Happy SGR Repeal Day

Yeah, it happened. The SGR is finally dead. Hooray! Sort of.

I mean, it's great and all that — we'll no longer have the annual threat of a massive payment cut from a poorly crafted piece of legislation from the 1990s; we'll no longer have to endure the annual ritual of last-minute legislative theatrics to avert the yearly cuts, we'll no longer have to waste our lobbying time and effort to make sure those cuts were never allowed to go into effect.

But let's not pretend this was in any way a win for physicians.

The replacement for the SGR, in the "Medicare and CHIP Reauthorization Act of 2015" (MACRA - get to know that acronym!) is that physician reimbursement is low locked into a long-term deflationary schedule. The Medicare Professional Fee Schedule will now post annual increases of 0.5% from 2015-2020 and 0% from 2020-2026. Even assuming this extended period of unnaturally low inflation continues for the next decade, that still amounts to a compounding negative real payment update every year. This may not be a terrible deal for, say, emergency physicians. I may not like it but my practice is very low overhead, and I can absorb a small negative hit to my income.

But for practices with meaningful overhead — rent, salaries and benefits for non-physician staffing, IT, equipment — this is really bad. Those costs are going to continue to rise, some well in excess of the general inflation rate. And that is going to continue to squeeze the viability out of general office-based practices, a trend that is already a decade old. It's worth re-emphasizing that many private payers track medicare fee schedules, so these reductions will ripplae across markets.

And let's not forget all the other crap that got piled into this bill while nobody was looking. The pay-for-performance program will now put an amount of physician income of 4%, rising to 9%, at risk for physicians and groups not meeting the as-yet-undefined performance metrics.

The performance metrics will, however, more or less require use of an EHR and are written in such a way that participation in the much-maligned ABMS Maintenance of Certification program is almost obligatory. There are also extensions of requirements for "Meaningful Use" of an EHR which I admit I am not an expert on but also seems to draw much ire from physicians.

It's a testament to how desperate the AMA and all the other organizations within the house of medicine were to get rid of the SGR, that there was not a single objection voiced to, well, to any provision of MACRA. We were prepared to accept anything, no matter how bad, to get rid of the SGR. Mission accomplished.

It's a bad deal. It's better than the alternative and probably the best deal possible from this Congress and in this budgetary environment, but we should not be too giddy about it, or pretend it's anything more than it is. The SGR is dead and the campaign to fix MACRA will begin, oh, any time now.

In Defense of the Hyperangulated Blade

Let me begin, as is my wont, with a story. Let's say, for the sake of discussion, that I was moonlighting at Janus General Hospital. I had a patient signed out to me by my partner: a young patient with COPD, influenza, and pneumonia. He was on BiPAP and supposedly stable waiting for an ICU bed. Murphy's law being what it is, immediately after my partner left, the patient deteriorated and clearly was going to require intubation. He had all the predictors of being a tough tube, so I made sure to have my back-up plans articulated and ready to go.

My go-to technique for quite a few years is video laryngoscopy (VL) with the hyperangulated blade of the GlideScope. My back-up is direct laryngoscopy (DL) and my ace-in-the-hole is the gum bougie. I'm not a huge fan of fancy tricks like awake intubation (too much work, and I'm lazy) and in any event, this guy was too sick for that. Since this was a daunting airway I made sure to have all the stuff ready to go, including our quick cric tray.

I couldn't get the tube with the GlideScope. While I had a nice view of the larynx, there were frothy secretions welling up through the cords so quickly that between the time I suctioned and tried to place the tube, I lost my view. Faced with crashing sats, I tried to bag him back up, but couldn't ventilate. I got his sats from 50% all the way up to … 75%, and he clearly wasn't going higher. So I had my partner prepping the neck while I went back to the old stand-by, DL, and I was able to snake the bougie in through the foam and successfully passed the tube (much to the disappointment of my partner, who was kind of excited at the prospect of doing a live cric). Here endeth the story.

