Medical care and airlines - should there be a difference?

A recent article by Pauline Chen features a group of primary care physicians at Tufts Medical Center in Boston, who have created a concierge practice that funnels income into the traditional general medical practice that sees less-advantaged patients. Surveys (performed by the medical center itself) found that patients rated the quality of interactions with their doctors similarly regardless of their affiliation. The only significant differences in responses had to do with the services offered — care coordination, physician access and interactions with office staff. According to the medical director, analogous to airline services providing both first class and coach services, the parallel practice gets patients to the same destination - some eating peanuts, others eating caviar.

I believe this is an intelligent hybrid that may have successfully reacted to our broken medical system, but the ends does not justify the means. Differing services based on the ability to pay is discrimination - it is demoralizing for coach flyers, but morally wrong for economically-disadvantaged patients. This is because medical care is not the same type of services as airlines - people will not die if they cannot fly to places, but they will die without medical care.

In a civilized society, its members should have equal access to life-saving services regardless of the ability to pay. Just like the fire department, medical care should be provided as a societal safety net so that, instead of worrying whether our house will burn down while we're off at work or whether a catastrophic illness will take away everything we've worked hard to earn, we can focus on higher pursuits like being a productive member of society.

Differences in health outcomes between two groups remain unclear. If they are unequal, then there is discrimination based on the ability to pay. If they are equal, then first-class patients pay more money without justifiable returns other than convenience and a more pleasant office staff, which I argue should not be different in any circumstances - I'd like to believe that medical professionals treat fellow human beings in sickness with utmost compassion at all times, regardless of payment scheme.

Either way, segregating patient care leaves a bad taste in my mouth. As a doctor, we ask patients to trust us with personal life stories that they may never share with their parents or their significant others. Such level of trust can hardly be established in the settings of discrimination.

Deep-fried snickers bars

Today I went to a lecture where a cardiologist showed us photos of disgusting food sold across America. The purpose was to convince all the cardiologists in the room that despite decreasing incidence of heart attacks from 2000-2007, cardiologists can rest assured that these fattening food items will keep them in business, and this is true only because America pay based on volume regardless of outcome. It makes me sad to think that cardiologists are happy when people eat deep-fried snickers bars.

Why do we use carrots and sticks if humans are not horses?

It was 6PM and I was still at the clinic. My last patient, Mr. R, had left over an hour ago and as far as the rules go, I could be home by then, eating dinner and taking a shower. But as I perused Mr. R's medication list over and over, I couldn't get myself to leave. He was taking over 15 medications and the pill burden was overwhelming. Since he recently lost Visiting Nurse Services and had to fill the pillbox on his own, he was exhausted from taking medications. I thought of how all the puzzle games I used to play had prepared me for this day as I went through different combinations of medications to arrive at the smallest possible number of pill counts for Mr. R. I continued to think of his case on my drive home trying to figure out a way to get a better control of his raging diabetes.

As I sat down and stuck a fork into the piece of chicken that was my dinner, the clock read 730PM and I thought about why I didn't leave earlier. Why did I spend time trying to fix the life of a stranger instead of feeding myself? What motivates us as doctors to stay late and perform a thorough task instead of clocking out on time and leaving the fate of our patients to other forces in the health care system?

And this is a pivotal question, because as our nation tries to make sense of why health care cost is spiraling out of control, the new system will be rebuilt based on what motivates health care workers to do a good job of caring for patients.

Many fresh carrots on newly-minted sticks have already been instituted in various areas of the medical system as part of the new health care legislation in an attempt to motivate health professionals to do the right thing, including programs like Medicare's Physician Quality Reporting Initiative (PQRI). According to the legislation, PQRI asks physicians to report how the care they furnish aligns with evidence-based clinical guidelines for a variety of medical conditions, such as diabetes or heart disease (1). In 2010, physicians who successfully report these measures will receive a 2% bonus on charges received from Medicare. The bonus tapers down to 1% in 2011 and 0.5% from 2012-2014. However, starting in 2015, physicians who fail to report these measures will receive a penalty of 1.5 percent deduction from their Medicare revenue from that year, increasing to 2% penalty in 2016 and each subsequent year.

But before we march forward to the trial and error of this new measure designed to induce higher performance, it is important to step back and ask ourselves: what motivates us as human beings?

According to Daniel Pink's book Drive based on numerous researches replicated in various settings over time, humans are motivated by three intrinsic drives: autonomy, mastery and purpose.

