Dr Fragen in the operating room


  • Medical Staff – Hospital Alignment


    I’ve been on staff and practicing at Desert Regional Medical Center for almost 20 years. During that time I have taken ED call for General Surgery and for half of that time for both Trauma and General Surgery. I have noticed many significant changes during that time.
    Over the course of the past few decades the practice of hospital medicine has shifted significantly. Initially, ER call was the primary method of increasing your practice and with the payor mix there was never really an issue of either paid call or not having enough physicians taking call. Beginning around 15 years ago the reimbursement for physician services changed dramatically. It soon became obvious that office expenses were ever increasing and reimbursement was ever decreasing. The economics of the private practice physician was quickly becoming economically unfeasible.
    Fundamentally the problem arises as many medical staffs, ours included, do not seem to understand the symbiotic relationship between themselves and the hospital. Many have openly expressed that the hospital wouldn’t exist without us. They don’t seem to understand that our livelihood also depends on a strong, viable hospital providing services and infrastructure that we depend upon. Most have no clear understanding of HCAPS scores, quality dashboards, PSI-90, or any other metrics by which hospitals are measured.

    Giving Millenials a Bad Rap

    As background, DRMC has never had large or even moderate sized physician groups. It has always been an aggregate of individual practitioners with a smattering of small groups. As the economics of medicine has shifted away from the viability of the solo practice towards a group practice, our physicians were set in their ways and seem unable to join together under any sort of meaningful cooperative venture. I believe that much of the current state, both in general and in specific, stems from the medical staff having a sense of entitlement. There are two distinct groups with different reasons for the sense of entitlement. Firstly, millennials, as a group, have a well documented sense of entitlement. This comprises our newer staff members. Secondly, our older, established physicians, seeing their reimbursement decline and their expenses increase believe they too are entitled because for years they supported the hospital and now they feel that the hospital owes them. With decreasing reimbursement there is more competition for patients.


    Many specialists are holding the hospital hostage in exchange for ED call coverage. We have seen the rapid growth of hospital based physicians filling some of this demand. To these physicians the threat of no longer taking call is thrown at every opportunity to get something they need/want from the hospital.

    Can’t Tell the Players Without a Scorecard

    I believe the solution, or a solution, lies in the understanding that the economics of medicine has shifted from physicians with outpatient practices who often practiced at the hospital, to

    • outpatient practices who rarely practice at the hospital
    • outpatient practices who need the infrastructure and services of the hospital for their primary practice, and
    • hospitalist based physicians whose primary practice is the care of the emergency department patient and the inpatient.

    The first group, those with outpatient practices who rarely practice at the hospital, aren’t the problem. Unfortunately they aren’t the solution either.
    The last group, hospitalist based physicians, I believe, comprise the majority of the solution. However, the current economics of solely having a hospital based practice requires non-RVU based compensation in many circumstances. It really doesn’t seem to matter whether this practice is ER, Anesthesia, Radiology, Surgery, Trauma, Hospitalists, Intensivists, or OB Hospitalists. I think the opportunity to create buy-in with these groups is much greater as they clearly have more incentive to assist with hospital administrators and their goals.
    The second group, solo or small group specialists, seem to have an unmistakable sense of self importance as they are the ones making all the money for the hospital. Because of this attitude they have little incentive or desire to assist in the overall goals of the hospital. They see the hospital as unable to exist without them.

    I’ll Take Door Number…

    I believe a hybrid solution is the answer. The administration should commit to a core group of employed physicians who would provide the bulk of the patient care for the ED and the inpatients. Whether these are directly employed physicians or physicians employed under a foundation model will depend entirely on State law and the hospital’s overall model. The traditional RVU based model will not work as the sole method of reimbursement as there are many intangibles, call coverage, physician alignment, etc. that are infinitely easier to accomplish and benefit the hospital more than simply counting RVUs. I refer to HCAHPS and other dashboard and quality metrics that may be difficult, if not impossible, to fully achieve without a motivated, responsive medical staff.
    The challenge is with the second group. I believe here the solution may lie in creating service line co-management agreements with these specialists. It is important that membership in these agreements is controlled by the hospital and that there is a clear benefit to being a member and working towards the service line’s goals and objectives. Members could be given benefits, such as preferred scheduling of procedures as one example. Of course those not cooperating for the mutual benefit would loose out.
    I understand that this is asking the hospital administration to offset declining physician reimbursement for the opportunity to have a much more engaged and aligned medical staff. I’m not quite sure an easier solution exists. But clearly having an engaged and aligned medical staff is essential to maximize both the quality and profitability of any hospital.
    When I first became Chief of Staff, I told our CEO that if I had a problem, I would try to bring a solution as well. I never promised a perfect solution, but hopefully a starting point.
    I believe there is a new paradigm in the delivery and practice of medicine and that new paradigm requires a tighter integration between hospitals and their medical staffs.
    Any thoughts?

