Health Care Economics II

The good old days of bartering are long gone. You used to be able to trade a couple chickens for a newspaper subscription (as shown above), and you knew what you were going to get. You could examine those birds and read an article before deciding to take the deal or not. But this does not translate to medical care. Say you broke your ankle and came to my emergency department. I'm bartering some morphine which took me a couple hours in the poppy fields to harvest. But because you're in excruciating pain, I could name any price. Is this just supply-demand economics? Perhaps, but there seems to be an ethical quandary here. Doctors (hopefully) go into medicine to relieve suffering, not profit over it. I'm not sure how much to charge for that morphine, but I'd feel morally reprehensible to take advantage of your duress.

Health care economics gets messier with the addition of the middleman. Like car accidents, lawsuits, and natural disasters, disease could strike at any time. And the cost of an unexpected diagnosis like cancer can be staggering (as detailed by the Time article). So society has decided to pool our resources to mitigate the effects of catastrophes. We (or our employers) have decided to pay a health care insurer to transfer the risk of a contingent, uncertain loss (that is, health care expenses). Here's the problem: we think we've bought everything. We think by obtaining health care, we have guaranteed ourselves every last bit of modern medicine. Though I fully agree with the new health care law's prohibition of annual and lifetime coverage caps, I think this worsens our illusion.

An astounding amount of health care expenses happen at the very end of life. Say a loved one had a terminal illness. She is admitted to the intensive care unit and the doctors say she will die in 1 week. But if they start hemodialysis, prescribe chemotherapy, perform surgery, check daily MRI scans, and hire a hypoallergenic puppy to stay with her, she may live an additional 3 days. If the bill goes to you, you'd say, "No way, I love her but the extra hundred thousand dollars for 3 days is simply not worth it." But if it is charged to the insurance company? "Hey, we'll take it. We'll take it all. And I want to keep the puppy at the end too." Sure, the insurance companies will fight it (or go bankrupt), but then they become the evilmongers who killed your grandmother by refusing treatment.

The problem is simply this: the cost of health care is too high to pay out of pocket so we turn to insurance companies. But insurance companies distance us from supply-demand cost-analysis decision making. Since the money is not coming out of our paycheck and we feel entitled to everything since we bought into health care, we demand everything. The cost of care skyrockets.

Image is in the public domain, from Wikipedia.

Health Care Economics I

One of my readers, Max, asked me to write about a recent Time news article by Steven Brill entitled "Bitter Pill: Why Medical Bills Are Killing Us." Thanks for your comment, Max! I read this article when it came out because my social media kept bringing it up. It is quite a long investigation into why health care costs so much, focusing in particular on a discrepancy between the cost of something to a hospital and the line itemization bill sent to a patient without insurance. It traces the stories of several patients who, due to lack of insurance or insurance with a payout limit, got stuck with a staggering bill. Although the doomsday message becomes a little repetitive after a while, it does bring up a lot of questions about health care economics.

Interestingly, physicians get taught nearly nothing about health care economics. As a medical student and a resident, I have probably had an hour of teaching total on the business aspect of things. Next year, as I get close to finishing residency, we have a couple didactic sessions. But the truth is, this is a big black box to us. And, I would say, to most physicians who do not own and operate their own practice. Maybe this is a throwback to the idealistic physician who cares not for money, who treats patients out of the generosity of his heart. There's the old joke: Which one doesn't belong: a radiologist, an ophthalmologist, a pediatrician, and a large pepperoni pizza? The pediatrician - the others can feed a family of four.

But jokes aside, you don't want a doctor who's only watching the bottom line. This is the whole issue with doctors owning MRI scanners; if you own an MRI machine, you're more likely to order MRIs because you make more money. This is supported by studies on the Medicare database. Similarly, you don't want a doctor who cuts corners and uses single-dose vials of medications on multiple patients because it's cheaper. Epidemiology outbreaks have traced infections to this problem.

Yet it seems almost unbelievable that residency graduates who have been in school for their entire life come out without an idea of how to manage finances, negotiate a contract, interact with insurance companies, hire and fire employees, and run a business. That's how it seems to be. As a result, I'm probably not the most appropriate person to comment on this article; I knew about most of the issues raised, but I have no magic solution, vilifying declamation, or stalwart defense. But the whole purpose of blogs is to ramble, raise discussion, learn, and challenge.