In a book by Deci et al published in 1985 (2), multiple researches on school children randomized to autonomy-supporting versus controlling teachers conclude that autonomy-supporting environment correlates with more creativity as well as enhanced intrinsic motivation and self-esteem. The concept of autonomy is replicated in the real world today by a successful Australian software company called Atlassian (3). Inspired by FedEx's promise to deliver a package in 24 hours, Atlassian instituted "FedEx day," when, once in each quarter, software developers are allowed 24 hours to work on anything they want, enjoying full autonomy. Results are brilliant bug fixes and new innovative features that otherwise would not be explored as successfully.

Another landmark article in 1959 (4) by Robert White, a professor emeritus in clinical psychology at Harvard University, proposed that the inherent satisfaction in exercising and extending one's capabilities is a strong motivator. It later inspired numerous experiments on mastery motivation which show multiple positive effects on performance, from leading test subjects to spend more of their free time on tasks (5) to increasing cognitive development in children (6). The 21st century example of these validated experiments can be found on Youtube, where there are millions of videos on the how-to of everything, from using make-up to writing computer programs, made by folks who enjoy the subjects in their free time, free of charge.

An interesting study by Adam Grant at Wharton demonstrates the power of purpose as a motivator (7). The study shows that employees working in a call center at a university fundraising organization who were given stories of how the money they raised affected the lives of beneficiaries earned more than twice the amount of donation compared to before the intervention. Volunteers exemplify the power of purpose in the real world, where people from all walks of life are driven, not by the extrinsic motivation of money, but by the intrinsic motivation of being part of a cause.

Interestingly, within decades of social studies research on motivation, the most surprising finding of all is that monetary rewards actually lead to poorer performance for cognitive tasks. The pervasive belief that higher monetary rewards lead to higher performance only applies to straight-forward, mechanical tasks – as soon as the job requires even the least amount of rudimentary cognition, monetary rewards produce negative effects on performance. This finding has been shown in works by numerous researchers, including Dan Ariely (a professor of behavioral economics at MIT)(8) and Dr. Bernd Irlenbusch (a lecturer at the London School of Economics) (9).

Despite the repeatedly validated science of intrinsic motivations, managers and organizations continue to use money to motivate workers for the more and more complicated cognitive tasks of the 21st century, the Medicare's Physician Quality Reporting Initiative (PQRI) included. The monetary penalties of PQRI will narrow physicians’ minds onto the goal of mechanically completing reports, eliminate autonomy and distract away from mastery and purpose. It sends the message that physicians should do a good job, not because our work has a higher purpose of keeping other human beings healthy, but because we will earn more money for it. In a way, it views physicians as rudimentary horses easily lured by rudimentary carrots, when in reality I would like to believe that physicians are human beings driven by the ability to direct our own fate, the desire to be good at what we do, and the heart to be part of something bigger than ourselves.

On my drive home after another hard day's work, listening to the repeating lyrics of the wise singers of "The Lox," I reflected back on our motivation as physicians as the radio crooned, "It's the key to life. Money, Power and Respect." Autonomy is power, and mastery brings respect, but the Lox was wrong about the last key to life. In the end, life is never about money - it is all about purpose.

(1) http://www.acponline.org/advocacy/where_we_stand/access/int_prac_guide.pdf
(2) Intrinsic motivation and self-determination in human behavior By Edward L. Deci, Richard M. Ryan
(3) http://www.atlassian.com/about/Atlassian_Media_Kit.pdf
(4) R. White. Motivation Reconsidered: The Concept of Competence. Psychological Review. Vol. 66, No.5, 1959.
(5) S. Harter. Developmental Differences in the Manifestation of Mastery Motivation on Problem-solving Tasks. Child Development. Vol. 46, No. 2 (Jun., 1975) pp. 370-378.
(6) K. Jennings et al. Exploratory Play as an Index of Mastery Motivation: Relationships to Persistence, Cognitive Functioning, and Environmental Measures. Developmental Psychology. Vol. 10, No. 4, 386-394
(7)http://www.management.wharton.upenn.edu/grant/Grant_JAP2008b_TaskSignificance.pdf
(8) D. Ariely, U. Gneezy, G. Lowenstein, &N. Mazar, Federal Reserve Bank of Boston Working Paper No. 05-11, July 2005; NY Times, 20 Nov. 08
(9)http://www2.lse.ac.uk/newsAndMedia/news/archives/2009/06/performancepay.aspx

Can entropy be reversed?

For those with an android phone, I'd like to introduce you to Edwin, one of the most amazing applications out there for android users that really puts the future in perspective. It is a speech-to-speech personal assistant program that lets you asks any questions, from what is the meaning of life to where is the nearest coffee shop, and it will give you the answers (which by the way are 42 and dunkin donuts on chapel street). It links to wolfram alpha, google translate, and other incredible computational programs that vastly increase Edwin's ability to assist, including calculations, word spelling/definitions, language translation, map/navigation - the list goes on. Below are just some of the quirkier responses you can play around with if you're bored:

Input: I love you

Response: Sadly, I was not designed to love, but if I were, I would love you

Input: I hate you

Response: I'm sorry you feel that way. Maybe with a later update, you will change your mind.

