David Mokotoff, MD

I recently sat in a small room, in the bowels of a local hospital, training for the impending implementation of CPOE. For those not familiar with current healthcare acronyms, this stands for: 

Nearing the end of my medical career, I could not help but admire the timing of this phenomenon. “They’ve finally done it,” I mused silently. They have replaced the medical secretary with none other than the physician. I supposed this was inevitable. After all, for years now I have been stuffing my own charts with order sheets and progress notes, applying patient labels to same, retrieving my own lab and radiology reports, etc. This was just the logical conclusion.

But for one who has been an EHR advocate, the irony did not escape me. For almost 10 years now my cardiology group practice has used an EHR, and although it took me a good six months to become comfortable with it, I now couldn’t imagine going back to a paper chart. So why is the hospital equivalent so painful for myself and many other older doctors?

Lack of compatibility and conformity is one big reason. I am on staff at six local hospitals, which have three separate EHRs. That means learning the ins and outs of three completely different means of accessing and inputting data. There are three different sets of user IDs and passwords, which change at different times and all with variable character requirements. If I read EKGs or diagnostic studies, it is probable that I must use a different application with other unique IDs and passwords as means of navigation.

How bad is it? Well, because of this, and other personal applications that I access, I succumbed to a password keeper application. In less than six months, I now have about 75 different apps, or programs, for passwords, which are now kept quite nicely on my iPhone, iPad, home computer, and in the “cloud.” For those of you technologically challenged, the “cloud” is a mysterious data storage area kept in a baffling location, holding onto a humungous number of bits, (or is it bytes?), of information all over the world. You can dump - and retrieve - data into and out of it with the touch of a keystroke. (Provided of course that you remember the correct user ID and password.)

Information technology (IT) is a wonderful thing. Yet, because of the ease, and wealth of information that can be handled, there is a tendency to abuse it. How much better is my life after reading, (or deleting), 100 or more e-mails a day? Do I really need a weekly e-mail update from the medical staff secretary about which drugs are now unavailable due to a “national shortage?” If I order it, and the pharmacy doesn’t have it, they will let me know, and I will order something else.

It is easy to lose site of the fact that IT is just a tool, and like any tool, can be used to improve our lives, entertain us, or to do evil, as in identity theft. My gripe is that the push for a nationalized EHR has come without any true means of having seamless integration of the multitude of programs. Few records, like hospital and physician offices, “speak to each other” electronically, and therefore create as many problems as they solve. Physicians’ efficient use of preciously limited time has become another victim.

We were sold a false bill of goods. Optimistic predictions by a RAND study in 2005 helped drive explosive growth in the EHR industry and encouraged the federal government to give billions of dollars in financial incentives to hospitals and doctors that put the systems in place. (And oh by the way, RAND’s 2005 report was paid for by a group of companies, including General Electric Co. and Cerner Corp., that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, from $1 billion to a projected $3 billion in 2013.) But evidence of significant savings is scant, and there is increasing concern that EHRs have actually added to costs by making it easier to bill more for some services. Whoops.

The U.S. health system is so large and heterogeneous that it is virtually impossible to integrate it in a seamless fashion. Imagine if we could carry around a microchip that stores all of our medical history and testing so any healthcare provider could access it instantly. So if you just had a coronary stent a few years ago in Miami, and while vacationing in Seattle you have chest pain, a local ER doctor can instantly read your old EKG and cath reports. Now that would be progress and provide potentially billions in savings. Of course there are privacy issues to overcome, but don’t tell me that the technology is not there to accomplish this.

We must standardize more. A decade or more ago as diagnostic studies became increasingly computerized, the cardiology and radiology fields faced a similar crisis. Ultimately, a universal display format called DICOM, was adopted, so viewing studies anywhere on any computer was feasible.

This is the only way for medicine and IT to become maximally useful and make doctors more efficient. Hopefully someone will spearhead this effort, but I will likely be retired and out fishing on my boat by then.

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Healthcare IT has great potential, but the lack of compatibility and conformity is making its role as a cost- and time-saving savior improbable. 

