May 15th, 2017 by Dr. Val Jones in Opinion
No Comments »
The New Yorker recently featured a long essay about a popular new episodic work style sweeping America: the “gig economy.” The gig economy unbundles units of work previously tied to an employer or specific job. Online platforms serve as conveners to match task requests with those seeking to complete them. The New Yorker notes:
TaskRabbit, which was founded in 2008, is one of several companies that, in the past few years, have collectively helped create a novel form of business. The model goes by many names—the sharing economy; the gig economy; the on-demand, peer, or platform economy—but the companies share certain premises. They typically have ratings-based marketplaces and in-app payment systems. They give workers the chance to earn money on their own schedules, rather than through professional accession. And they find toeholds in sclerotic industries. Beyond TaskRabbit, service platforms include Thumbtack, for professional projects; Postmates, for delivery; Handy, for housework; Dogvacay, for pets; and countless others. Home-sharing services, such as Airbnb and its upmarket cousin onefinestay, supplant hotels and agencies. Ride-hailing apps—Uber, Lyft, Juno—replace taxis. Some on-demand workers are part-timers seeking survival work, akin to the comedian who waits tables on the side. For growing numbers, though, gigging is not only a living but a life. Many observers see it as something more: the future of American work.
The pluses and minuses of this kind of work are fairly straight forward. On the positive side there is speed and convenience (both on the part of the worker, and the one who needs the work done). Rapid matching of task to worker occurs in an online environment that promotes competition and favors those with high ratings and a track record of success. There is flexibility for the worker – he or she can commit to as much or as little work as is convenient, and there is the opportunity for augmenting earnings as small, paying “gigs” can be added to already existing work. Variety provides challenge and interest.
On the negative side, choosing to do gig work full-time leaves the gigger without employee benefits (such as health insurance) and an insecurity of income stream. Without a large, trusted company as the agent for work, there are fewer guarantees of service (or protections) for both the hiring entity and the worker. With freedom comes insecurity. And then there’s the question about career advancement and long term economic effects of short-term work.
It seems to me that for most people outside of the healthcare marketplace, the gig economy works best as an income supplement, not replacement. In medicine, however, full time gigging may actually have more pros than cons.
In a system where fee-for-service healthcare is rapidly being replaced with bundled payments, shared responsibility, and accountable care, it is ironic that the workforce is moving in the opposite direction. Although initially physicians were driven to become hospital employees (instead of independent practitioners), now the pendulum is swinging in the gigging direction. Primary care is embracing the “direct pay” model, and more and more physicians are joining locum tenens agencies. I myself was an early adopter of both concierge medicine and locum tenens work.
Direct primary care is efficient – patients pay only for what they need (presumably from an HSA account), and there are incredible cost savings involved for providers, not having to code and bill insurance companies for services. As I’ve said previously, using health insurance for primary care is like having car insurance for windshield wipers. Expensive overkill.
As far as locum tenens is concerned, there is no better way to prevent burn out and overwork than to reclaim control of your work schedule. Short term work assignments may be accepted or declined at the physician’s convenience. You can travel as far and wide as you have interest (there are international locums assignments available too), and gain exposure to various practice styles and locations. You set your hourly rates, and the pay is fair and transparent. No more uncompensated hours of extra work that fuel resentment towards your employer.
New companies such as Nomad Health are poised to revolutionize the gig economy for physicians. By directly linking physicians with job opportunities in an online marketplace, agency costs are avoided, saving money for hospitals and allowing for higher doctor salaries. The question remains if they will gain the user volume necessary to compete with agencies. Nomad Health will succeed if it can convene sufficient numbers of hospitals and physicians to make it worth the time on the site.
The gig economy is the natural evolution of our modern culture. As technology enables an on-demand lifestyle, work is becoming as modifiable as our media consumption. Will chopping work up into smaller bits have a net positive or negative effect? For the companies creating the niche platforms that support the work marketplaces, the outlook seems positive. Uber, for example, is currently valued at about $28 billion. They have drawn inspiration from video games to psychologically incentivize drivers to work longer hours, contributing to their success – and perhaps downfall. By maximizing their own profits at the expense of the drivers, their gigging community is beginning to look for greener pastures at Lyft. Competition is a critical part of the gig economy.
