Archive for the '“It’s Time We Talk…”' Category

A Straight Face Test for Health Care: Would Patients Pay for This?

Health care in America is fracturing right down the middle, and doctors are going to have to figure out if or how long they can straddle the divide between what patients want and what the Government and Corporate America want them to have.

Up until this point, the momentum has been with the payers, Medicare and the insurance industry. But the more heavy-handed they become, the more inevitable the public backlash is becoming.

It will come down to this, a kind of “straight face test” for health care: Would patients pay for this?

The Annual Wellness visit, better named “Medicare’s Non-Physical” and some forms of “Population Management” are examples. Both are great ideas; an annual health review and planning session as well as doctors maintaining an overview of, and reaching out to, high risk groups of patients – in theory neither would be anything to argue with.

But the way it has to be done today, if we want to get paid, micromanaged from afar through bureaucratic edicts, is alienating the patients this was all intended to benefit.

Totalitarian Health Care is Doomed

I grew up and went to medical school in a socialist country. I admit Sweden had a kinder, gentler, soft-core socialism, but I also visited and followed the news about the Soviet Union, the Baltic states, East Germany and the former Czechoslovakia.

American health care, as manifested by Medicare and the big insurance companies, is more and more starting to look like my visit to the Soviet Union with my surgery class in 1977. The most striking example of disregard of individual customer preference I saw was at a very large restaurant near the Red Square. The sour-faced, haggard breakfast waitstaff told our group bluntly that we could all have either coffee or tea, but they could not accommodate individual orders for different beverages.

The “planned economy” of the Soviet Union collapsed, and I suspect its counterpart in American health care eventually will, too. I think our system will split in two: One system for what patients see value in, and would pay for, and another system, which the politicians want them to have, but which most people would have nothing to do with if they had any say in where their healthcare dollars go.

Two dichotomies are driving this inevitable split down the middle of our healthcare system: First, the improbable marriage of public health and medical care; and, second, the opposing ideals of standardization and individualization.

Public Health vs Medical Care

It is insanely inefficient to mandate that highly trained physicians, with an “opportunity cost” of $7-10 per minute in primary care, and multiples of that in many procedural specialties, carry forth the nation’s public health agenda with their patients one by one during their office visits. Medicare’s requirement that we document an intervention for every patient we see with a Body Mass Index over 30 is a glaring example of that. Having our nurses or other staff members do that isn’t much better. Our teams have a lot of tasks and routines to maintain proficiency in, and since obesity affects a large proportion of our society, it would be better addressed on a national, cultural and political level. It suddenly became our job, it seems, as health care professionals, because whoever had the ball before us failed at fixing the problem. But soft drinks and breakfast cereals are made by big, powerful corporations, and our Government lacks the guts to reign them in. So, someone thought, let the docs spin their wheels for a while; they don’t have enough to do.

A healthcare system designed for setting fractures, treating pneumonias and removing appendixes is ill suited for treating societal ills. Quite frankly, it doesn’t pass the straight face test: Ask citizens if they want their health insurance premiums (or out-of pocket costs in a Direct Primary Care model) to cover à la carte anti-obesity campaigns or if that should be included in State and Federal budgets. I know what the answer will be.

The difference here isn’t subtle: If public health is financed through workers’ insurance premiums, its cost is more evenly spread, and thus affects middle and lower income people more than if it comes out of corporate (think Pepsi, Coke, General Mills and Ocean Spray) and progressive personal income taxes.

Standardization vs Individualization

There is a rapidly growing interest in personalized health care in America today among patients and health care entrepreneurs. Genetic profiling is now used in choosing which medications to prescribe, for example.

At the same time, payers are tying reimbursement to doctors’ adherence to blanket recommendations (read “Evidence Based” treatments) derived from large population studies that were designed to find lowest common denominators: In general, for example, low dose aspirin, beta blockers, lower blood pressures and blood sugars are helpful, but we are now seeing that there are more and more subgroups of patients who don’t have the expected benefits from any given “Evidence Based” intervention. In some cases, people are harmed by them. As long as Medicare and the insurance companies hold the purse strings – actually, dole our own money back to us according to their standards – the welfare of a few is routinely sacrificed for the benefit of the many.

Again, applying the straight face test, patients wouldn’t want to pay us for delivering care to them that was designed or chosen to help someone else, just so we could show off high compliance rates. If doctors are held in too tight a grip of uniformity by the conventional insurers, patients in this new era of deepened insight into the variation of disease expression will take their money to providers and insurers who will respect their preferences.

