COMMENTARY

How Healthcare Reform Handcuffs Doctors, Creates Issues

Arthur L. Caplan, PhD; Scott D. Hayworth, MD

Disclosures

November 12, 2014

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The Challenges of Group Practices

Arthur L. Caplan, PhD: Welcome to Close-Up With Art Caplan. I am at the New York University (NYU) Division of Medical Ethics in New York City. Today I have as my guest physician leader Dr Scott Hayworth, who is the chief executive officer (CEO) of the Mount Kisco Medical Group (MKMG). Scott, tell us about the practice that you are running in Westchester.

Scott D. Hayworth, MD: We are a 300-plus physician multispecialty group. As of January 1, we will have 450 physicians and 100 midlevel practitioners. We cover the entire Hudson Valley, from Mount Kisco all the way to Kingston.

Dr Caplan: For those outside of the New York area, that is about a 100-mile radius.

Dr Hayworth: That is correct. We take care of approximately 300,000 patients today, and with the additions in January, we will be up to 400,000 patients.

Dr Caplan: I have been eager for this interview because our readers will be keenly interested. They will either say, "He finally has the devil incarnate as a guest" or "My hero has appeared." The topic of group practice sets off a lot of strong feelings about ethical, social, and fiscal issues. You started off as an obstetrician/gynecologist. How did you wind up on the administrative side of things?

Dr Hayworth: In 1988 I joined MKMG with 28 physicians. I became president in 1996 and the first CEO in 1998. We were a turnaround. It is strange how things happen in life. I was a chief resident and then a resident in obstetrics and gynecology, and I practiced obstetrics for some years. The group continued to grow. We had to grow with all of the changes in medicine, and we have had fairly rapid growth over several years.

Stop Entering Data and Practice Medicine

Dr Caplan: In today's climate, what are the toughest challenges in managing a multidisciplinary practice in terms of dealing with the physicians?

Dr Hayworth: Fortunately, we have very well-trained physicians, and we are blessed being close to New York City. We have always recruited the best and brightest. Doctors are having a tough time today. We have turned our doctors into data entry clerks with meaningful use, which has frustrated physicians both within and outside of my group; and as I travel and speak across the country, everyone is finding this to be an issue. Our doctors are inputting more data. We have to figure out ways to free them up so that they can practice medicine again.

Dr Caplan: When I go to the primary care provider, his head is in the computer, and I wave and say, "I am over here, you know, remember me?" I know you need to enter all of this information. When you say "too much data entry," is there a return on that? There have been a lot of promises that if we could get more information technology, and collect more information, then quality and safety of care would improve. What do you think?

Dr Hayworth: From a safety standpoint, we have had electronic medical records (EMRs) for 16 years. We were very early innovators, but many of the hoops we are being asked to jump through just don't make sense.

Dr Caplan: Can you give me an example?

Dr Hayworth: We have always had a dictation system. Recently, we have gone to the Dragon system, and we will go to data input.

Dr Caplan: Dragon is the oral reporting system?

Dr Hayworth: That's right, and we are going to have to go to templates. But if you read a medical note, sometimes you will get six or eight pages of data when someone comes in for a cold or sore throat, and there is nothing meaningful in those pages. The dictated note was a much better note. But because we are using structured data, if you were to pull the data to be able to do the reports that are required of us, we have to force people off of dictation.

Dr Caplan: We are taking all kinds of notes, tracking all kinds of information within the healthcare system. Reams of information are being generated. Can people pay attention to all of this information? Can we track it all?

Dr Hayworth: We are visited by many leading politicians who say that we are the cutting edge, and we are doing what people want for America. Yet, when they handcuff us and make it hard for us to do what we need to do, then we have to step back and pause.

HIPAA: Take Down Those Baby Pictures!

Dr Caplan: From the point of view of patients, part of the data explosion has involved, for good or bad, the evolution of the Health Insurance Portability and Accountability Act (HIPAA), the federal privacy protection act. Are the patients doing better because we have a lot of information protected by HIPAA?