Now I share this to highlight a couple of points regarding airways. I could make the point regarding the importance of having your back-up plans ready and practiced and not being afraid to progress to a surgical airway, but that point has been made at great length and far more articulately by others. It is a good illustration of the principle, though.

I'm more interested in comparing the relative benefits of VL vs DL and particularly the geometry of the blades.

I admit to being disappointed in seeing the cognoscenti of airway masters coalescing around the position that VL is at best, a necessary evil, and that if it must be tolerated, it should be performed with a standard geometry blade. The C-MAC device, which has a Macintosh-style blade with an attached screen, seems to be the device of choice. (For the record, I have not been paid by either device maker but am more than willing to accept bribes, if any are on the offering.) They make a good argument that the C-MAC is better because it helps develop/preserve the DL skill-set, is its own built-in back-up with no need to change devices, and for attendings allows good supervision of trainees. I agree with all these points.

From my perspective, though, I still favor the GlideScope, which differs from the C-MAC in that it has a hyperangulated blade. (There may well be other brands out there with similar shapes, but I’m not as familiar with them.) And despite the failed airway above (my first ever failed airway in hundreds of cases with this tool), the GlideScope remains my first-line intubating approach in most if not all cases.

A couple of important caveats: I had been intubating with DL for many many years before I ever touched a Glidescope. DL is the ultimate and necessary skill that must be completely mastered before moving on to the hyperangulated blade. For trainees: stick with DL till you've done a few hundred. This is a varsity level device. For occasional intubators it might be a good idea to stick with DL to keep the skills sharp.

I, however, am in none of those categories. I have intubated hundreds if not thousands of people over the years, am highly comfortable with my DL skills, and I continue to intubate pretty frequently. And here’s why I will continue to use my GlideScope until they pry it from my cold, dead hands:

It is a better tool that is easier to use & harder to mess up.

There. I said it. I am, as I said, very lazy, and I will always choose the easy and reliable tool over the dodgy tool which requires a lot of effort to use correctly.

This is why I believe it to be so: when I perform DL, I need to establish a direct line of sight with the larynx. Unfortunately, mother nature thoughtlessly designed the human anatomy so that there are lots of fleshy bits between my eye and your vocal cords. There are lips, teeth, the tongue, the glottis, the salivary glands, and all the redundant fat, muscles and soft tissues of the sublingual space. If I want to establish that direct line of sight, I have to get your head & neck in perfect positions, put the tip of my blade in precisely the right spot, seated in the vallecula, and then lift, sometimes with quite a lot of force, and then I have to hold the blade in place and sort of squint to see way the hell down there for the cords. Blade a little too shallow or too deep? U NO SEE CORDS! Blade slightly off midline with tongue oozing around it? NO CORDS FOR YOU. And the motor skill to lift just the right way is tricky. Rotate the blade and not only do you not see cords, you break teeth. You have to lift up and forward just a bit, and if it’s not quite right, you have to apply cricoid pressure bimanual manipulation to see your target.

This does not look comfortable

I can do it. I’m pretty good at it, still. But there’s a lot of room for error, and sometimes it’s really freaking hard. Even as an experienced intubator, there are times that I am sweating bullets or feeling like I dodged a bullet when I succeed on a tough tube. Because you are fighting the anatomy, and the anatomy is set against you.

But the GlideScope, well, it’s designed so that with no manipulation of the native anatomy, it will drop directly into the necessary position and provide a beautiful view of the larynx. Every damn time. No lifting. No squinting. No fiddling. And if the fleshy bits (excuse the technical anatomic jargon) are still in the way, I don’t care. I can still see my target. It's even forgiving of less than optimal patient positioning. With the GlideScope all the airways are easy, because your tool is designed to work with, not against, the anatomy. That’s the beauty of the hyperangulated blade, and that’s why it has been so widely adopted. You don't need to manipulate the anatomy to see your target, and reducing that step reduces the possibility of error and a failed airway, or at least relieves the cognitive workload of the procedure. It’s rare that I ever have to take a second look, and it seems like every tube slides in effortlessly. And reducing the cognitive workload, reducing provider stress, is not a small benefit when you are dealing with a critically ill patient. If I don’t have to sweat the tube, I can better dedicate myself to management of the patient’s overall condition.

