Dr. Chen’s debut column, “Healing the Doctor-Patient Divide” admits that there is a divide and calls for an open dialogue via the internet. She states that, “It is difficult for any one of us to change today’s health care system, but there is one thing every one of us can do. We can begin the conversation.”

Sources:
“Doctors and Patients Start Talking” – The New York Times, September 11, 2008
“Healing the Doctor-Patient Divide” – The New York Times, September 11, 2008

Post from: EveryJoe

New York Times Column Looks At The Doctor-Patient Communication Gap

For someone with a PhD in economics, you would think that Goodman realizes that the emergency department is the most expensive way to access health care in this country. Moreover, treatment for a disease is almost always more expensive at later stages, and is definitely more expensive than preventing the disease in the first place. I can’t imagine telling diabetics to just sit tight and come to the ER when they have a crisis — that’s taking a problem that can be managed with relatively little expense if managed regularly and turning into a single episode of care that could cost tens of thousands of dollars.

Here’s exactly what was said:

“So I have a solution. And it will cost not one thin dime,” Mr. Goodman said. “The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American — even illegal aliens — as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care.

“So, there you have it. Voila! Problem solved.”

Yeah, problem solved, all right.  Thanks for making the world’s least efficient, most inequitable health care system even more expensive and dysfunctional. Or, as Steve Benen of CBS news puts it:

“In other words, the man responsible for crafting McCain’s healthcare policy effectively described the most inefficient system of socialized medicine ever devised.”

Post from: EveryJoe

The “ER” Health Plan?

As an expert in cancer care and how that care is delivered to patients, I can categorically say that access to an emergency room is not the same as “access to health care.” If you’re a cancer patient, what you need is access to expensive pharmaceuticals, experienced physicians, and expert oncology nurses who will actually hook up your chemotherapy IV and treat you for the disease. I’ve never seen someone get their cycle of AC+T chemotherapy at the emergency room (which isn’t to say it’s never happened, but I’m having trouble thinking it might).

An emergency department can’t turn you away if you’re in need of “immediate” care, but what if you’re just fatigued and feeling bad, or experiencing fevers that come and go… these are symptoms of cancer, but I think you’d have trouble getting care from the emergency room unless something else went terribly wrong to send you there in the first place. And if you have to have a mastectomy for breast cancer, is the emergency room going to help you get reconstructive surgery afterwards? I doubt it.

The problem of the uninsured is real, and it’s not going away. Instead of ignoring the problem, we need to find ways to tackle it in this country.

(and if you’re interested in reading about the economics of health savings accounts, which I’ll post about another day, try this first — one of the best articles I’ve ever read on health or medical savings accounts and how they work.)

Post from: EveryJoe

In the “You Can’t Be Serious” category… Does McCain’s Health Care Advisor “not believe in the uninsured?”

These results aren’t that surprising, but what concerns me the most is the cost-saving potential of getting the correct test ordered, completed, and reported to both physician and patient in a short period of time. We waste a huge amount of money in our health system because test results are often not available or are vague (for example, the physician sends the patient a note with the words “positive” or “negative,” or otherwise lacking clarity, such as “within normal limits.”) If that patient must go to another provider or if the patient lands in the emergency department, that facility must redo the test, even if the patient can say “hey, they told me that my count for [insert test here] was a little bit high.”

Part of this problem is the lack of electronic medical record (EMR) implementation across the board.  If the only copy of your lab results is sitting in a manilla folder at your primary care physician’s office, the ER doctor will never know that your cholesterol is dangerously high. Part of the problem is also patients. The idea of a Personal Health Record, or PHR, that would contain this information is still a bit pie-in-the-sky… although companies such as Microsoft, with HealthVault, and Google Health are promising an EMR/PHR revolution through their products.

Regardless of the technology barriers, the physician ordering a test should have the responsibility for getting the result back and contacting the patient as soon as possible, whether by telephone or mail (or another secure avenue). Not only is it poor customer service to leave patients hanging (or to not ever tell them their results, letting many assume they are fine when there might be a problem), it’s poor business practice, and it can lead to overspending and overtesting.

Post from: EveryJoe

Family Physicians — Testing Positive for Lab Result Errors

Physicians who are paid on a fee-for-service (FFS) basis are paid per service they provide, whether this service is a surgical procedure , a PET/CT scan, or an office visit. The more expensive services are reimbursed more handsomely. (This scheme does not apply to physicians who are reimbursed by capitation or on other prospective payment systems.)

FFS reimbursement and other retrospective forms of payment reward the provision of services and the provision of expensive services, such as imaging, and provide a disincentive for provision of core services such as a physical examination and interview (what those of us in the health care industry call an “H&P,” or “history and physical”). Services such as H&Ps are not profitable — Bach points out how the doctor’s best money-making proposition is to provide short visits and use as much technology as possible, as patient turnover and use of expensive technological services results in an improved bottom line.