Doctors and the Information Technology Paradox

Along with the decision to go into medicine, the next most important professional decision a physician makes is when to leave it. As I rapidly approach the Medicare age, there is much to consider. Although my contract with the cardiology group I started in 1982 ends in June 2014, I could always renegotiate it, or seek an alternate practice opportunity. The question for me then, and many other docs my age, is can I retire? And, if so, when is the best time?

My financial planner tells me I can afford to retire in another year and half, so it would appear that money is not a deterrent or excuse. In order to achieve clarity on this, I have asked myself: "Do I really want to retire, and if so, what will I do after medicine?"

For many doctors, like my father, medicine was all they knew, and they practiced pretty much up until the time of their death. I love medicine, but not that much. A now-retired surgeon once said, "Medicine is a very jealous mistress." In other words, the practice of medicine can be 

consuming that it leaves a doctor with little time or energy for other interests.

Growing up in a family where the patriarch had only two interests - medicine and investing - I am keenly aware of this conundrum. Therefore, I have made a conscious effort to develop other pastimes. To name a few: writing, reading, fishing, cooking, gardening, and travel. I have learned much by observing other retired doctors and seeing how they fared.

Some do not do well. A cardiac surgeon friend of mine came out of retirement after only a year, because he was "bored." Another former partner has spent the last six months traveling after retirement, and so the jury is still out for him. A former adviser of mine summed up the post-retirement question well by asking, "So, what are you going to do on Monday?"

In the end, job satisfaction is the key. I had no illusions that the practice of medicine wouldn't change significantly over the length of my career. However, accepting this in theory and living through it are two distinctly different things. It is easy to wax nostalgic about the pre-DRG and pre-HMO days. I can even remember when a nurse would stand up, without me asking, to give me her chair, or when there were actually medical secretaries who stuffed charts full of fresh progress notes and order sheets. Now, with a plethora of insurance people, home healthcare aides, case managers, medical students, interns, and residents, I am lucky if I can find a seat in the nursing station, let alone a computer to use for charting.

Then there is the omnipresent assault on Medicare reimbursements that has lead to yearly declines in physician incomes, without the SGR formula even being implemented. To work harder is one thing. However, to be paid progressively less for that work is downright discouraging. Physicians in private practice have always been fiercely independent, and to a large degree this has lead to our undoing. Unable to amass the coherent solidarity and funds needed to advocate our case against hospitals, insurance, and legal lobbyists, we are now viewed by the healthcare industry as replaceable workers. The regulatory environment has added so much to private practice overhead and damaged office morale, that it is no surprise when every year more physicians and groups sellout to hospitals, or just quit.

Some pioneers, like Dr. Keith Smith of the Surgery Center of Oklahoma, have championed consumer-driven healthcare by posting prices for operations. Others have given up accepting insurance entirely, or started concierge medical practices.

It would likely take a unique opportunity for me to stay in medicine –– something that could excite and challenge me again. I will miss the rewards of healing patients. What I won't miss is the constant overseeing of my day-to-day work by faceless bureaucrats, politicians, and third-party payers.

For me, the time to hang up the stethoscope has not arrived, but that moment is not far off.

is a private practicing cardiologist in St. Petersburg, Fla., and a contributor to Practice Notes, 

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This article originally appeared in the February 2013 issue of 

Cardiologist David Mokotoff writes about why he has decided to retire; and why he won't miss the constant overseeing of his work by faceless bureaucrats, politicians, and third-party payers.

'Why I'm Leaving Private Practice'

Recently both President Obama and the AMA have called for physicians to talk with their patients about gun ownership, especially if they sense mental health issues. This request sounds innocuous enough, but let’s explore the implications and the reality.

First I need to issue a disclaimer. I am neither a member of the NRA nor do I necessarily feel that more gun laws and bans will reduce the recent tragedies like those in Newtown, Conn., or Aurora, Colo. Gun safety should be of paramount importance to all gun owners. However, if I am going to ask all my patients about gun safety and ownership, then there are a few more dangerous things I need to ask them about as well.

