Memorial and Catholic Health Initiatives

In my January column, I wrote that we have an ongoing obligation to provide non-profit care locally so that Memorial’s mission of compassion, established in 1949 by our community forefathers, can continue. I am thrilled that Memorial has strengthened its ability to deliver on that mission by becoming part of Catholic Health Initiatives (CHI), effective June 1. CHI operates 89 hospitals in 18 states, with more on the way.

Much has been written about the transfer of ownership already, so I thought I’d comment on what this transaction is not:

It is not a takeover of physician practice. CHI has committed to preserve existing physician relationships in the community and build new ones. CHI’s relationship model with physicians is very much dependent on the region of the country they are in. Ultimately, improved coordination of care and better patient outcomes have to happen. Quality, efficient care is the focus, not whether or not physicians are independent or employed.

It is not a transfer of care to Houston. In fact, CHI wants to see Memorial become an even stronger hub for healthcare in the region. Of course, we will have increased access to highly sophisticated care through closer ties to CHI St. Luke’s Health in Houston and its affiliations with Baylor College of Medicine and Texas Heart® Institute. That will only strengthen our position in the region and improve the quality of care we deliver locally so that even more health care can remain local. Over the next two to three years, it is CHI’s intent that Memorial will become a part of CHI St. Luke’s Health. In my own area of cancer care, this can only enhance my options for my patients, including improved access to clinical trials.

It is not a drain of money from the local economy. The fact is, Memorial’s board recognized that the landscape of healthcare had so fundamentally changed that maintaining mission in a fiscally responsible way was becoming increasingly challenging without the resources and expertise of a well-capitalized, national partner. Over the next 5 years, CHI will invest more than $1 billion to expand and enhance the southeast Texas region’s health care infrastructure. Memorial, for its part, is guaranteed to see significant capital improvements over the next 6 years.

It is not a change of mission. Having read the Ethical and Religious Directives for Catholic Health Care Services – the guiding document for ethical behavior in health care for Catholic institutions – I can tell you that CHI’s mission and Memorial’s mission mesh beautifully. Both Memorial and CHI share a commitment to putting the health of the people and communities we serve at the center of everything we do. CHI intends to maintain the core health care services and charity care currently provided by Memorial in the East Texas community, which will continue to be overseen by a local board of community and physician leaders. I have the privilege of serving on that board, and I can state with confidence that Memorial’s strong commitment to charity care will continue.

It is not an end of an era. In 1949, our community forefathers got together to establish Memorial Hospital to take care of the people here in deep East Texas. They were compassionate, innovative, and forward-thinking. Their descendants – some in name and all in spirit – have led this health system to maintain that mission for sixty five years. Today, with no less compassion and thought for the future, we have taken a bold step to preserve and advance non-profit care for our region. Here’s to the next 65 years!

The Profession of Medicine

Physicians today rarely encourage students to consider becoming a doctor. There are quicker ways to start earning a good living. (Petroleum Engineering and Investment Banking come to mind.) But beyond the financial aspect, being a doctor just isn’t the same as it once was. Increasingly, patients don’t trust doctors, much less respect them or care whether or not they are happy.

A recent online Daily Beast article suggests the public should have more empathy for doctors. The author notes that 300 physicians will commit suicide this year, making it #2 on the list of the 19 jobs where you are most likely to kill yourself, according to Business Insider.

Why? She believes well-intentioned people working to solve the healthcare crisis have come up with answers that are “driving up costs and driving out doctors.” A simple example: “Just processing the insurance forms costs $58 for every patient encounter.” She also quotes noted writer Malcolm Gladwell, “You don’t train someone for all of those years in [medicine]… and then have them run a claims processing operation for insurance companies.”

Insurance claims, bureaucratic red tape, “quality” metrics (that are often more about trying to successfully report than actual quality) – all of these take away from face time with patients and chip away at the joy of what is increasingly becoming an unrewarding profession, not only monetarily, but emotionally.