I will write more in the days to come, but I will start with a story. I had a personal experience with these broken health care economics when one of my closest friends went to the emergency department. She runs her own business and has insurance that she negotiated for her small company. That insurance policy has a payout limit which her 8-hour emergency department stay exceeded. When I went to see her in the E.D. (as a friend, not a provider), I was quickly reassured because medically, the diagnosis and treatment were straightforward. I didn't realize the finances were far more complicated, and scary.

Hemorrhagic Shock

Shock is a lecture I've heard at least a dozen times. It's such a core concept to emergency medicine and critical care that it's a perennial topic in the medical student and resident syllabus. Almost every time I hear about it (and when I teach it to students), it's categorized the same way: cardiogenic, hypovolemic, distributive, (and occasionally obstructive). Most of the time, the least interesting shock is hypovolemic shock. In this state, a patient's tissue perfusion is low because they have no blood volume: either they're severely dehydrated or they're bleeding to death. The consequent physiologic parameters (blood pressure, heart rate, central venous pressure, etc.) and treatment are straightforward. They don't have enough fluid? Give them volume. Not enough blood? Transfuse.

It is the least interesting shock until you have to deal with it in person. An octogenarian with breast cancer metastatic to bone sustains a hip fracture and is taken emergently for a hip replacement. Her bone is more than osteoporotic; it is riddled with tumor. Because the tumor is highly vascular, this is a surgery that will bleed without remorse. Going in, I knew we were going to lose a lot of blood, but once the surgeons got to work, I realized we were in hypovolemic hemorrhagic shock. Her blood pressure sagged relentlessly; while it responded to boluses of pressors, what she needed was volume. I ran in liters of saline and hetastarch, bottles of albumin, units of blood and frozen plasma. I realized this shock was no small entity, no uninteresting bystander. As I ordered product after product, did my best to catch up with the blood pouring from the surgical side, I learned not to underestimate hemorrhagic shock. Without central access or an echocardiogram, I was relying mostly on clinical signs, the surgical field, physical exam, and the patient's responsiveness to assess where I was with regard to volume status. It was challenging, but a surprisingly satisfying enterprise. She probably lost a whole blood volume - an amount equal to all the blood in her circulation when we started - but when I woke her up at the end of the case, extubated her, and took her to recovery, I could not be more proud that we'd made it through. She opened her eyes and said, "Hey, you're my anesthesiologist right? Are we done with the surgery already?"

Animals in Science

Sometimes, curiosity reveals the strangest things. Recently, I have been learning to read simple EEGs. We occasionally use this monitor in anesthesia, especially with total intravenous anesthetics. Although the monitor analyzes EEG data and spits out a number, I've wanted to understand the raw wave forms. Some of the literature is wonderfully bizarre; the image above appears in a paper published in Anesthesia & Analgesia in 2006. It turns out dolphins sleep with one side of their brain at a time. While one hemisphere dozes off, the other hemisphere keeps the dolphin swimming (which causes it to circle rather than swim straight); that hemisphere takes a nap when the first wakes up. Bispectral analysis monitors can detect the differential hemispheric activity. Talk about a cool experiment!

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Medical Students on Anesthesia

The problem with doing a medical student rotation in anesthesia is that it is hard to get a good perspective of what anesthesia is like as a resident, attending, or private practice physician. For most students (including me, when I did my anesthesia rotation), everything is so foreign and alien, it's hard to know how to fit in. The normal things that medical students are good at - pre-rounding, interviewing patients, reading about diseases - all go out the door. And practical anesthesia deals with things medical students are no good at - doses, how to draw up a medication into a syringe, how to talk to an attending surgeon, what a ventilator does. But it's important to realize that we don't expect a medical student to come in with any knowledge about anesthesia. We don't expect anyone to go into this field. We don't expect a medical student to make our day easier or do stuff for us. The case will go fine and the patient will do well with or without a student. But we do want to see enthusiasm, curiosity, motivation, participation, and engagement with what's going on. There are no stupid questions, and there is always something to learn for anyone - even if they are going into a completely different field. It also bothers me if a student comes in solely to do procedures. Anesthesia provides opportunities to learn procedures, but it is by no means solely procedures, and in most cases, procedures are the least interesting part. In a two week rotation, no one will become proficient in any procedure, especially because appropriate patients, supervision, and teaching will not happen with each case. So the purpose of a brief exposure to anesthesia, in my mind, is to engage medical student curiosity and nurture an appreciation for perioperative care.