It just fits!

Yes, VL has its limitations. I didn’t say it was perfect. Secretions, blood and gastric contents can confound any intubation, particularly video. Electronics are fallible. Back-ups are necessary and you need to be able to use them. And the use of VL and the hyperangulated blade is a different skill set. Since you can’t see the larynx directly, you need a decent spacial understanding of where you are blindly shoving the blade/tube and the degree of force (or lack thereof) that is safe to use. That only comes with experience and attention to the differences between DL and the hyperangulated blade. It's kind of like tying your shoes in the dark - not exactly tricky, but you do need to be able to visualize what your hands are doing without seeing them directly. But after performing many many intubations with both types of device, I feel that intubations with the GlideScope are easier and less fraught with error.

The airplanes at my flying club are equipped with really cool GPS-linked 3-axis autopilots. But when I was learning to fly, we focused exclusively on basic stick-and-rudder skills, and never touched the autopilot. As I got more advanced, however, we began to use the autopilot more and more. Finally, by the time I was IFR certified, I could take off, turn on the autopilot, fly the entire trip and a linked approach on it, and turn it off just as I began the landing flare.

I see this as highly analogous to the DL-vs-GlideScope debate. You still need your basic airmanship skills. Without those, you die. But the autopilot is a tool which, correctly used, is more reliable than you are at keeping your wings level and frees up your mind and attention for other critical tasks and therefore should be used as much as possible. For those who are more comfortable with DL or VL with a standard geometry blade, I am not saying that there is any evidence-based benefit to GlideScope or that there is clear superiority - keep doing what you're doing if it works for you. This is a personal preference based on my own skill set and how I have found these tools to work. But, contra the growing consensus that VL-with-a-standard geometry-blade is the way to go, I would suggest that outside of the training environment, there are distinct advantages to the GlideScope and would not relegate it to an afterthought among the modalities of airway management.

On Call

Every ER has its call roster, that sacred list of oracles, laying out who we can call when our patients need some service that we cannot provide. If I need a cardiologist, or a neurosurgeon or even a dermatologist for some acute emergency condition, all I need to do is ring up the operator and tell them, “This is the ER doc, I need [insert name of specialty here].” And like magic, ten minutes later, I’m talking to the local expert in whatever the patient has.

Fun fact: in the last month, I have consulted both physiatry and rheumatology from the ER.

So I was a little surprised recently when I had a patient with a nine-millimeter proximal infected ureteral stone and I called the operator to get me urology, only to be told, “There’s nobody on call for urology.” Huh? I pulled the call roster from the wall and scanned it:

Urology - No Coverage
Opthalmology - No Coverage
ENT - No Coverage
Plastics - No Coverage

Wow. That’s a lot of specialties that we don’t have access to. For the record, we are not some little 40-bed rural hospital. We are a 100,000 visit facility that styles itself a “regional medical center” and accepts transfers from a large catchment area. And evidently there are multiple services we no longer offer, at least not in the evening and at other inconvenient times.

Why is this? Because these local specialists have decided, as individual groups, that ER work is taxing, difficult, low-paying and high-risk. (Tell me about it.) And one by one, they have decided to quit. They just said, “Nope, not covering the ER any more.” And our hospital is not the only one facing this problem. It is, in fact, probably the biggest challenge facing emergency medicine nationwide.

Now I get it. I die a little inside when I have to call in a board-certified urologist at 0300 to put in a foley on some poor 87-year-old in urinary retention, after all my nurses and I fail to get it in. I really hate inconveniencing them, especially when it’s something that I maybe should have been able to handle myself. But that’s the life of an ER doc and I am pretty inured to it by this time. (Maybe I’m all the way dead inside?)