In other words, practicing medicine has become a demeaning, demoralizing, punitive, bureaucratic nightmare for many physicians.

Don’t get me wrong. Most physicians make a good (or even great) living. I do, and I am not ashamed of it. As an honor graduate from Rice University with a medical degree from Baylor College of Medicine, followed by an additional four year residency, I am proud of my training and feel I have worked hard to get where I am. But with position comes responsibility.

Unfortunately, physicians have, for decades now, not paid attention to the cost of prescribing the latest and greatest drug when an older, cheaper generic is just as effective. Likewise, we put expensive imaging and treatment equipment in our offices and refused to acknowledge that there may be a conflict of interest, when studies show we order more tests and do more procedures as a result.

On top of that, I fear there is a growing contingency of younger physicians who see the practice of medicine as a job only, with a corresponding (and alarming) callousness toward the poor and uninsured.

There is hope. We have many physicians in Lufkin who have earned our respect, and I am honored to call them colleagues. Since 2008, Drs. Ravinder Bachireddy, George Fidone, and Kay Carter (and Mrs. Demetress Harrell) have each been recognized as Healthcare Professional of the Year at the Lufkin/Angelina County Chamber of Commerce Salute to Healthcare banquet. The Chamber has also honored Drs. WD Thames, Anna Beth Connell, George Thannisch, Dan Spivey, and Jacob Thomas with Lifetime Achievement Awards. Young physicians, who may not have gone into medicine for the “right’ reasons – indeed, all of us – would do well to follow their example.

Emily Shelton, the wife of my long-time partner, Dr. Bill Shelton, gave me sage, simple advice when I first moved to Lufkin in 1992: “Just do what’s right.” A sense of duty, compassion for the poor, cooperation with the healthcare team, communication with patients and families, collegiality with fellow physicians, and, of course, excellence of care are hallmarks of a great physician. That’s what being a doctor is all about. It can still be a rewarding, respected profession if we “just do what’s right.”

What’s Coming in Healthcare Reform in 2014?

My middle daughter is a graduate student in opera at Eastman School of Music. After October 1, if I go to hear her sing in an opera and get injured while there, a specific code must be used if my healthcare is to get paid. That code is Y92.253: “Opera house as the place of occurrence of the external cause.”

Perhaps I will be at Ellen Trout Zoo and get “Bitten by turtle, initial encounter” (W5921XA). And if, for some reason, I am stupid enough to get injured again by said turtle, there is a code for that, too:  “Struck by turtle, subsequent encounter” (W5922XD). But the current favorite new code among pundits has to be V9027XA: “Drowning and submersion due to falling or jumping from burning water
-skis, initial encounter.” Really? Who comes up with this? Is this a sick joke?

Our current system of coding for clinical encounters in healthcare is ICD-9, which has been in use since 1979. ICD-9 contains around 13,000 diagnosis and 3,000 procedure codes, arguably more than we need already. But get ready, because ICD-10 jumps to 68,000 diagnosis and 72,000 procedure codes, including the ridiculous ones noted above.

The change to ICD-10 illustrates the problem of government involvement in healthcare. First, complexity increases exponentially while usefulness – what I call the common sense factor – plummets. Then, the government tightens the rule belt, so that if you do not code correctly (how did I know you were bitten by a turtle before!), you do not get paid. Not only that – and this is what really galls me – if you don’t do it correctly, as narrowly and obscurely defined as only the federal government can do it, it is labeled fraud and abuse.

Someone asked me, as I explained this to them, “How will the government know if you didn’t do it correctly?”

Simple. They contract out to firms that employ high school-educated workers to go out and look for “fraud and abuse”. These firms get paid for what they find – whether or not what they find is really accurate – and then the government takes back those “fraud and abuse” payments from the provider (the doctor or the hospital, for example). Then, the provider has to fight multiple levels of appeal in order to get their money back, if they can afford the appeal process.

This is how our federal government is “saving money” with healthcare reform: make the hoops impossible to jump through; only pay you if you manage to make it through the hoop; then take back what they pay you because someone else with an unfair incentive claims you didn’t really make it through the hoop after all.