Computer Security

Stanford Hospital is doing a pretty remarkable and herculean task of ensuring the security of protected health information. In today's technology-driven era, so many computers and devices have restricted data on them. If I access a patient's chart from home to prepare for a case, some of that data may be unwillingly and unknowingly transferred to my computer. If I check email on my phone and receive the daily operating room schedule, I have protected health information. If any of this gets stolen, the ramifications can be absolutely devastating. So the hospital is doing the most concerted high-volume effort I've seen to update, secure, and replace everyone's computers and mobile devices. When I arrived at the security line with my laptop, the line went out the door, filled with researchers, attendings, residents, graduate students. Yet the line moved quickly as there was an army of technicians to examine our computers, update the security software, and back data up. If the computer was too old to ensure security, the hospital assists us in replacing it. Considering the number of employees that work with protected health information, the wide range of operating systems they use, the number of computers in the hospital (of varying age), this is really an ambitious, impressive, and necessary feat.

Jet Ventilation

One of the rarer forms of airway management used in anesthesia is jet ventilation. In cases where a breathing tube or device cannot be placed (either due to disease, anatomy, or surgical need), a jet ventilator can be used. Oxygen from a supply pipeline goes to a pressure regulator connected to a hand-held valve. Squeezing the valve blasts oxygen out of a narrow outlet. This can be connected to a ventilating bronchoscope, laryngoscope, or in an emergency, an angiocath placed through the neck into the trachea. Thus, one can direct pressure-controlled blasts of oxygen through a surgeon-manipulated device or emergency airway.

A young patient with subglottic stenosis presents in extremis with acute shortness of breath and stridor. He acquired subglottic stenosis as a premature infant when he was intubated for several weeks. As a result, his vocal cords are normal, but below his vocal cords, his trachea has narrowed significantly so that he breathes through a straw. The surgeons want to dilate the stenosis, but obviously cannot work around an endotracheal tube. Although the patient has had a tracheostomy in the past (an opening from the skin to the trachea bypassing the stenosis), the surgeons would like to avoid that. This is the perfect case for jet ventilation.

The patient was rushed up from the emergency department to the operating room. After placing monitors, we induced anesthesia with propofol and remifentanil. We paralyzed with rocuronium and used a continuous twitch monitor to maintain adequate paralysis. We handed the airway over to the surgeon who placed an anterior commissure laryngoscope. By attaching our jet ventilator to the laryngoscope, we could blast oxygen through the tip of the blade which sat just beyond the epiglottis.

The jet ventilator is pretty easy to use, but it is absolutely crucial to do it correctly. If the laryngoscope blade is misdirected, the high pressure oxygen can blast through the soft tissues around the trachea, leading to subcutaneous air, a pneumothorax, and other damage. Exhalation is passive so if jet ventilation is done too quickly, the patient will retain air until the lungs burst. Yet we still oxygenate at a pretty high frequency (60 breaths/minute). Passive exhalation also means CO2 will build up; at the end of the case, our end tidal CO2 was 80 (twice normal). We have to be careful not to insufflate the stomach and use the minimal pressure necessary to oxygenate. And we have to maintain paralysis, not only because the surgeons are working on a 2mm airway, but also because if a vocal cord closes and we use the jet ventilator, we will get permanent vocal cord damage. We coordinated closely with the surgeons as they worked in between the breaths we gave. The patient did outstanding, woke up without any problems, and had much more relief in his breathing. Although emergent shared airway cases can be complex and difficult, good communication and coordination allows a very safe anesthetic.

Three Years

Some medical schools in New York have started developing three year MD programs. In an attempt to save money for students, create more physicians, and improve efficiency of medical education, they have compressed the traditional four years into three that include summer courses. It's an interesting thought. This experiment happened several decades ago but failed. Yet there are some medical schools (in Canada, for example) that have a three year curriculum that works. And Duke has a four-year curriculum where one of the years is entirely dedicated to research or an additional degree.