In healthcare, I worry that a significant physician shift towards gigging could be disruptive to care continuity and result in higher costs and poorer outcomes. That being said, the alternative of physician burn out, early retirement, and flight from clinical medicine is not acceptable. I suspect that the gig economy is going to change how physicians engage with the healthcare system – and that within a decade, a large segment of the workforce will be part-timers and short-timers. This may provide a sustainable way for older physicians (or those with family or childcare demands) to continue working, which could substantially improve the physician shortage.
Gone are the days of cradle-to-grave relationships with primary care physicians – I mourn the loss of this customized, deeply personal care, but I stand ready to embrace the inevitable. I just hope that I can connect with my “short-term” patients so that my advice and treatment captures their medical complexity (and personal wishes) correctly. With all the technological tools to personalize medicine these days, it is ironic how impersonal it can be when you rarely see the same physician twice. The gig economy forces us to be perpetual strangers, and that is perhaps its greatest drawback.
April 21st, 2017 by Dr. Val Jones in Opinion
3 Comments »
At the risk of vilification by my peers, I’m going to say something extremely unpopular. We physicians have it pretty good financially. Our salaries are generous, and we have a much higher standard of living than most others in America. When I read online physician complaints about student loan debt, I cringe a bit. Because of all the people in debt, we are some of the most likely to be able to pay it down quickly.
Medical school and residency are emotionally, mentally, and physically exhausting. There is no doubt that we are severely cash-strapped during those years, and yearn for the day when we can go out to a nice restaurant and order anything we want from the menu. Most of us are eager to splurge on ourselves the minute we get our first job, and do not think about loan repayment. However, the truth is that if we gutted it out (living “like a resident”) for a mere 2 more years, most of us could pay off our student loans completely.
Let’s say we have an annual salary of about $200K and a student loan debt of about the same. What is the average household income in America? About 51K? Maybe if we lived on that amount for 2 years, and put all the rest (after taxes) into our loans – we’d be debt free.
I feel worried for young Americans who have a similar total student loan debt as physicians, but graduate with much lower earning potential. Students should soberly consider educational debt against their likely ability to repay it. We must all choose our education wisely, as it may have life-long consequences for our standard of living.
Physicians have many legitimate gripes, student loan debt (in my view) is not one of them.
April 7th, 2017 by Dr. Val Jones in Opinion
1 Comment »
Over 1 million virtual doctor visits were reported in 2015. Telehealth companies have long asserted that increased access to physicians via video or phone conferencing saves money by reducing office visits and Emergency Department care. But a new study calls this cost savings into question. Increased convenience can increase utilization, which may improve access, but not reduce costs.
The study has some obvious limitations. First of all, it followed patients who used one particular telehealth service for one specific cluster of disease (“respiratory illness”) and narrowed the cost measure to spending on that condition only. Strep throat, coughs, and sinusitis are not drivers of potentially expensive care to begin with, so major cost savings (by avoiding the ER or hospitalization) would not be expected with the use of telehealth services for most of these concerns.
Secondly, the patients whose data were scrutinized had commercial insurance (i.e. a generally healthier and younger population than Medicare beneficiaries, for example), and it is possible that the use of telehealth would differ among people with government insurance, high-deductible plans or no insurance at all.
Thirdly, the study did not look at different ways that virtual doctor visits are currently being incorporated into healthcare delivery systems. For example, I was part of a direct primary care practice in Virginia (DocTalker Family Medicine) that offered virtual visits for those patients who had previously been examined in-person by their physician. The familiarity significantly reduced liability concerns and the tendency for over-testing. Since the doctor on the other side of the phone or video knew the patient, the differential diagnosis shrank dramatically, allowing for personalized real-time treatment options.