Earlier this morning, NBC’s Today show described how we may be exposed to unnecessary radiation through a proliferation of x-rays, CT scans, and other diagnostic tests that may not be completely necessary when performed. It would be difficult to prove that this trend has no underlying economic reason.

How can we pay doctors to spend more time with patients and spend less time sending patients for diagnostic tests that may be misguided?

Post from: EveryJoe

Are we “paying doctors to ignore patients?”

At the same time, the New York Times is reporting on Philadelphia area insurers that are offering bonus payments or increased payments to physicians for using tools such as telephone visits, e-mail “visits,” and electronic monitoring of patients’ conditions to improve continuity of care and chronic disease care.

Can we save money by spending more? The statement seems counterintuitive, but paying more for the rightkinds of care and treatment can save money in the long run. For example, e-prescribing is often safer (no messy handwriting, less potential for drug interactions) and less of an administrative burden (less paperwork, faster transmission of information) than prescribing on paper. Checking in on patients daily or weekly and tracking blood sugar or blood pressure over time rather than waiting for the patient’s condition to become a crisis leads to lower spending, just as prevention is cheaper than a cure. With that in mind, both of these programs should be on the right track.

Post from: EveryJoe

Will higher physician payments and bonuses lead to lower costs?

Image by seiu_international on Flickr

The proposal in question relates to a Dept. of Health and Human Services (HHS) memo that defines abortion as any measures, including prescription drugs such as birth control pills, “that result in the termination of the life of a human being in utero between conception and natural birth, whether before or after implantation.”

Another part of the memo reportedly discussed cutting off federal funding to providers and clinics that refuse to hire nurses and other staff who are opposed to providing abortions and/or birth control pills.

Some Catholic and other conservative media outlets are discussing this proposal as an “anti-discrimination” measure to keep health care employers from discriminating against pro-life employees. The WSJ health blog’s discussion seems to take the angle that the proposal centers around emergency contraception issues.

Post from: EveryJoe

Clinton criticizes Bush administration contraception policy

Reimbursement for oncology services has been broken for a long time, but recent changes and headlines in the news — from the high cost of cancer drugs and biologic agents to the possible slashes in Medicare reimbursement — are bringing this issue to a critical point. Why can’t we find a way to pay physicians better for their cognitive skills and the time-consuming activities of developing tailored treatment plans (and the research that goes along with it) and delivering these plans to patients rather than forcing them to run their practices as dealers of expensive drugs or boutique pharmacies for infusion?

Post from: EveryJoe

Doctors, as well as patients, stung by high cancer drug prices

According to the video below, she had been waiting in the ER for over 24 hours before she collapsed. This is not the first time that this particular hospital has failed to properly treat its patients, and according to a number of sources, this incident is just one in a long line of sad cases that will become more and more common as the U.S. health system continues on the path that it is on.

Post from: EveryJoe

Patient Dies on ER Floor – Is This How We Are Caring for Our Patients?

I agree with the first one (pressure ulcers) for the most part, and definitely with the last three — these three items are sometimes called “never events” because they should never, ever happen (and rarely happen when a hospital has good procedures for staff communication and safety double-checks). However, denying reimbursement for catheter infections or staph might be taking it a little too far. Sometimes, these things just aren’t preventable, and it’s even possible that a patient could come into the hospital after already being exposed to such bacteria.

The new items CMS is proposing to add to this list are perfectly reasonable (and by that I mean rather preventable):

• Extreme blood sugar derangement
• A collapse of the lung resulting from medical treatment
• Staph infection in the bloodstream
• Surgical site infections following certain elective procedures
• Legionnaires’ disease

But a few just aren’t 100% preventable occurrences, or for some other reason, are silly to include. Why?

• Delirium — can occur especially in older patients and in those with dementia, and may appear with little warning or opportunity for prevention
• Ventilator-associated pneumonia – it’s actually not that easy to determine whether or not a patient truly has VAP or whether they have pneumonia from another source… some interesting papers have recently been written on why VAP shouldn’t be a quality measure of any sort 
• Deep vein thrombosis/Pulmonary Embolism — while DVTs/PEs are almost always preventable and are never a good thing, certain patient populations, such as those with cancer, are more susceptible to DVTs/PEs, and for some patients, anticoagulative therapy is contraindicated even after surgery because of other conditions, such as risk of stroke from bleeding in the brain
• Disease associated with Clostridium difficile infection — C. diff is nasty. C. diff is another thing that is almost always preventable. However, it is also one of those things that a patient can get by no fault of the care team. It can be related to a long course of antibiotics, is difficult to diagnose, and often can be made worse before it’s better.

Post from: EveryJoe

AMA Infuriated by Medicare’s “No-Pay” List