In my opinion, there is too much to learn in medicine in three years, or four, or five. It's a lifelong activity. Three may be sufficient to build an adequate foundation of knowledge, skills, and learning. But I'm still a little hesitant. The time in medical school is time for emotional and professional maturation; it is time for exploration, reflection, discovery, and passion-finding; it is time to integrate the ideals, principles, values, and ethics of being a physician. One can learn pharmacology or neuroscience or anatomy at a faster pace, but it's much harder to build character, decide on a specialty, and feel like a physician at an accelerated speed.

The benefits may outweigh those downsides. We do need more physicians, the cost of medical training is absurdly high, and this may be an attractive option for those who are older, coming from other jobs, or certain about their specialty. With the right selection of candidates, appropriate assessments, and a well-planned curriculum, the physicians graduating may be indiscernible from those coming out of traditional four year programs. Nevertheless, I was happy with the pace of my medical education and wouldn't have opted otherwise.

Advocacy

Every few months, I attend the regional California Society of Anesthesiologists meeting. We usually go to a nice restaurant, listen to a lecture, and discuss updates in the political scene at a state and national level. These meetings remind me several things. Because community anesthesiologists attend, they often give perspectives on practice outside the academic setting. When we had a talk on difficult airway devices and techniques, I was surprised to find that I was more comfortable with the newer approaches than many non-academic anesthesiologists. Being at Stanford affords me the opportunity to use technological advancements that smaller hospitals and surgery centers have yet to adopt. It reminds me that when I finish residency, I have to prioritize active and continual learning so as not to lag behind the latest ideas.

The second part of the meeting reminds me of the importance of advocacy. I've realized more and more that we have to support our profession. There are a lot of competing interests, especially ones to control cost of care, and not all of these are the best for our patients. We still advocate a physician anesthesiologist in charge of all anesthesia care including pain procedures (rather than independent mid-level practitioners). We still fight cuts to reimbursement that may discourage physicians from caring for the Medicare population. We still seek to educate and inform the public about what we do as anesthesiologists, and hopefully this blog plays a small role in making that happen.

Brainstem

General surgeons often say, "Don't mess with the pancreas." Perhaps the equivalent for a neurosurgeon is, "Don't mess with the brainstem." I always thought the name brainstem was interesting because some of the most essential, basic, and crucial functions of the brain lie here, as if the stem's purpose was to support the flower. Unfortunately, sometimes a neurosurgeon must venture into this delicate territory, whether for a tumor, a vessel malformation, or other abnormality.

The problem with mucking around the brainstem is that inadvertent pressure, bleeding, irritation, or activity can cause the autonomic nervous system and hemodynamics to go haywire. A burst of vagal activity can drop the patient's heart rate dramatically until the heart stops. We place pacemaker pads and prepare atropine and epinephrine in case of intraoperative cardiac arrest. Luckily, in my last brainstem case, I didn't have anything life-threatening. But we did experience an episode where the heart rate halved within seconds. Telling the surgeons and having them pause quickly returned it to normal.

Like cardiac and pulmonary procedures, neurosurgery can have direct effects on what anesthesiologists see and worry about. Thus, it's critical to be aware of what the surgeons are doing, to anticipate potential changes, and to know how to respond.

Image is in the public domain, from Wikipedia.

Bedside

When I was an intern, there was a big push for better bedside medicine. The fear was that with greater technological advances and widespread use of the electronic medical record, we would forget how to be a doctor: how to hold a child and look in the ear or clasp a hand of someone who was dying or listen to a patient's story and tease out the details that would make the diagnosis. We were taught to make the history and physical the cornerstone of our care.

Strangely enough, I find that now as an anesthesia resident, I spend much more time at the "bedside" with a patient than I ever did as an internal medicine intern. True, I spend little time when they are awake, but when I do, I engage in it deeper than I did as an intern. Information-gathering is no longer the primary aim; instead, I want to build trust and rapport, get to know the patient's fears and anxieties, and confirm those relevant medical details. It takes work, and I can tell you, if I miss that first IV, I work twice as hard to keep the patient's confidence.

