicians I have known and with whom I share this; that we are all a little bit nuts and that we never cared about money. Our staff were always pushing us to hurry up and stop gabbing with our patients.

You simply cannot practice medicine in an 8 minute encounter. It just does not work. Look at an old Oxford or a Webster’s dictionary and you will find that there are only three professionals, the Clergy, Law, and Medicine. Why? Because they are “callings.” You truly, from the bottom of your heart and in the depths of your soul, care about people. It is impossible for you to see them as your pay check. My patients always had my home number and could call me at anytime. They never abused this. They were always welcome to bring me articles. I had absolutely no problem telling them that I did not know something or that they told me something that I did not know. That is why it is the practice of medicine.

So, the truth is, you have to be a little bit crazy but that is the passion, the essence of a calling, or at least the way I believe it is supposed to be. The American Medical Business model is antithetical with respect to this concept and as such I believe dangerous to your health. So, in my world view, HIPPA is a costly infringement on my ability to care for my patients and as such, potentially harmful to their health.

Dishonesty Ruins So Many Things

Posted on September 5, 2014 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’m always struck by this simple concept: Dishonesty make so many things more difficult than they should be.

We see this all over healthcare. Look for example at patient privacy and security. If people were just honest and thoughtful with patient data, our privacy and security challenges would be so much simpler. Imagine how much time and heartache we’d save if people were just honest when it comes to privacy and security. Yes, I’m looking at the million of hackers that are trying to take people’s personal information. Imagine if we could focus all the money and time we spend securing applications and apply it to improving healthcare. What a difference that would make.

The same could be said for reimbursement. Our reimbursement system would look drastically different if people were just honest. Yes, I’m talking about the billions of dollars of Medicare and other insurance fraud that’s out there. What a sad expense on our current healthcare system as dishonest people try and make a quick buck. While that expense is large, the even larger cost to our healthcare system is the toll that fraud adds to the honest actors.

Look at our current model of reimbursement for healthcare. So much of our insane documentation efforts are tied to the fact that insurance companies are trying to combat fraud. They don’t and can’t trust providers billing levels and so they’ve created layer and layer of requirements that makes the healthcare documentation process miserable. If you don’t agree with me, then you aren’t someone that’s involved in healthcare reimbursement.

This expense gets passed on to the employer and patients as well. Have you ever tried to make sense of the bill or statement of benefits coming from your doctor or insurance company? It’s like trying to make sense of a new language. It doesn’t make sense since you as a patient don’t know that language. Are they screwing you over in what they’re billing you or not? You don’t know either way and good luck trying to find out the answer. The person on the other end of the phone likely isn’t sure either because it’s so complex.

I first learned this principle in the credit card world. Why on earth do we pay 3+% of every transaction we do on our credit card. The answer is simple. Credit card fraud (otherwise known as dishonesty) is rampant and why credit card transactions cost so much. Imagine a world where the doctor wasn’t giving 3% of their business to process a credit card transaction since the cost to change digital digits should be nothing.

Unfortunately, the reality is we do live in a world with a lot of dishonest people who try and game anything and everything. We have to pay attention to security and privacy with these dishonest people in mind. We have to deal with insane reimbursement requirements as these payers try and combat fraud. We have to deal with credit card fraud and pay for it in the process.

It’s unfortunate, because dishonesty almost always catches up with people. Even when we think it doesn’t, dishonesty pays its own toll on a person as they can never be comfortable. Having a clear, honest conscious is one of the most beautiful things in life.

My 2012 EMR and Health IT Wish List

Posted on January 3, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

As I said in my previous EMR and Health IT in 2012 post, I’m going to create some of my own lists for 2012. I decided to tackle the first one on the list: My 2012 EMR and Health IT Wish List. This was kind of fun to think about. I’m also sure that I’ll come up with other ideas once this is posted, so don’t be surprised if I add things to this list in a future post.

I should also note that I’m not sure any of these things are going to happen in 2012. In fact, I bet that many of them aren’t, but this list isn’t about what is going to happen. This list is about what I wish would happen.

EHR Companies Would Embrace Interoperability – It’s an incredible shame that in 2012 we still don’t have interoperable health records. EHR companies need to get off the stump and make this a reality. The technology is already there and has been there for a while. EHR companies need to start making this dead simple because it’s the right thing to do. Sometimes doing the right thing is more important than the bottom line. Plus, doing the right thing ends up often being the best long term strategy for your bottom line as well.