I’ve also been answering questions for eDocAmerica for over 10 years. This service offers employers a very low cost “per member per month” rate to provide access to board-certified physicians who answer patient questions 24/7 via email. eDocs do not treat patients (no ordering of tests or writing prescriptions), but can provide sound suggestions for next steps, second opinions, clarifying guidance on test results, and identify “red flag” symptoms that likely require urgent attention.
For telehealth applications outside the direct influence of health insurance (such as DocTalker and eDocAmerica), cost savings are being reaped directly by patients and employers. The average DocTalker patient saves thousands a year on health insurance premiums (purchasing high deductible, catastrophic plans) and using health savings account (HSA) funds for their primary care needs. They might spend $300/year on office or virtual visits and low-cost lab and radiology testing (pre-negotiated by DocTalker with local vendors). As for eDocAmerica, employers pay less than a dollar per month for their employees to have unlimited access to physician-driven information.
The universe of telehealth applications is larger than we think (including mobile health, remote patient monitoring, and asynchronous data sharing), and already extends outside of the traditional commercial health insurance model. Technology and market demand are fueling a revolution in how we access outpatient healthcare (which represents ~40% of total healthcare costs), making it more convenient and affordable. As these solutions become more commonplace, I have hope that we can indeed dramatically reduce costs and improve access to basic care.
Keeping people well and out of the hospital should be healthcare’s prime directive. When those efforts fail, safety net strategies are necessary to protect patients from devastating costs. How best to provide that medical safety net is one of the greatest dilemmas of our time. For now, we may have to settle for solving the “lower hanging fruit” of outpatient medicine, beginning with expanding innovative uses of telehealth services.
April 5th, 2017 by Dr. Val Jones in Health Tips, Opinion
1 Comment »
This blog post first appeared at: Curious Dr. George
Rehabilitation medicine is one of the best-kept secrets in healthcare. Although the specialty is as old as America’s Civil War, few people are familiar with its history and purpose. Born out of compassion for wounded soldiers in desperate need of societal re-entry and meaningful employment, “physical reconstruction” programs were developed to provide everything from adaptive equipment to family training, labor alternatives and psychological support for veterans.
Physical medicine and rehabilitation (PM&R) then expanded to meet the needs of those injured in World Wars I & II, followed closely by children disabled by the polio epidemic. In time, people recognized that a broad swath of diseases and traumatic injuries required focused medical and physical therapy to achieve optimal long term function. Today, cancer patients frequently benefit from comprehensive rehabilitation as they recover from the effects of chemo (neuropathy, weakness, and cognitive impairments), radiation (scarring and range of motion limitations), surgery (flaps, plastics procedures, tumor resection, amputations), and brain injuries (edema, debulking, gamma knife and neurosurgery).
Rehabilitation is a phase of recovery occurring after any major life-changing medical or surgical event. Our bodies are designed to regenerate and repair, though optimizing this process takes skilled guidance. PM&R physicians (also known as physiatrists) are trained to use physical modalities (stretching, strengthening, heat, cold, etc.) to mechanically enhance healing. They prescribe medications to manage pain, spasticity, nerve injury, and cognitive impairments, while also leveraging the power of physical therapy to increase cardiopulmonary fitness, muscle strength and flexibility. PM&R physicians are also experts in neurologic injury, and can adapt exercises to coax spinal cord, brain and peripheral nerve injuries to construct new pathways for movement and repair.
Inpatient rehab’s prime directive is to get patients back home. To succeed at home, patients need to be able to function as independently as possible, using trained assistants for managing the activities that cannot be performed without help. Admission to a rehab hospital or unit offers the patient home practice opportunities – with simulated challenges that can include everything from terrain parks, test kitchens, medication management trials, driving simulators, balance tests, electric wheelchairs and even exoskeletons that allow paralyzed patients to walk again. It is like a robotic Disney World, with endless aquatic and equipment possibilities for restoring movement and independence.