Sitting at the bedside in the operating room with an asleep patient is an odd way to get to know someone. I learn their sensitivity to drugs, where their blood pressure lies, how compliant their lungs are. I can discern whether they really took their blood pressure medicines this morning and guess whether they really quit smoking. I know the patient's height and weight by heart. I know where their largest veins lie. I look at their teeth. I see a patient's scars and tattoos, indirectly examine their heart and kidneys. At the end of a surgery, I really know someone's physiology, even if they are asleep the whole time.

Occupational Hazards

Even though this is medically incorrect (the common cold does not turn into a pneumonia), I thought it was a pretty amusing poster and a good reminder that we are still in the flu season. Many physicians have been out sick; luckily I've avoided bad infectious diseases so far, but it's always an occupational hazard.

Image is in the public domain, from Wikipedia.

The Emotional Burden

A lot has been discussed about the physical exhaustion of being a doctor and especially a resident, but it is important to acknowledge the emotional side as well. Doctors willingly surround themselves with sick people. Every day when we go in, we immerse ourselves in our patient's sorrow, grieving, stress, fear, and uncertainty. And even though we try our best to relieve pain and suffering, to cure illness and debility, those emotions and experiences of our patients affect us.

It is the young and sick who affect me most. A man my age is hit by a car in a crosswalk. A young woman with two kids has a newly diagnosed invasive cervical cancer. A medical student undergoes surgery for obstructive sleep apnea. In the quiet moments of anesthesia, I wax philosophical. How lucky I am to be healthy. Yet anyone, no matter their age or how they care for themselves, could have some dormant illness yet undiagnosed. How sudden life can change if one gets into an accident or if that lingering cold turns out to be something more sinister. All our well-laid plans go to dust.

It is important for physicians to care for themselves physically and emotionally. I must not let those awful and rare circumstances, diseases, and injuries I see occupy my mood for the entire day. We must not hide our emotions, but we must not let our mood overwhelm us. The feelings we have when we care for patients echo the reasons why we go into medicine, but letting them overtake us is to succumb to illness ourselves.

Excitement

The dread terror of the difficult airway mellows out after a year of anesthesia training. An older gentleman with metastatic renal cell cancer presents for tumor debulking for palliation of symptoms. He is morbidly obese at 280 lbs while only 5'3". Along with hypertension, chronic pain, cervical spine stenosis, and gastroesophageal reflux disease, the patient has a thyroid goiter. The mass is 5cm large and compresses the trachea.

A year ago, this constellation of symptoms would strike the pit of my stomach with fear. He could be an airway disaster. If the patient goes off to sleep, his tracheal compression may get worse. The mass distorts normal anatomy and can make it difficult to pass an endotracheal tube even if the cords are visible. His cervical spine disease limits his neck extension. And his body habitus limits the oxygen reserve he has and the amount of time he can be apneic (not breathing) before his vital signs start crashing. Positioning a man this large is no small task. And his kidney disease may cause some to hesitate before giving muscle relaxants for intubation. The safest method is an awake fiberoptic intubation so that the patient is spontaneously breathing until the breathing tube is in the trachea, but this requires a lot of patient buy-in. And the patient was extremely anxious.

After discussing this case with the patient, a head and neck surgeon, an anesthesiologist who specializes in the difficult airway, and the oncology surgeon, we decided to proceed with putting the patient to sleep in a rapid fashion. After optimizing positioning, we introduced a fiberoptic laryngoscope while keeping the neck stable. Luckily the cords were immediately visible and the endotracheal tube passed smoothly. I cannot say I wasn't nervous the whole time, but I managed to stave off that dread terror I would have felt a year ago. My facility with the potentially difficult airway, my understanding of anatomy and available tools, and a year to build manual dexterity, speed, and confidence all helped. Nevertheless, I don't underestimate the potentially difficult intubation, and that's why I get consultation and input from all the available experts.

Who Should Run the Hospital?