Our healthcare system truly needs to be reformed, but so far, very little is happening that gives me hope that we are headed the right direction. I foresee an explosion of job opportunities starting October 1, and anyone with expertise with how to code under ICD-10 will be golden. Orthopedic surgery, for example, will see one code under ICD-9 – 821.01 Fracture of femur, shaft, closed – expand into at least twenty four possible codes under ICD-10, depending on laterality, displaced or non-displaced, location, fracture type (greenstick, comminuted, transverse), type of healing (routine, delayed, non-healing), malunion, nonunion, open or closed, and encounter type (initial or subsequent). Those who can play the game successfully will survive.

At a time when payment for healthcare services needs simplification, we are taking a major step in the wrong direction. Now, is that step left, or right? There’s probably a code for that.

Winning the War on Cancer

“I have cancer.” What is your first reaction when someone tells you that? Not the same as when you hear, “I have diabetes,” or, “I high blood pressure.” Something about cancer scares the bejesus out of us. But, should it?

Twenty-plus years ago, when I first started practice, I would quote that we cured around fifty percent of patients. People didn’t believe me then, and you may not think we cure that many today. In fact, we now cure fully two-thirds of cancer patients! We have made remarkable progress in the war on cancer, thanks in no small part to the work of the American Cancer Society. In lung cancer alone, there has been a 20% decline in cancer death, largely due to decreased rates of cigarette smoking.

We just celebrated the fiftieth anniversary of the Surgeon General’s report on smoking and health. This major report, relying on research conducted by the American Cancer Society, exposed the lies of the tobacco industry and laid to rest any doubt that smoking causes lung cancer. We still don’t cure very many lung cancers today – about 15 out of 100 – but we can prevent the vast majority of cases. Since the Surgeon General’s report, eight million lives have been saved, and almost 20 years of life have been added to those lives saved!

Unfortunately, lung cancer is a global problem. There were six trillion cigarettes consumed in 2009! Last century, tobacco killed 100 million people worldwide. This century, tobacco is projected to kill 1 billion people, mostly in the developing world.

Decreasing lung cancer death rates in the United States is just one success story. Over the last nearly 40 years, breast cancer cure rates have increased from 75% to 90%, colon and rectal cancer cure rates have risen from around 50% to two-thirds, and prostate cancer 5-year survival has gone from 68% to 100%. How did we do it?

Better yet, how did YOU do it? You got your mammograms, Pap smears, PSA blood tests, and colonoscopies. You prevented cervical cancer by taking care of precancerous lesions found on Pap smear, or by getting your HPV vaccine. You prevented colorectal cancer by having precancerous polyps removed. You caught your breast cancer or your prostate cancer early by getting a mammogram or a PSA blood test. You noticed a mole changing and had it removed. YOU took charge of your health!

But there is a new danger lurking: obesity. Predictions are, obesity will surpass tobacco as the leading cause of death in the next two decades. Like with tobacco, both cancer and heart disease risk are increased with obesity. Fighting obesity is a lifestyle change, for sure. To change up an old phrase, “An ounce of prevention… is a TON or work!” And, unlike screening tests, you have to work at the diet and exercise continually. (Funny how I preach to myself in these columns!)

Anyway, next time you hear someone say, “I have cancer,” know that they are quite likely going to beat it. The war on cancer isn’t over. We still need to support research, provide prevention and detection programs, work for access to quality healthcare programs, and advocate for smoke-free public places. Walk in Relay for Life on Friday, May 2, 2014 at 6:00 PM at Lufkin Middle School! Support the Cattle Barons Gala, which will be October 25th! The American Cancer Society is the backbone in the fight against cancer. Finally, be a friend and encourager to those with cancer. It’s all about more birthdays, after all!

A New Paradigm of Volunteerism

Last week, I had the privilege of speaking at the annual Chamber banquet as outgoing Chair. This was my charge to the 700-plus in attendance, and my hope for Lufkin and Angelina County.

