EPtalk by Dr. Jayne 4/12/18

I read a lot of press releases and this one from CMS particularly caught my eye this week. Normally a fairly bland and non-partisan source of news for all things CMS, the media relations group has really dialed up the rhetoric on this one. I don’t disagree that the Affordable Care Act is imperfect and we have a long way to go in achieving a workable and affordable system of healthcare in the US, but it feels like we’re losing the ability to participate in constructive discourse and everything is becoming polarized.

From Gone to the Dogs: “Re: burnout. My institution has dealt with this issue as it deals with many issues. The phrases ‘pennywise and pound foolish’” and ‘putting lipstick on a pig’ are perhaps the best descriptors.They’ve put together various wellness committees, invited speakers on mindfulness, and hired (costly) consultants on ‘improving communication.’ The most legitimately helpful thing they’ve done is have a puppy-petting party with a group of prospective guide dogs (which helps the dogs get socialized and relaxes the staff). At the same time, they continue to ratchet up required numbers of RVUs (on threat of contract non-renewal if targets aren’t met), throw people under the bus for any untoward events, display a general lack of supportiveness, etc. The broader burnout issues are also unchanged: insane regs, endless documentation requirements, frustrating pre-approval demands from insurers, and still trying to help really sick patients.” Our local high school invites a therapy dog agency to work with the students during finals week. I have to say, it’s hard to be aggravated when you’re staring at a cute puppy (unless that cute puppy just chewed the heel off your favorite pumps). The comment about RVUs is also particularly striking since we’re not supposed to be focused on visit volumes in the new world of value-based care. Keeping patients healthy and having fewer visits should be the goal, right? I still see RVUs as a metric in 90 percent of the organizations I serve.

Several readers sent their own “weirdest interview ever” stories.

My weirdest interview was with a major consulting firm. I had passed two telephone interviews and was flown out to have the final round of interviews with major players. I first met with president of the branch and he was bland and did not have many questions or comments (or energy). Then I met with one of their directors who had previously worked at another consulting firm that I had also worked at. He was a great interview and covered a lot of items. But the kicker was the last interview. This director sat down and nearly choked on her coffee when she realized that the date on my resume was when I graduated with my masters and not what she had assumed was my birth date! She didn’t believe I had any of the experience on my vitae, nor did she want to hire someone of my age. She excused herself and had security walk me out of the building. I’m not sure if she had many bad experiences with interviewing candidates, but security? At least I had a nice trip on their dollar.

I once interviewed for a position with an organization where the decision-maker shared a large office with another high-level person in the organization. Let’s call them Mr. Abbott and Mr. Costello. Mr. Costello would ask me questions, while Mr. Abbott, within earshot the whole time, was ostensibly engaged in other matters. But at different points in the process, Costello would call across the room to ask for Abbott’s thought or opinions. Abbott generally replied, “It’s your interview, I don’t know why you’re asking me,” or, “I don’t know – you should know that.” This went on for about 20 minutes or so, at which point I got up and said, “Thank you very much. I am not interested in the position” Costello had difficulty understanding why I abruptly made up my mind that this was not a place I wanted to work, but was apologetic. I don’t know where those two and the firm wound up, but I hope they started group therapy sessions as soon as I walked out the door.

That last story really resonates with me. As a candidate, when we attend interviews, we tend to be on our best behavior and I think we assume the people we are meeting with are likewise on their best behavior. I am sometimes left wondering that if what I have just seen is an organization putting their best foot forward, how wild it must be when they’re not trying.

From Crazy Ivan: “Re: tradeshow booths. This is my favorite ever. The only thing missing is the unmarked white van.” Every year one of my booth crawl BFFs and I fantasize about taking over one of the no-show booths at HIMSS and using the company’s name to create a fake business just to see if we can get prospects to stop by and chat. This year our delusion expanded to a couple of other people in our circle and the idea is gaining steam for next year. Another good reason to always check out the “little guys” on the trade show periphery – you never know who you’re going to find there.

From The Big Divide: “Re: this article. Would love to hear your thoughts. Is this a trend? It makes me nervous. Can’t help but believe it does deepen the divide in healthcare.” Concierge medicine is certainly a trend, although its market penetration varies across different regions of the country. I do see a fair number of direct primary care practices, many of which are priced in a way to be much more accessible to a broader swath of patients especially when those patients have a high-deductible health plan. The more accessible versions differ from typical concierge practices in that they’re more about cutting out the middleman (insurance) and providing value then they are about the white-glove service or 24×7 access than some retainer/concierge practices would be. I think the Michigan program especially raises concerns because of its association with a teaching hospital, and many teaching hospitals have a historical mandate to serve the underserved.

The hospital affiliated with my medical school had a “concierge floor” back in the day, where VIPs were cared for in swanky rooms with better meal service and no house officers. We only had a chance to breathe that rare air in the event of a code blue, when it was all hands on deck for the on-call team. They also sometimes had poorer outcomes because there were no house officers, which sometimes means less attention. Depending on the reason you’re in the hospital in the first place, not having interns and residents and students bothering you can be a bad thing.

On the other hand, when looking at concierge practices, they seem inevitable with the commoditization of medicine. One knows that when one purchases a Lamborghini, they will receive a different level of service than if they purchase a Chevrolet. People of means pay cosmetologists to come to their house to perform a pedicure rather than go to a salon. They have housekeepers rather than clean the bathrooms themselves. If the practice of medicine is no longer a calling but rather a business, why should it be any different than any other service? Even in a hypothetical single-payer system, there will always be people who are willing to pay more to get more. The question is whether we as a society are willing to commit to a minimal level of care for everyone else.

What do you think of concierge practices or direct primary care? Leave a comment or email me.

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