Start doing what’s right and making your EHR interoperable!

Meaningful Use Would Go Away – I’m actually certain that this one won’t be happening in 2012, but I wish it would. I guess there’s a small chance that it could go away if Republicans take control of Washington and start slashing everything Obama related. However, I have a feeling that even then meaningful use will find its way back into Washington. There’s too much invested in it.

My reasoning for wanting meaningful use gone is clear. It provides a perverse incentive to providers and often incentivizes them to choose an EHR software that doesn’t work well for their practice. As I’ve mentioned in some recent posts, far too many clinics are so focused on meaningful use and EHR incentive money that they’re ignoring the real and tangible business cases for implementing an EHR in their clinic. I think this is a bad thing for healthcare and EHR software in general. The short term bump in EHR adoption won’t be worth the cost of EHR implementations focused on the wrong criteria.

I also really hate how meaningful use has hijacked the software development cycle of pretty much every EHR vendor out there. This is a real travesty since rather than developing for user/customer requirements EHR vendors are developing for a criteria. Talk about a perfect method for destroying innovation. This is a real travesty in my opinion.

Of course, I’m a realist and realize that meaningful use isn’t going away. We have to make the most with what we’re given and live with the realities that exist. However, in this New Year Wish list, I wish that meaningful use would be a past memory.

New Healthcare Model that Provides Care, Not Reimbursement – I’m sure many of you might be thinking that I’m calling for ACO’s in this wish list item. We’ll see how ACO’s evolve, but my gut tells me that the ACO model still won’t make the fundamental change that I wish would happen in healthcare. There’s far too much focus on reimbursement the way our healthcare is structured today. I’m not arguing that doctors and other healthcare professionals not get paid what they deserve. I’m just wishing that there was more focus on care for patients and less worry on maximizing the reimbursement.

How does this have to do with health IT and EHR? I’ve long argued that the biggest bane to EHR systems is the onerous reimbursement requirements. I can’t imagine how much healthcare could benefit from fabulous EHR systems if the energy spent on maximizing reimbursement were spent on improving patient care.

Diabetes Prevention App – I’ll admit that this is a little personal. I come from a long line of diabetes in the genes and I love sweets far too much. I’m pretty much destine to be a diabetic. I think that mHealth apps can have amazing power if done correctly. My wish is for someone to create a Diabetes app that will help me overcome the seeming destiny I have in this regard. The key will probably be illustrating in a profound way the impact of the choices I’m making.

Of course, you could insert hundreds of other chronic illnesses into this wish list too. I’d love to see mobile health work to solve those as well.

A True Patient Identifier – I realize that America is a large place, but we’re also a really creative country that can figure out creative solutions to problems. The lack of a true patient identifier is a challenge and a problem in healthcare. I’d love to see this problem finally resolved. I think every EHR company would rejoice at this as well.

Real EMR Differentiation – My heart absolutely goes out to doctors, practice managers and others who have the unenviable job of trying to sift through the 300+ EMR companies. I’d love for some EMR companies to really do something so innovative to differentiate themselves from the rest of the pack.

No doubt part of this problem is what I stated above about meaningful use. Hard to create innovation and differentiation in EHR when you have to develop for a government list of requirements.

EHR Data Liberation – I’ve wanted EHR data Liberation for a long time, but I think in 2012 this is one thing on the list that could become a reality. It’s a bit of a long shot, but I think there’s potential for this to happen.

My gut tells me that if we can find a way to liberate the data that’s stored in EHR software, then we’d see a dramatic increase in adoption of EHR. One of the major concerns doctors have with selecting an EHR is that once they select an EHR they know they’re locked in with that EHR for the long run. If a doctor knew that they could switch EHR software if they made a bad choice, then they’d be much more likely to pull the trigger on EHR adoption.

We need a wave of EHR vendors that aren’t afraid of liberating their EHR data, because they:
1. Know that their EHR software is so good users won’t leave
2. Know that if someone wants to leave their EHR software it’s better that they find one that’s good for them than the few extra dollars the EHR company will make off an unhappy user.

How’s that for a wish list? I think achieving these things would do an amazing amount of good in healthcare and EHR. Of course, I won’t be holding my breathe on any of them happening any time soon. That doesn’t mean I won’t keep holding out hope.