A couple generations ago, a good percentage of hospitals were run by physicians; now, less than 5% of hospitals have a physician in charge. Instead, there has been a trend to hire those with business or management savvy, and we started favoring MBAs and degrees in hospital administration. But who should run the hospital? The purpose of a hospital, I would venture to simplify, is to provide medical care to patients and a community. But the inner workings of a hospital are highly dependent on its financial acumen, internal organization, and relationship to outside entities like regulators and insurance companies. A leader does not need to know how to diagnose pneumonia, start an IV, or interpret the latest clinical trial. Indeed, medical knowledge is less useful than communication skills, financial strategy, decision making, operations assessment, human resources management, or information technology know-how. But we must not forget the patient. And that's why my absolutely biased opinion is to favor the physician leader. Doctors do not forget the patient. They don't let other goals - financial, regulatory, marketing, strategy - take priority to patient care. Our 7+ years of medical school and residency training ingrain within us that responsibility and privilege of caring for the patient in a way that is not reinforced in business school or graduate training. Physician leaders are truly rare and few doctors have all the other essential qualities of running a hospital, but that simply means we have to train and encourage more physicians to pursue leadership positions.

Grandfathering

In the "good old days," anesthesiologists did it all. After residency, one could and was expected to anesthetize cardiac patients, pediatric patients, and obstetric patients. But as science and medicine progressed, fellowships were developed for those who wanted further in-depth exposure to a subspecialty field like pediatric anesthesia or cardiac anesthesia. Eventually, these fields became officially recognized and developed separate board certification processes. Whereas older attendings didn't have fellowship opportunities, recent graduates have a smattering of choices to get further certification.

Now, hospitals, surgery centers, and institutions want to say they have board certified pediatric and cardiac anesthesiologists doing relevant cases. But all of a sudden, the only people they can hire are the young attendings who did the fellowship; all the older attendings who have done pediatric or cardiac anesthesiology for decades do not have subspecialty certification. Yet an attending with thirty years of experience taking care of children doesn't need a fellowship and may be better than a freshly minted physician who finished fellowship last year. But because the latter applicant has board certification, he gets the job so that the hospital can boast board certified subspecialists.

There is a process of grandfathering into board certification without doing a fellowship if one's practice consists of a high percentage of subspecialty cases. But this is a long and involved procedure and providers may not feel it's worth it. In the end, despite a desire to promote subspecialization, the process restricts those generalists who've been doing subspecialty cases for generations.

Collateral Damage

A 30 year old woman presents with a history of progressive neck and back pain, followed by weakness, numbness, and tingling in her arms and legs. Eventually, a diagnosis of a spinal tumor is made. The intradural cervical (as in neck location, not reproductive organ) mass has grown quite large and may be a metastasis from an unknown primary cancer, though no obvious source is found. She undergoes an all-day cervical-thoracic laminectomy for removal of the tumor.

The anesthesia for this case has interesting aspects. The mass has grown so large that the patient cannot extend her neck; the steroids to shrink the tumor cause a Cushingoid body habitus and a rudely-named "buffalo hump"; edema in her face has made her tongue swell. All these factors make her a difficult airway, but using a video laryngoscope, we are able to intubate her smoothly. I did not want to write about this case because of the anesthesia, though, but because of what happens surgically. In order to resect the tumor, the surgeons cannot help but enter the dorsal columns and adjacent tissue.

Those of us who remember our basic neuroanatomy from medical school remember that the dorsal columns carry sensory information. Intraoperative neurologic testing confirms that the patient loses her somatosensory evoked potentials. When the patient wakes up from the surgery, she will not have feeling in her arms and legs. Even more concerning, the tumor is quite close to the motor pathways and despite the surgeons' care, neuromonitoring shows a decreased signal for one of the arms.

At the end of the surgery, which we consider successful, the patient's symptoms will be worse than when we started. True, the tumor is all out, but the collateral damage is not insignificant. It will take months to years for her to regain sensation and strength, if at all. She will no longer be able to work, and her life will be permanently changed.

For most surgeries, patients come out better than they started. Although there may be perioperative pain and discomfort, we hope patients eventually will be able to do more, have less pain, be healthier, live longer, stay happier. When I have a case in which this is not the outcome, it really strikes me. "First, do no harm" is a mantra that simplifies clinical situations too much. We weigh risks and benefits, and sometimes have to sacrifice one thing for another.

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