“Do you own a pool?” (Quite relevant since we live in Florida.) “If you do, do you have small children at home or as guests? Do the neighborhood children come by? Do you have a pool fence and is it locked at all times? Have you thought about how many accidental drowning of children there are in Florida every year? Have you taken a course in pool safety?”

Or how about this topic: “Do you own a dog? What kind of dog is it? Were there any pit bulls in its family lineage? Do you have small children at home or grandchildren? Has your dog ever bitten anyone? (Okay, the mailman doesn’t count.) Have you taken a course in dog safety ownership?”

You see where I am going with this of course. First of all, I, and most doctors, don’t have the time to engage in this dialogue with my patients, since I am too busy asking about percentage of seat belt use, quitting smoking, updating medicine lists and system reviews, and filling out ridiculous “meaningful use” of EHR forms, just to get paid from Medicare. And even if I did have time, it is really none of my business. And if even if it was my business, asking this would not prevent a mentally aberrant person from finding weapons and using them in a hideous fashion.

The fatal flaw in this logic is that the desire to do good, does not lead to good results. In fact the opposite is often the case. A recent opinion piece in the 

. He was a criminal prosecutor in the District of Columbia from 2007 to 2009. In essence during the strictest gun ban years, the rate of homicides increased. Ultimately in 2007, the U.S. Court of Appeals in D.C. ruled the city’s gun ban to be unconstitutional. The U.S. Supreme Court also affirmed the ruling the next year. Since the ban was struck down in 2008, the homicide rate dropped from 186 to 88 in 2012, the lowest number since the original ban law was enacted in 1976.

Recent shooting tragedies do launch a knee jerk reaction by well-intentioned politicians, but as usual, the beneficial results of new laws often achieve the opposite, since the criminal, or deviant mind, will always find a way to purchase weapons. So here are my thoughts on what might help.

• Loosen the HIPAA laws so deranged individuals can have their psychiatric history quickly accessed by mental health providers.

• Tighten the “gun show” loop holes, so gun purchases meet the same measures at shows as at a gun store.

• If the government insists on throwing more money at a problem, (and they excel at always doing so), then invest in more mental health professionals and treatment facilities.

• Make it easier for teachers, (who want to), learn gun safety and obtain concealed weapons permits. Every adult who supervisors school outings in Israel is trained in weapon use and carry semi-automatic guns on field trips. You never hear about these tragedies in that country.

But mandating doctors to ask patients about gun possession? You can count me out on that one. This is an invasion of privacy, and worse, will do nothing to curtail the periodic catastrophe that occurred at Sandy Hook.



“To be prepared for war is one of the most effectual means of  preserving peace. A free people ought not only to be armed, but disciplined.”


      - George Washington, First Annual Address, January 8, 1790
      
      
 

The president wants physicians to ask patients about their gun ownership. To me, this is not the best use of our time or the solution to avoid future tragedies.

Guns, Doctors, Patients, and the Second Amendment

When the marketing of Obamacare began in 2009, I always believed that the end game was for a federal single-payer system. Since the present Affordable Care Act (ACA), was passed in 2010, there has been nothing to convince me otherwise. The only reason single-payer wasn’t passed two years ago was because it was hard enough to arm-twist and bribe even Democratic legislators to pass the present 2,000+ pages of legislation. The following is my prediction of how this will unfold.

Remember the president’s marketing lines? “This won’t cost a dime. It will be funded by savings in fraud and abuse.” Millions of dollars in fraud and abuse have been recouped, but the dollars saved do not even come close to paying for this program. Or how about this one, “If you like your health plan and your doctor you can keep it.”  True - assuming that your employer still offers you health insurance, as many will drop this worker benefit come 2014.

Doctors have always been the weakest link in the healthcare chain. Compared to pharmaceutical companies, AARP, attorneys, health insurance companies, and hospital chains, we are poorly organized and underfund lobbing efforts. So like the slowest gazelle in the pack, we are the easiest to pick off first. By the end of 2013, estimates are that over one-half of cardiologists will be owned and or financially affiliated with a hospital corporation. Office-based ancillaries such as imaging and cardiac cath labs have had reimbursements cut to below levels of provider cost, making it almost financially impossible for a cardiologist to remain independent. How did this happen? Let’s see.