Which is why I was kinda incensed by the recent post over at Kevin’s site: Should Doctors be paid overtime for taking call?

The cardiologist writing that post painted a beautiful picture of how much call sucks, and I get it. I know the absence of call played into my decision to pursue Emergency Medicine as a career. But the question posed, in the context of the current situation, feels almost like blackmail: “Pay me or I’m gone, too.”

The history here is that being on call has pretty much always been a service that is part of the practice of medicine. No matter your specialty, if your patient got sick at night, you would be called in to deal with it. As the number of patients without established doctors grew, most hospitals had “no-doc” coverage rotating for unassigned patients. When you are on call, you don’t get paid for phone calls, but you do get paid if you have to come in and see or admit a patient (presuming they have insurance). In the old days call may have been a practice-growing revenue stream, but for a long time now it’s been a poorly-reimbursed time suck for most specialists.

A growing trend we are seeing nationally is for specialists to demand — and receive — reimbursement from the hospital just to be on call. Our hospital being a skinflint catholic shop responsible steward of resources told the specialists to pound sand, which led to their absenting themselves from the medical staff and call roster. But many hospitals, especially those in highly competitive markets, have started to pony up and pay docs to take call.

The math of this is really challenging. Once you are paying one group to be on call, it’s hard to justify not paying all of them. The most demanding, in my understanding, have been ENT, Hand, Neurosurgery, Optho, Plastics and Urology. The going rate seems to be about $1,000 per night, though YMMV. Ironically, these are among the least-consulted and highest-paying surgical subspecialties, which further creates an unseemly impression of physician greed. But if you meet their extortionate demands, that winds up costing the hospital $6,000 a day, 365 days a year, or about $2.2 million annually, assuming all the other specialists don’t pile on with their own demands. That’s for nothing, mind you: for being “available” without doing any work. No calls? You still bank nearly as much as I did for a busy shift of seeing patients.

And there is a tendency to see the hospital as the font of endless dollars, but hospitals are in rough shape. Their typical profit margin is in the 2-4% range, frequently dropping to zero or negative when the economy dips a bit, and under relentless pressure from medicare and insurers to accept lower reimbursements. While it’s tempting to look at the gross revenue and assume that of that $50-100 million, "surely the hospital can afford to pay to keep me on call,” in reality that is not the case.

The grim reality is this: we pay more than any other society for health care (and get less for it). There is no new money coming into the system; quite the opposite. When specialists demand extra money for a service that they have previously provided not for free but based on only professional reimbursement, that’s going to pull resources from somewhere else. Maybe it’ll be fewer ER nurses. Maybe it’ll be fewer staffed inpatient beds. It’s going to come out of the budget somewhere.

Which is why I am kind of glad our facility held firm in the face of the extortion of the surgical specialists. These guys all make ~$300K a year. I feel that if I (also well paid) have to see folks at 3am as part of my gig, they should too, and not command some premium for the service.

Am I bitter? Yes, a little. But much of that comes from the fact that I see the consequences of the specialists who opt out of call. I feel like they are still really well paid and are shirking their duty to the community and to the patients. That patient with the kidney stone? I had to transfer him out of our gleaming $500 million hospital to the county facility where a resident could take care of him. His care suffered because of the greed and entitlement of the local specialists; this wasn’t the first or last time I will encounter this problem. I don’t like seeing patients used as pawns, and I get a little enraged when local doctors jeopardize patient care over economic concerns. As I see more and more physician practices being bought by hospitals, in part to secure their call networks, I see these guys digging their own graves.

So, no, I don't favor paying specialists for being on call. Suck it up, guys, and do the right thing for your patients. Structure your practices to make call suck a little less, maybe. I empathize. When I'm sitting in a mostly empty ER at 4AM, I'm not getting paid either. But overall, we both make enough to have pretty good lives and still not opt out of caring for those who are unlucky enough to get sick at inconvenient times.