When I discuss admission to inpatient rehab with my cancer patients, I ask them about their goals, motivation, and energy levels. Timing of rehab is important, because it must dovetail with treatment, so that the physical exertion strengthens, not saps, the patient. Often times when a person is newly diagnosed with cancer, they want “everything done” – intensive chemo/radiation/surgery as well as rehab/exercise. But staggering these interventions can be more effective.
In other cases when care is palliative, learning new skills and being fitted with battery or electric-powered equipment can mean the difference between living at home or in an assisted environment. Some successful cancer patients come to inpatient rehab to practice managing their activities of daily living with varied amounts of assistance, preparing for increased needs as time goes on so they can enjoy being at home for as long as possible.
For the physiatrist, cancer is a cause of impairments that can be overcome with creativity and practice, no matter the long-term prognosis. Adaptive equipment, physical exercise, and cognitive retraining may be applied intensively (3 hours a day in the inpatient setting), or at a slower outpatient pace, depending on individual need. Rehab physicians desire to support and sustain patient function at the highest level, and “add life to years.” As such, rehabilitation should be considered an integral part of successful cancer care and management.
March 27th, 2017 by Dr. Val Jones in Health Policy, True Stories
No Comments »
We’ve all heard the saying, “age is just a number.” Nowhere is that more important than in the hospital setting. Over the years I’ve become more and more aware of ageism in healthcare – a bias against full treatment options for older patients. Assumptions about lower capabilities, cognitive status and sedentary lifestyle are all too common. There is a kind of “senior profiling” that occurs among hospital staff, and this regularly leads to inappropriate medical care.
Take for example, the elderly woman who was leading an active life in retirement. She was the chairman of the board at a prestigious company, was an avid Pilates participant, and the caregiver for her disabled son. A new physician at her practice recommended a higher dose of diuretic (which she dutifully accepted), and several days later she became delirious from dehydration. She was admitted to the local hospital where it was presumed, due to her age, that she had advanced dementia. Hospice care was recommended at discharge. All she needed was IV fluids.
I recently cared for an attorney in her 70’s who had a slow growing brain tumor that was causing speech difficulties. She too, was written off as having dementia until an MRI was performed to explore the reason for new left-eye blindness. The tumor was successfully removed, but she was denied brain rehabilitation services because of her “history of dementia.”
Of course, I recently wrote about my 80-year-old patient, Jack, who was presumed to be an alcoholic when he showed up to his local hospital with a stroke.
Hospitalized patients are often very different than their usual selves. As we age, we become more vulnerable to medication side-effects, infections, and delirium. And so, the chance of an elderly hospitalized patient being acutely impaired is much higher than the general population. Unfortunately, many hospital-based physicians and surgeons — and certainly nurses and therapists — have little or no prior knowledge of the patient in their care. The patient’s “normal baseline” must often be reconstructed with the help of family members and friends. This takes precious time, and often goes undone.
Years ago, a patient’s family doctor would admit them to the hospital and care for them there. Now that the breadth and depth of our treatments have given birth to an army of sub-specialists, we have increased access to life-saving interventions at the expense of knowing those who need them. This presents a peculiar problem – one in which we spend enormous amounts of resources on diagnostic rabbit holes, because we aren’t certain if our patients’ symptoms are new or old. Was Mrs. Smith born with a lazy eye, or is she having a brain bleed? We could ask a family member, but we usually order an MRI.
My plea is for healthcare staff to be very mindful of the tendency to profile seniors. Just because Mr. Johnson has behavioral disturbances in his hospital room doesn’t mean that he is like that at home. Be especially suspicious of reversible causes of mental status changes in the elderly, and presume that patients are normally functional and bright until proven otherwise.
Last month I hit a new age record at my rehab hospital – I admitted a charming, active, 103-year-old woman after a small stroke caused her some new weakness. She was highly motivated in therapy, improved markedly and was discharged to an independent living center. I bet she will live many more years. When I joked that she didn’t look a day over 80, she winked and told me she had stopped counting birthdays years ago. She said, “It doesn’t matter how old you are, it matters what you can do. And I can do a lot.”