The rap against cardiologists, and other specialists, has been that since they owned so much diagnostic and treatment equipment, that over-testing and procedures, largely due to self-referral, drive up the cost of healthcare. That is a legitimate hypothesis, but has never been proven. Medicare’s solution was to simply cut away at physician-owned outpatient facility payments while simultaneously increasing the reimbursements for the same procedures at the hospital; thus eliminating any conflict of interest when a doctor orders a test or procedure. In theory, this idea seems sound, but in actuality, it ends up costing Medicare more, not less. That is because any test, or procedure, done in the hospital costs many times more than if it was done in the physicians’ office.

For example, in my area of Florida, a physician-owned cardiac cath lab can do a procedure for under $2,000 and still make a profit. The exact same procedure in the hospital (even if it is done as an out-patient), can cost Medicare anywhere from $5 to $10,000. Plus the patient must pay a Medicare Part A deductible, which is more than Part B. None of this has dissuaded Medicare from cutting reimbursements to non-hospital owned outpatient cath labs, which will likely become extinct within the next two years.

Along with this big stick, is also a big carrot. Hospital-employed cardiologists are now paid on the basis of work relative value units (RVUs). So no longer do they have to worry about being under-, or non-reimbursed, for their work due to poor or a lack of health insurance. The hospital can more than make up for these bad debts by write-offs and over-charging Medicare and other private carriers. Thus, it has become a win-win for the hospital and the cardiologist. Who loses? We all do. There is now even less of a free market system of healthcare testing and procedure purchasing, and costs will inevitably rise.

I believe that federal government policy makers are not blind to this. When most cardiologists are employed by hospitals in the not-to-distant future, Medicare and other payers will start to cut payments to the hospitals as well, under the guise of reducing costs of the program. Inevitably, rationing will then increase, as it has in every industrialized country with national health insurance. Private insurance premiums will escalate, and the populace will become increasingly angry and demand changes. The politicians will throw up their hands and say, “Oh well, we tried to do this through the private sector, but it just hasn’t worked out as we had expected.” Voila: single payer.

I hope I am wrong. But as implementation of Obamacare rolls along, and Medicare directs better payments to hospitals than physicians, I doubt it. The only alternative is consumer-driven healthcare. But that is a subject for another day.

As the Affordable Care Act moves forward, it is inevitable that consumer-driven healthcare is its goal. Here's why.

Single-payer Healthcare is the End Game of Reform

I recently saw a 90-year-old patient at my cardiology practice. She was demented, but cooperative with the exam. A devoted daughter, with whom she lives, accompanied her to the appointment. Her dementia was severe enough to make a cogent history from the patient impossible. However, the daughter had something on her mind, and it had nothing to do with her mother’s heart condition.

“My mother’s primary-care doctor wants her to have a mammogram and colonoscopy. I don’t feel good about this. What’s your opinion?” she asked

“Is she having a problem with her bowels or her breasts?” I responded.

“No,” she replied. “[The doctor] just says it needs to be done.”

At this point in such a discussion I usually remain neutral, not wanting to second-guess the recommendation of a colleague. However, this seemed so blatantly ridiculous that I could not hold my tongue.

“Well,” I started, “If it were my mother, I would not consent to those tests.”

The daughter seemed satisfied with that answer, confirming her intuition and already made decision.

After the appointment, I looked at the name of the patient’s primary-care doc and insurance. I knew the doctor well, but saw few of her patients, as she belonged to a Medicare replacement HMO that referred rarely to our group. Having known this HMO for years, I was not particularly fond of its track record for providing high quality care. I was even more surprised when days later I read one of their ads in a local newspaper, during the yearly enrollment period for new Medicare Advantage subscribers, and they were bragging they had received a 4.5 (out of 5) star rating from Medicare. Hmmm.

Immediately, I knew that this must have something to do with money. As it turns out, that suspicion was correct. Medicare has started rating its Medicare Advantage plans with one star to five stars, awarded based upon various factors, such as “improving or maintaining health.” Preventive measures like flu shots, mammograms, and screening colonoscopies are included. What apparently isn’t included in the target measures of quality are any age limit. There is absolutely no evidence that these tests improve, or extend, the life of a nonagenarian. Indeed, doing these tests in this setting is not only a waste of money, but potentially dangerous.