I have a passion for Lufkin – for her growth, her people, her churches and volunteer organizations. We live in a city and county that lives philanthropy. We have inherited a community built and sustained by many visionary leaders who made things happen, often, so the legend goes, by simply picking up the phone. And because of that legend, we run the risk of becoming complacent.

We are guilty of two things, as I see it, and I am intentionally using hyperbole to make a point. First, we are guilty of a reductionist view that thinks all advancement centered around Arthur Temple and that circle of leaders, as influential as it was. Second, we are guilty of a pessimistic view that no one is left who can make the big things happen. Now, of course, neither is true, but we shouldn’t allow ourselves to simplify and excuse away the need for hard work.

There are four keys to our continued success, as I see it.

First, COMMUNICATION.

When I was in medical school, one of the hardest lessons for me to learn was to pick up the phone and call someone for advice when I didn’t know the answer. There are experts out there in all fields. Maybe the Arthur Temples and Murphy Georges, the George Hendersons and Bubba Shands, the Rufus Duncans and Joe Denmans – I could go on – maybe it just seemed like they could just pick up the phone and call one another and get things done. We can, too, but we have to communicate. We are all in this together, and all have the same goal, whether city, county, Chamber, public or private sector, for-profit or non-profit. Let’s communicate!

Second, COOPERATION.

This actually dovetails with communication. Not only do we need to talk to each other, we need to work together. And we are! One thing I do believe is different today from the previous generation, perhaps, and that is rules and regulations are just more complicated. But everyone has to play by the rules, so let’s all get in there and do the work… together, and across organizational lines.

Third, CREATIVITY.

Partly because the rules of the game have changed, we need to get more creative with our solutions. I think of the discussions community leaders have had regarding Economic Development and how both the City and the Chamber have an interest, and how at an Economic Development Partnership meeting we were able to identify common interests as well as areas where either the City or the Chamber should take the lead (for example, bringing in manufacturing jobs versus business retention and retail initiatives). Let’s embrace our different approaches and creatively structure our relationships for maximum effectiveness.

Finally, CONTINUED INVOLVEMENT.

Last month, we buried Lizzie Wallace, a courageous teenager who died from a rare liver cancer. Her two-year fight with cancer didn’t stop her from working to make a difference. “Be the change you want to see” was her motto. As Lizzie saw it, we all have a responsibility to continue to use our influence in a positive way, even if – as in her case – we are near the end of our journey.

Whether you bring youth and energy to the table or the connections and influence that come with age and experience, you are needed. Get involved; stay involved! Together, we can make our dreams for Lufkin and Angelina County come true.

What a Hospital Should Be

Healthcare reform may be the most polarizing issue today. Depending on your point of view, you are either eagerly anticipating or just dreading the changes that are happening. Either way, we can all agree there is profound upheaval in the system. We are in the middle of an earthquake waiting for the ground to stop shaking.

While the focus on Obamacare has been on the individual’s access to healthcare, we need to remember that our hospitals are feeling the earth move underneath them as well. When hospitals are merely trying to survive may not the best time to consider what a hospital is and does, but I believe it is exactly when we need to take a step back and focus on mission.

A hospital is, first and foremost, an institution to take care of the sick. The Latin root for hospital is the same root for hospice and hospitality. Hospices in the Middle Ages were way stations for pilgrims who needed a place to rest/ Today, hospices are known for end-of-life care for those on their final journey. And the word hospitality denotes kindness and generosity. What a great family or words! Hospitals should provide comfort for travelers on a journey – a journey from illness to wellness. And that hospitality should be extended to all.

We, as a country, have decided that healthcare is not a universal right, in that not everyone (even under Obamacare) will have free care. Yet, we can’t seem to decide what level of individual responsibility (either in terms of healthy lifestyle choices, like smoking, for example, or huge deductibles which the average person cannot afford) goes along with whatever care we do receive. That leaves us with a broken system of inflated billing and inadequate reimbursement that continues to leave a good number of our sick not only without resources but with outrageous bills.