  • Not on My Watch


    OK, I was sent a nice, likely canned, email asking if I’d point to [Kimberly-Clark Health Care’s Healthcare-Associated Infection website][1]. It seems to have a bunch of information.
    Remember to use your Kleenex™.
    [1]: http://haiwatchnews.com/

  • Baby Steps to Healthcare Reform


    Since I’m sure all members of Congress will have the opportunity to read and comprehend the entirety of whatever is the current healthcare legislation the following small steps to improve the situation will be meaningless. I have 3 simple proposals that could fit on a single page. Heck, it fits in a single post.

    1. Eliminate pre-existing conditions as a reason to deny insurance.
    2. Allow insurance companies to sell in any market in the US.
    3. Malpractice reform — Loser Pays

    I think the first 2 are self evident so lets focus for a moment on the third.
    Loser Pays
    What I mean is that all legal fees will be paid by the losing party to the litigation. This would include naming a doctor in a med mal suit and then dropping them from the suit.
    You see, just because a doctor gets dropped from a suit doesn’t mean that his malpractice carrier doesn’t incur costs. In fact, it’s usually about $20K to defend a suit that is dropped.
    Interestingly, anytime a doc is dropped from a suit, they must sign a release stating that they will not sue the plaintiff’s attorney. I once tried not to sign this but my lawyer told me he’d never seen it done before.
    Yeah, I know, it doesn’t solve many of the problems facing our healthcare industry. But I bet it would improve the situation with minimal effort.

  • Nationalized Healthcare and the Free Market


    Nationalized/Universal healthcare will happen. Obama ran on it and he intends to deliver. What’s more, I can see a manner in which the country will flock to it under the current free market insurance system.
    First, the federal government will expand Medicaid to cover the unemployed and uninsured. Second, the Congress will pass some law that mandates employers to provide health insurance for not only full-time employees, but part-time employees too.
    Oh, by the way, the federal government will also make available a _government-sponsored_ insurance plan to _compete_ with the other available HMO and PPO choices. Of course the government plan will cost you (the employer) 40-50% less than the next most expensive plan.
    You (the employer) will offer your employees the _government plan_ as per the terms of the new law and they (the employees) will have the option of spending almost twice as much for a different commercial plan. I don’t really expect many employees to avail themselves of the opportunity to spend more money for little perceived increase in services.
    Soon 80-90% of the country will be on the _government plan_ and physicians and hospitals will effectively have a single payor.
    Welcome to nationalized/universal healthcare.

  • Appendiceal Duplication


    I had a very interesting case the other evening. First, for the uninitiated, it’s usually a bad sign when the surgeon says it was a very _interesting_ case. Generally routine is best.
    Anyway, nice 50ish year old female with few days of diffuse abdominal pain now localizing to RLQ. Nausea and vomiting. Anorexia. Acute peritoneal finding in RLQ with percussion. Outside CT reportedly showing acute appendicitis.
    I look at the patient. Story is great. Almost sounds like she’s read [Cope][1]. I take her to the OR. I feel a mass on exam after induction. Sorry guys I do open appys. 3 cm McBurney incison and mobile the cecum. There’s a 5cm mass but seems to be mobilizing from the superior aspect of ascending colon not inferiorly. Anyway, I deliver what appears to be an appendiceal phlegmon into the wound and fire a GIA-55 across its base. The base is along a tinea adjacent to the ileocecal valve. Doesn’t look like there’s any free perforation so I irrigate and start to close.
    I’ve got a couple of clamps on the peritoneum and then I see a relatively normal looking appendix starting at me. Naturally it comes out.
    Patient home in less than 24 hours.
    Path report shows:
    * appendix – acute appendicitis
    * pericecal diverticulum and phlegmon – appendiceal duplication with acute perforating and gangrenous appendicitis
    Comment on path report is _duplication based upon the presence of circular muscle around the diverticulum, its location and gross appearance_.
    I’ve never seen that one before. All I can say is I’m glad I saw what I considered to be a _relatively_ normal appearing appendix prior to closure.
    [1]: http://www.amazon.com/Copes-Early-Diagnosis-Acute-Abdomen/dp/0195175468

  • General Surgery in NY


    So here I am in NYC at the American Society of General Surgeons clinical meeting. The program is correctly termed controversies as I’m quite certain many of the described treatment paths would cause you to fail your oral boards.
    Of note is that it seems that most of the attendees have been in practice for over 10 years. The lecturers are mostly all teaching faculty at the local ivory tower and they seem to use less invasive treatment and laparoscopy far more than I would.
    For example, laparoscopic closure of diverticular perforation with irrigation and drainage but no resection. Not sure I would ever do this open so I can’t see why it’s an acceptable treatment plan laparoscopically. Maybe I’m just old fashioned.