The more stars the HMO gets, the more money they get from Medicare. In fact, this system was part of the Affordable Care Act. The health plan can garner millions of extra dollars and reward their docs as well. Bingo. Now I understand.

To be clear, I have nothing against preventive medicine. However, this is a classic example of how government mandated rewards for following boilerplate guidelines misses the mark and leads to unintended consequences. Pay-for-performance is an increasingly popular, yet largely unproven, concept for rewarding the providers of healthcare. Also known as "P4P," this payment model rewards physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures for quality and efficiency. Depending upon how they are used, practice guidelines can be helpful or harmful. Based upon their track records, forgive my skepticism when they are placed in the hands of bureaucrats, masters of public health, and politicians.

National Center for Policy Analysis in 2011

, John C. Goodman gave a sobering view of how the P4P policy is still unproven:

“We examined the effects in 260 hospitals of a pay-for-performance demonstration project carried out by the Centers for Medicare and Medicaid Services in partnership with Premier Inc., a nationwide hospital system. We compared these results to those of a control group of 780 hospitals not in the demonstration project. The performance of the hospitals in the project initially improved more than the performance of the control group: More than half of the pay-for-performance hospitals achieved high performance scores, compared to fewer than a third of the control hospitals. However, after five years, the two groups’ scores were virtually identical."

For better or worse, with the Affordable Care Act now the law of the land, I suspect we will see more of these types of good intentioned guidelines resulting in little improvement in the overall health of the elderly.

Pay-for-performance is an increasingly popular, yet largely unproven, concept for rewarding the providers of healthcare. They can be helpful …or harmful.

The Problem with Pay-for-performance Incentives for Physicians

June 30, 2014. I don’t need to have this date circled on my calendar, or on my phone calendar reminder app. It is now etched in my brain. That is the date of my anticipated retirement from private practice. It is hard enough for me to grasp that next summer I can enroll in Medicare, let alone quit working - something I have done with only one, brief three-month break since I was 16. Yet this is a self-imposed deadline. The contract with my medical practice ends then and I have stated my intention to retire on that date. I probably could renegotiate a contract with them; however, in less than a year, they will likely start searching for my replacement. So the question is, “Do I really want to retire?”

Friends and patients ask me continually, “What will you do if you retire?” And my answer is always the same, “Fish, read, write, cook, garden, visit the grandkids, and travel.” My financial advisor says I should be able to afford it. Yet, the work ethic is so deeply engrained within me that the mere thought of not drawing a regular paycheck gives me pause to reflect. It is in these moments that I recall a line from 

’s book, "Man’s Search for Meaning" - “Your work is not your worth.” Or another famous quote, whose author escapes me, “ No man dies wishing he had spent more time at work rather than with his family.”

Devoted and long-term patients grow increasingly anxious and ask me about the date. I half-jokingly tell them, “It depends upon who wins the election.” But this too is a dodge. No matter who wins, medicine will never be the same. Change of course in life and nature is inevitable. But all change is not necessarily better. Some changes in the practice of medicine seem to be an improvement, such as electronic records and point-of-contact lab testing. Others seem worse for doctor and patients, like pre-authorizations, guidelines, effective comparisons, bundled payments, and HMOs, to mention only a few.

The reality is that in order to gain satisfaction from practicing medicine today, doctors must come to grips with the cold reality of diminishing autonomy over decision-making roles. As a breed of fiercely independent individuals, we are loath to do this. At least for me, this sense of powerlessness, or someone always looking over my shoulder, is in essence the biggest hindrance to job satisfaction. Mitigating that is the occasional complement by a patient or family for a job well done.

I may keep a foot, or toe, in medicine after June 30, 2014. However, as that date creeps ever closer, it is a good time to reflect on a life of service, and how it has affected the lives of others, and not just me.

After contemplating a career that is seeing diminished autonomy, I've selected the date I'll retire from private practice medicine.