And, unfortunately, the government is placing more and more burden on the hospital to make sure that patients not only receive high quality care in the hospital, but are taking their medicine and seeing their doctor once they are back at home. The hospital is now supposed to be Big Brother. If a patient is readmitted to the hospital too soon after being discharged, the hospital does not get paid for that stay, even if it was because the patient was noncompliant with their own care outside the hospital. One can argue the fairness of regulations such as this, but all hospitals are required to play the same game now, and some will be better at it than others.

I would argue, some will have better results than others in the new quality outcomes paradigm because they “cherry pick” their patients based on ability to pay. That brings me to my main point: We must not let a divided system of care (non-profit versus for-profit) keep the sick from accessing care.

As a non-profit institution, Memorial has a mission to provide care for all, regardless of ability to pay. In an era of declining reimbursement, for-profit institutions – who report to investors – are increasingly turning away those without insurance (except in emergency situations, where federal law requires care to be administered to stabilize a patient). All hospitals operate on a tight margin, and non-profit hospitals (especially those outside of metropolitan markets) are increasingly feeling the pinch. We in Lufkin have an ongoing obligation to provide non-profit care locally so that OUR mission of compassion in Lufkin can continue. It is what our community forefathers established. It is what hospitality demands.

Heart Disease Prevention for the Holidays

My brother just had a heart attack. He had classic chest pain and immediately went to the ER. Before he could sneeze, he was transferred from his small town to a regional center for a heart catheterization, where they found a single vessel blockage. He had a stent placed and has no significant damage. He’s doing great. He’s more upset that A&M lost to LSU.

I’m the one not handling it well.

You see, my brother is only five years older than me. He exercises regularly, jogging 3 miles at a time. He’s even been to the Cooper Clinic in Dallas for all sorts of tests. Our father will be 80 years old in a few weeks, and he has not had a heart attack. Why my brother? And, to the point of my worry, why not me?

Now, I know that we all just gorged ourselves over Thanksgiving, and Christmas is right around the corner. Any talk of diet and exercise should wait until after the first of the year, right? If you are like me, it takes awhile to get psyched up for this. Habits are hard to start and easy to break. This needs to be a lifestyle decision. Mind you, I am not a stranger to exercise… I just haven’t been very friendly with him lately.

If you are like me, there are things you just don’t really want to change. I like my morning latte from Standpipe Coffee and cookies from Confections (shout outs to Ben and Dawn!), and when I travel, I often seek out nice restaurants. At 178 lb, many would say I am not overweight. The insurance industry, however, would disagree. My BMI is right at 25, the cutoff for being “overweight”. Scary word, that one, but not as frightening as “obese”, which a significant percentage of Americans are now.

Dr. Huber, my internist, would like to see me lose 10 lb or more. He told me so last year. In one ear and out the other… Actually, I did lose weight, but gained it back. I should learn to schedule my appointments at the low end of the scale.

As a cancer physician, I preach prevention and early detection every day. The facts with cancer are irrefutable: diet, exercise, and not smoking are three very important things we can do to help lessen our risk of getting cancer. Well, those three things also happen to be the key to lowering one’s risk of heart disease, which kills even more people than cancer.

We are fortunate to have access to incredible cardiac care right here in Lufkin. Truly excellent cardiologists and cardiac surgeons practice here. I would not hesitate to have my heart cath done down the hallway from my office here at Memorial if I had to. But like my cancer patients tell me, they really didn’t want to ever see me professionally, and I’d just as soon keep my relationship with my cardiology friends a social one.

I don’t want to be a “do as I say, not as I do” role model and end up on the cardiac cath table in five years. I see Dr. Huber this month to discuss what other measures – tests? medication? – I need to take for heart disease prevention.

And, I’ve decided that December is a good time to start my diet and exercise program. Yes, I’m going to enjoy Christmas! But maybe I can limit my portion sizes some and NOT go for that second (or third) slice of pecan pie! (Or that second cookie at Confections!)