Input: Where is my car?

Response: Not sure, but wherever you find it, that's where it is.

Input: Why are you awesome?

Response: If I have computed more, it is by standing on the shoulder of giants (plus a lot of hard work - with all due respect to Sir Isaac Newton).

Input: Do you have a brain?

Response: I am capable of universal computation; that I can say.

All fun aside, Edwin just shows that all the fancy technology we ever imagined in sci-fi novels/movies will become reality only in a matter of time. Edwin seems to be a primitive ancestor of Multivax, the all-knowing AI in the famous short story "The Last Question" by Isaac Asimov. With more computational power and programmed responses, Edwin will maybe one day tells us how entropy can be reversed. Until then, the next game-changing discovery will be something we have never ever imagined, sensed or comprehended in human history - a completely separate dimension that will change everything and how we operate. In a way I feel like we are ants, unaware of the human world above us. When Armageddon comes we wouldn't understand why, when in reality God just spilled a bag of skittles on us.

Extra Hour in the Sun

As a new intern at a well-endowed medical institution, I was disappointed despite the flurry of excitement that comes with orientation. I was disappointed despite the brand new privilege to save lives and relieve human sufferings. And the disappointment was made clear to me over the past two days.

What has happened in the past two days? As I will be working at two separate hospitals, for the past two days I have sat through training for at least 5 different EMR systems, none of which are similar or produced by the same company, all of which are designed to do the exact same things as hundreds of other EMR systems used in other parts of the country.

What really drove this home, as I zoned out during training for the 4th EMR system of the day, was the fact that in the mix, I didn't receive access for one of the EMR systems. The technician at the training center instructed me to call help desk when I got home. At home on the phone with the help desk specialist, I was told that the issue unfortunately could not be solved on the phone and I would have to return to the training center. As I hung up the phone, I thought how nice it would have been if I had found this out 15 minutes ago when I was still at the training center.

But I wasn't told that stopping by the help desk was an option. I wasn't informed that the help desk was in the same building as the training center. I didn't know that there was a possibility that this issue could not be solved on the phone.

Could this whole ordeal have been foreseen? Could it even be possible that I'm not the first person who fell through this trap? Very likely. But this is only one of the possible failings in our highly fragmented, variable medical system. With 5 different EMR systems in only two hospitals, how could a human being possibly plan for all the possible shortcomings these non-uniform processes create?

It's not a matter of inconvenience that new providers have to learn 5 new computer systems in two days - it is a matter of patient safety. I continue to be amazed that despite all our advances, we as a country have not reconciled our differences and agreed on a uniform EMR across most, if not all, medical institutions. The benefits are many, including the ability to consolidate fragmented/repetitive medical information, better coordinate care and reduce possible mishaps created by each separate system. The waste that goes into reinventing the wheel, retraining medical professionals, troubleshooting hundreds of different EMR systems nationwide is likely enormous.

I believe that amidst the effort to reform health care, the time is ripe for us as a country to put our self-interests aside and work together so that future medical professionals and patients do not have to settle for this substandard, fragmented medical system. But until then, I am walking back to the training center to tell Jim, my computer trainer, what had happened to me so that future interns can have an extra hour in the sun instead of spending time at a computer training center.

Tricky questions about the DMV and car insurance

DMV

Q: What is the difference between Title and Registration?

A: Title confers ownership of the car, while registration allows you to operate the vehicle regardless of ownership. Usually the two processes are completed together by the dealer when you buy a car, but they can be done separately at any time. Read more here.

Q: How do you transfer license from other states?

A: The processes are usually detailed on that state DMV website, but basically until you have a real license in hand, starting a transfer process means starting everything over (you'll have to redo the eye test, knowledge test, road test, pay for another 8-hour pre-licensing course). This is true for both learner's permit and interim license.

Auto insurance

Q: How can I get great prices and coverage on car insurance?

A: Edmunds.com has a good article explaining everything in detail here.

Q: Can you get insurance on a car that is not registered/titled to you?

A; Yes. Title and registration do not mean much - it is the car insurance and the coverage that really matter. If you need to drive someone else's car and would like to buy insurance to cover you and your friend's car in case you wreck it, you can certainly do so. Read more here.

Q: Do I get car insurance based on the state of registration, the state where I live, or the state where I drive the car?

A: Car insurance is based on the state in which you drive the car, basically where the garage is. Every state has different requirements and you can check the above link from Edmunds.com to see what they are.