Dr Hayworth: We always protected patients' data. There are some good aspects to HIPAA, but there is also some ridiculousness. We have to take down the baby pictures. The mothers always send me pictures to thank me. One year, I had delivered a bunch of triplets, so I had pictures. We can't keep the pictures up now. Their names aren't even on them, but we have gone around to our offices and taken down the baby pictures. The nurses are crying. The doctors are crying. The patients are crying. They sent the pictures in because they love their doctors.

Dr Caplan: It seems absurd. The people who are feeling the brunt of HIPAA are the florists, who are wandering around every hospital trying to find rooms and can't deliver their flowers. The hospitals won't give them names anymore.

No Protection for Physicians

Dr Caplan: We are in a sea of information, and maybe we will work our way out of it. Now, I will switch to the patient perspective. Is today's doctor able to spend time talking with the patient, or are we missing that because we are charmed by the data or worries about liability or other things?

Dr Hayworth: Let's touch on liability. Liability is a real problem because nothing in the Affordable Care Act (ACA) was done to protect doctors against liability. I am the first person to say that if a patient is truly harmed and it was something that could have been controlled (not a bad outcome over which the doctor had no control), then the patient deserves compensation, and we should figure out as a country what is the proper compensation.

However, what happened with the ACA was that there was no protection. Doctors should be protected if they follow the protocols. The national protocols should be protecting them from lawsuits. It should be a safe harbor, but what happens is that in one room, we are self-insured for medical malpractice, and we tell our doctors not to be afraid to order a test; and in the next room, we are standardizing care and trying to squeeze cost out from under the world of population health. We say, "Think twice before you order the test." Our physicians accuse us of being bipolar or schizophrenic. As a country, the only way we are going to save money is if we take the liability monkey off the doctors' backs.

Dr Caplan: People pooh-pooh it, but when you talk to people out in the real world, they complain about it bitterly. The people in the ivory towers say that it is not a big driver of cost. It seems to me that liability is a huge driver of practice.

Dr Hayworth: It is. I am national treasurer of the American Congress of Obstetricians and Gynecologists, and we look at C-section rates, which are exploding in this country. What is the doctor asked every time in court? Why didn't you do a C-section? It is outcry from the public. We should have lower C-section rates, but we will never achieve them until we take care of the problem of liability.

Competition and Advertising: Necessary Evils?

Dr Caplan: It is very competitive these days in the medical marketplace. To some extent, we have put our chips on competition to keep costs down. Is that ultimately good or bad for the patient?

Dr Hayworth: Competition is good. It makes everyone improve their game, and fair competition is fine. We have to be careful. The government is telling us that we need to get big, to have big systems like ours. Hospital systems are combining left and right, for savings and to practice population health. Whoever controls the premium dollar in the future is going to win. If you, as a system, can take care of that premium dollar, take care of the risk, do it well, and provide a quality product, you will be successful.

However, we also have hospital groups breaking up. We watch these things happen all over the country. Both ends of government have to talk to each other. You can't have one side say that we should grow and expand and then have the other side say, "Whoa, we have antitrust."

Dr Caplan: It is similar to the telecommunications industry. Let's get big, but let's break it up so we can continue to compete. What is your view about direct-to-consumer advertising? Does it help people seek out better care, or does it create headaches for the doctors?

Handcuffed by Health Reform

Dr Caplan: What is your view on the overall health reform effort? Is that lean? Is that getting us where we ought to go?

Dr Hayworth: Not at all. The intentions of the ACA were good, but it is a very expensive system, and we are not going to save money doing it. Our patients are suffering from high deductibles now. Patients ask us all the time to waive fees, which we can't do, so we are handcuffed.

Dr Caplan: Tell me more about what you see as some of the flaws. Expanding access seems reasonable to do, although we hear that we haven't expanded the number of people providing primary care, so that could be a crunch. People say that we are going to contain costs by using more evidence-based medicine.

Dr Hayworth: I am not convinced. We are trying to squeeze down the costs. In a big system like ours, we are able to do it, and we are concentrating on it. We have a program called One MKMG, where we get together the specialists in each of the areas. I will sit in a room with 25 or 30 obstetrician/gynecologists from our system and we will talk about Pap smear rates. We will talk about when to order mammograms or when to do an endometrial biopsy. You would be amazed—when you have 25-30 well-trained people in the specialty, there is a bell-shaped curve, and we can tighten that up. I say to our cardiologists (I am not a cardiologist, nor are any of my medical directors), "Pick national guidelines. I don't care which national guidelines you pick. Pick one that you feel comfortable with, and follow that national guideline."