Pain and Suffering in the ER

I took a recent family trip Down Under and had the good fortune to be in Australia's Gold Coast at the same time as the SMACCGold Conference. (Well, it wasn't entirely a coincidence.) I was happy to get to make it there one day and it was a great experience. I got to meet uber-tweeter and stalker Minh LeCong, organizer and LITFL dude Chris Nickson, St Emlyn's own Simon Carly, the Irish EM blogger Andy Neill, Kangaroo Island doc Tim, and many, many more. I had an extended conversation with Karel Habig of Sydney HEMS under the misapprehension that he was Cliff Reid. (Did I mention the open bar?) Sorry about that!

I haven't the time to do a full write up now, except to note that this was the only conference I've ever seen where there was an open bar in the exhibitors' center ... at 9AM. Because 'Straya.

I love the SMACC guys and I love the SMACC ethos. One of the cool things about it is that they put their talks online, freely available, as part of the FOAMed (Free Open Access Medical Education) concept. So if you missed it, you can enjoy the full conference after the fact. Most of the talks are short, usually less than 30 minutes, and they have a rather different focus than that which you will find in more traditional academic EM.

The talk that I most enjoyed, was this one, by St. Emlyn's co-blogger Iain Beardsell. It's a bit of a head fake, and not the topic one would have expected to emerge as the show-stopper, but it sure was for me. You can watch it here:

Iain Beardsell - Pain and Suffering in the ED from Social Media and Critical Care on Vimeo.

You can see most of the talks on Vimeo where they are posted in full video format, or download them as iTunes audio podcasts to listen to them on your way to the ER. The opening ceremony ... a surreal experience ... is truly not to be missed.

Best of all – SMACC is coming to the US next year, of all places, to my hometown, Chicago. The dates are June 23-26, so be sure to be there!

Someone is WRONG on the internet! (Hospital admission edition)

The grandiosely-named "MD Whistleblower," recently wrote a post, reblogged at KevinMD, entitled "Why the ER admits too many patients."

I will begin with the time-honored ad hominem attack, since I am aware of all internet traditions. "Whistleblower MD"? Really? That's so cute. You see, as a whistleblower, he is a genuine hero, someone who is willing to expose himself and his career to enormous personal risk in his unrelenting search for truth. Unlike the rest of us, who are just random jerks on the internet with a bunch of opinions. He's a truth-seeker, so his opinions should be given special weight and are clearly objective, unbiased, pure Truth. Or maybe he's just another opinionated jerk like the rest of us, and in this case, a spectacularly ill-informed one.

Having said that, I would like to explain why he is wrong, in all the myriad ways, in his contention that emergency physicians (EPs) admit too many patients because of improper motivations. Note that I am not going to argue that EPs don't admit too many patients - that's a legitimate discussion to have and there may be some merit to the case, though the pendulum is clearly swinging against the trend of excess admissions.

The Whistleblower, a gastroenterologist named Dr Michael Kirsch, alleges that EPs admit patients who do not have a need for inpatient care for the following reasons:

  • EPs are incentivized monetarily for admitting patients.
  • Hospitals pressure EPs to inappropriately admit patients.
  • EPs admit to minimize malpractice risk.

The third point, I will agree, has some merit, so we will leave that alone. The first two, however, are profoundly ignorant to the realities of the actual practice and economics of acute hospital medicine (from all perspectives - those of the EP, the hospitalists who do the admitting, and the hospitals themselves).

First of all, remember that a substantial majority of EPs are not employed by the hospital, and receive their sole reimbursement from the patient's insurer, for the professional service bill. This means that whether I admit the patient or send them home, presuming that I did some sort of work-up and considered complex data and potentially risky diagnoses, I've got a level 5 chart on my hands. Nothing more is to be gained for the physician if the patient is admitted. Not. One. Penny.