Q: If I'm a new driver, can I get a cheaper insurance if I add another experienced driver on the policy?

A: I tried this while soliciting online quotes and discovered that the more drivers you add to the car, the higher the premium, regardless of their driving records, impeccable or not.

How to deal with car dealers

I recently bought a 2010 Honda Fit Base Automatic in silver with security system installed for $16,002.36 as a base price, $17,707.07 out the door with NY sales tax and registration (sales tax $1420.21, registration fees $197 ($214 with sales tax - dealer only charged $212), title fee $50, inspection fee $10, tire tax $12.50 for 5 tires). I believe it was a good price and I wanted to share my experience with you so that you can get the best deal on your future cars!

First, I read these tips on buying new cars on Edmunds.com. It gives a good, step-by-step overview of how to navigate through the whole process, most importantly how to not get scammed by dealers. After perusing the article, I went through the following process.

- I went on www.truecar.com, which is a great website that updates true cost to dealers (how much it actually costs the dealers to sell you the car) and true market value (the average of how much everyone is paying for this car) of your new car more regularly than Edmunds. According to truecar.com, the true cost to dealers of a new 2010 Honda Fit Base Automatic without the security system installed is $15,740. A great price is less than $15,912, good price is less than $16,343, and $16,344 or more is overpriced. These figures include destination fee (what dealers pay to get cars from factories to the lot) and regional ad fees. With these figures in mind, I have an idea of how much I should be paying for the car

- Truecar.com provides a list of dealers with the lowest prices in your area, so I solicited quotes from the internet departments of the 3 cheapest dealers. To save yourself some time, make sure to solicit out-the-door price through internet transactions only - beware of dealers trying to get you to come in for a test drive with unrealistically cheap base price for the car. Once you make a trip out to the dealer for a test drive wasting many hours of your day, they will add on ridiculous fees here and there so that in the end, you end up overpaying for the car. As a result, you want to negotiate based on the total price you will be paying, all fees included. I solicited quotes from both CT and NY, because even though I lived in NYC at that time, I was about to move to CT and could get the car at either place.

- I lucked out and got a ridiculously cheap quotes from a dealer in CT: $16,967 out the door, security system installed, including CT sales tax 6% - that's $15,847 base price with security system included. Considering the fact that true cost to dealer was $15,740 and the security system is worth at least $165 or so without the installation fee, this price was too good to be true. They were probably hoping that I will make a trip to CT so that they could force on ridiculous fees when I'm stuck there, but it did not matter.

- With this ridiculous quote in hand, the next thing I did was checking out the inventory of potential car dealers in the area. Dealers do not want to keep cars on their lot, so if you are willing to take cars that dealers already have on hand, they will be more eager to sell it to you, probably at a cheaper price just to get rid of the car. We searched for dealers with a lot of Honda Fit on hand and said to them, "if you could beat this quote, I will take the car off your lot today." This got many dealers squirming for business.

- I landed at a big dealer in Queens with the cheapest out-the-door price of $17,707.07. Base price with installed security system was about $16,000 like I mentioned above, and I made sure that all the other fees were not bogus. Sales tax is easy to check and is based on the state in which you register the car (it does not matter where you buy the car - you pay sales tax based on the state of registration). Registration fee varies, but you can use the DMV dealer's registration fee calculator to see if the dealer is overcharging you for registration. Title fee and inspection fee are standard and are always listed on the DMV website. Tire tax applies at least in NYC where the government charges tax for recycling your tires.

- People usually think that buying a car with a full cash amount up front will get you a better deal, but this is untrue. Dealers either do not care or would prefer that you finance the car, so that they can sell your debt to outside banks and make more profit on the deal.

Beware of the following dealer tricks:
- Some of them will make you sign a price offer, stating that if the dealer could match your price, you automatically have to buy the car. Do not sign this form - so that should you come upon a cheaper quote from another dealer, you can easily switch without your hands tied.
- If you decide to get extra options for your car, after you have agreed on a price, dealers will try to make you switch from OEM (original equipment manufacturer) options to other non-authentic options made by some random companies. They will say the non-authentic options are basically the same, but have better features, so as to persuade you to switch, but do not fall for this trick. Obviously, OEM options are worth more and will get you a better price for your car when you trade it in later on.
- Even though you have agreed on a price, dealers will try to sell you random extras while you're signing the contract - do not agree to buy unless you have thought carefully and decided you really want these options - most of them are junk. If you feel like you might be intimidated in the dealer's office and fall for these tricks, you can try to have dealers come by your house or fax the contracts over, but I found that dealers rarely agree to do this. Remember to be strong and do not buy anything because you feel bad or pressured.

More on tricky DMV questions in the next post!