Dr Caplan: Some people say that following guidelines and trying to create a safe harbor with professional standards and recommendations is just cookbook medicine. Don't individual patients need some judgment?

Dr Hayworth: The government is driving us to cookbook medicine whether we like it or not. I tell our doctors that there is always going to be that rare patient for whom you need to do something different. We have 28 (soon to be 40) locations. A patient should be able to see a gynecologist in any of those 40 locations and receive roughly the same care. That is my goal.

The Changing Profession of Medicine

Dr Caplan: How do you see technology affecting the future provision of care? We have robots coming, and people are building more proton beam centers and so forth. Will we ever get a handle on cost, or no matter what we do, is technology going to continue to increase the cost of healthcare?

Dr Hayworth: It will drive up costs. Some hospitals in the country are still adding beds, but we have to be careful about where we add things. The world is moving to outpatient medicine. Groups such as mine definitely are the future. If I can make a plug to young graduates, residents, and attendings who are reading this, if you are looking for positions, multispecialty groups are the way to go. I am biased. I am also the former chairman of the American Medical Group Association, which is the largest medical group in America. I want readers to be aware of my bias because we are talking about ethics today.

It is nice to have specialist right there. With one EMR, everyone has access to the same information. It is safer and leads to better care for patients.

Dr Caplan: You mentioned the young residents. Parents often ask me whether they should encourage their sons or daughters to go to medical school. Is this a good time to enter medicine? They see physicians hounded by bureaucrats. They see them getting yelled at by ethicists, and lawyers are chasing everybody around. Maybe medicine is not as lucrative as it seemed in the past, at least for some specialty areas. How do you respond to that?

Dr Hayworth: Over time, medicine will become less lucrative. It already has. Doctors of the future will be making less than what they are making now. Medicine has been a wonderful career for me. I have been very fortunate. I have had a lot of different responsibilities, and I love my patients and what I do, so I encourage people to go into medicine. In reality, medicine is almost like a law degree today. You can do lots of things with it. It is a very exciting time, whether it is genomics, administration, entrepreneurship, or information technology. A medical degree today is very different from a medical degree 25-30 years ago.

Dr Caplan: When I was at the University of Pennsylvania, and now at NYU, one fourth of the class is not going directly into clinical practice. They may go into business, public policy, or working for a union. There are many different avenues. You are right—the MD is starting to look like a JD.

Maybe your spouse someday will be sitting in this chair. Why don't you tell us who you are married to and how that influences what you have said today.

Dr Hayworth: My wife is Dr Nan Hayworth, an ophthalmologist and the first female physician to be elected to the US House of Representatives. She is running again, so whenever I do presentations, lectures, or TV shows, I always remind everyone that, like many couples, my views are my own and not my wife's, and her views are her own. We keep a firewall on policy, and we run our separate professional lives.

Making Promises, Managing Expectations

Dr Caplan: The public has a lot of expectations now. Part of it is driven in the media. I have seen it with the Ebola outbreak. How could they have made a mistake? How could anybody die of Ebola? We have the most wonderful healthcare in America. It is impossible. You look at some of the rhetoric that surrounded the introduction of the ACA. We are going to have healthcare for all. It will be not your problem anymore.

We have made a lot of promises to the average patient. What would your warning be to that patient about being realistic?

Dr Hayworth: You need to be realistic about what you are buying. Many people will buy a plan thinking that they have coverage for certain things, but they don't. They think that they have coverage with certain doctors, and they have a narrow network. People need to be very careful about what they buy.

We also have to be careful about what we promise. Things are free in America. We want everyone to have access to care, and we need to subsidize it for poor people, but the middle class is getting squeezed. We have to be open and honest and transparent. I run my organization in a transparent way, and we need to promise care in a transparent way.

Dr Caplan: Thank you for sharing your experience with us. This was very enlightening for me, and our readers will have a lot of reactions and thoughts. You shared a great deal of information and opinions, and they were valuable and much appreciated. Scott, thank you.

Dr Hayworth: Thank you for having me, Art.

Dr Caplan: This has been Close-Up With Art Caplan.

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