In fact, admitting the patient will likely decrease my net productivity and thereby, compensation, and certainly generates more work and makes my job a ton harder. Bear in mind that Whistleblower MD stipulated that we are talking about patients who do not meet inpatient criteria.

So if I want to get this borderline patient admitted, I have to get a skeptical hospitalist to agree to accept the admission. They know full well when I'm slinging them a line of BS, and if I try to elide the truth to get the patient admitted, my credibility with them the next time I try to admit a borderline patient is shot. So I need to be honest that it's a BS admission - whether it's a social admit, or an observation admit, or someone who just doesn't look right. Hospitalists are under extreme pressure from hospitals not to admit patients like this (more on that in a moment) and they also tend to be overworked and disinclined to admit another patient if the patient doesn't need it. So most hospitalists are going to try to block this admit, or make me do some extra work to try to get the patient home, or if nothing else subject me to a withering cross-examination that takes away from time I could be using to see another patient and making more money.

Then, let's say I get the patient admitted. Great. I win, right?  Well, if I work in some sort of utopian ER where admitted patients go directly to the floor and become someone else's problem, yes. In the real world, unfortunately, admitted patients tend to board in the ER for many hours, sometimes many many hours, often on hallway gurneys. So this admitted patient, who could have gone home, is now going to squat in one of my beds for hours, congesting the ER, consuming nursing resources and preventing me from seeing patients languishing in the waiting room. To be clear: excessive admissions, as an EP, cost me money.

Now what about the hospitals? Are they going to be pressuring EPs to admit more, or even, as Whistleblower hints, improperly financially incentivizing admissions?

Again, to even suggest such a thing reveals a disconnect from reality that only a specialist who hasn't practiced acute care medicine in a decade could possess.

See, Medicare decided some years ago that inpatient care was costing too damn much. So they decided that they were going to get really aggressive about reviewing admitted cases, and then, retrospectively, denying payment for patients who were incorrectly admitted as inpatients when only observation care was indicated. Observation care reimburses the hospital only about one-sixth the amount that inpatient care does. They've gone through some contortions to try to clarify what they mean, including redefining the criteria for inpatient care and issuing the infamous two-midnight rule. So rather than pressuring EPs to admit more, the hospital administrators and utilization review folks have become intensely focused on reducing preventable admissions, and correctly categorizing observation admits as such. Hospitalists are generally the most sensitive to the hospital's concerns on this front and tend to act as a first line of defense in trying to keep the marginal admits out of the hospital.

Then you consider RAC audits. These bounty-hunting contractors are empowered to examine hospital records and retroactively recoup improper payments years after the fact. This year, RAC audits are expected to result in hospitals having to return over $3 billion to the government. Oh, and hospitals face penalties for re-admitting patients to the hospital within 30 days. Oh yeah, and medicare general medical admits generally have a flat to negative contribution to the hospital's profit margin.

So, um, no, hospitals are hardly pressuring EPs to admit to keep the wards full.

Finally, the real evidence that Dr Kirsch couldn't find his ass with both hands and an ass-finding device is the ignorance of the real revolution in ED care over the recent years: the proliferation of new treatments and decision-making tools which have allowed EPs to treat formerly admitted patients as outpatients. Consider just a few that occur to me off the top of my head:

And many more. While the valiant Whistleblower derides EPs for admitting tummyaches, the truth is that EPs are treating more and more people with formerly inpatient diagnoses as outpatients and saving the healthcare system countless dollars. We are not perfect: there are patients whose clinical need is genuinely indeterminate from the ER, and there are some indecisive or anxious docs who admit more than is strictly necessary. If Dr Kirsch wants to inform himself on the facts and make policy suggestions to improve care, his voice would be welcome. On the other hand, if he just wants to make ignorant insinuations towards the improper financially-driven motivation of an entire specialty, perhaps he would be better advised to stick to performing $6000 screening colonoscopies.

(hat tip to Whitecoat for flagging this egregious post. If you haven't it, you may wish to check out his own snark-filled rebuttal.)