A Moral Compass

The straight face test has to be our moral compass as we work our way through our daily allotment of twenty-odd patient encounters with fifteen minutes to spend as wisely as humanly possible.

People can vote their politicians out of office, they can form cost sharing cooperatives or sign up for Direct Primary Care. But we, physicians, need to make sure we don’t forget who ultimately are our customers. Even without politicians and insurance conglomerates there will always be doctors and patients. May we never lose our trust in each other.

It’s Time We Stop Comparing Health Care to Manufacturing

From ancient times, doctors have appreciated that, for all their similarities, no two patients are exactly alike. This understanding is what made physicians act like, and earn society’s respect as, professionals.

The commercialization of health care has brought in managers from other industries and other branches of academia, and their rise to power has been predicated on their ability to treat patients and doctors not as individuals, but as small cogs in the new health care industry.

There is no doubt that healthcare today is an industry, but I disagree with the notion that it can be closely compared with manufacturing.

In manufacturing, every aspect of production is built around standardized processes and standardized raw materials. But in health care, the “raw materials”, people with illnesses and risk factors we doctors seek to mitigate, are all different. And the processes often involve judgement calls and compromises between different objectives when patients have more than one disease.

Compare this to two types of carpentry:

Some carpenters build houses on empty plots of land, according to detailed architectural drawings, using standard sized lumber, creating homes that are identical, square and uniform. Novice carpenters learn relatively quickly how to build such homes, because the manufacturing process is consistent and predictable from one brand new home to the next.

Healthcare is more like old-house restoration than manufacturing. Put another way, real patients are more like old houses than new tract homes.

I have recently had reason to watch a master carpenter and a master painter turn a 1790 house and barn from a neglected near-dilapidated state into an inviting and comfortable home. Almost everything these two craftsmen did was improvised. Every flaw or asymmetry they tackled inevitably lead to another one that could not have been anticipated, let alone described with enough detail in architectural drawings or engineering diagrams for someone without decades of experience to tackle. Every decision these men made almost automatically and with little fanfare was a judgement call or an impromptu recreation of some antique detail; the carpenter chose lines to work from so that the house seemed straighter to the eye than if he had followed his level, and the painter filled gaps in the antique moldings with joint compound in a way that made the house seem tidy and whole but still showing its age.

When restoring a 200 year old house, there are no perfect squares or true plumb lines. The walls are never even and the floors are never level. But that doesn’t make such a house less livable, or less beautiful. It adds to its value. Manufacturing principles don’t apply when you set out to restore an old house, and the same holds true in holistic primary health care. Putting new drywall over a wavy plaster and lath wall is quicker than preparing the original surface for fresh paint, but the result breathes life and history into spaces that are now ready to live on with renewed purpose and dignity.

In medicine, whether it is doing plastic surgery, treating aging patients with three or four chronic medical conditions or counseling a patient facing life-changing circumstances, the manufacturing model can only cover the most rudimentary basics. It is the skill and experience of the practitioner in balancing all the variable manifestations of disease in real people that makes their treatment a source of healing.

Even the most predictable patient care processes, like taking out somebody’s appendix, don’t quite lend themselves to the manufacturing analogy. In medicine, the first step is not how to begin to remove the appendix; it is making the decision whether to do it in the first place. That isn’t always a straightforward, scientific decision, even with today’s imaging tests. It sometimes comes down to a judgement call here, too.

It’s Time We Talk: A Doctor is a Doctor is a Doctor, Right?

I am a foreign born, foreign trained doctor, serving many patients from an ethnic minority, whose native language I never mastered.

So, perhaps I am in a position to reflect a little on the modern notion that healthcare is a standardized service, which can be equally well provided by anyone, from anywhere, with any kind of medical degree and postgraduate training.

1) Doctors are People

No matter what outsiders may want to think, medicine is a pretty personal business and the personalities of patients and doctors matter, possibly more in the long term relationships of Primary Care than in orthopedics or brain surgery. Before physicians came to be viewed as interchangeable provider-employees of large corporations, small groups of like-minded physicians used to form medical groups with shared values and treatment styles. The physicians personified the spirit of their voluntary associations. Some group practices I dealt with in those days were busy, informal and low-tech, while others exuded personal restraint, procedural precision and technical sophistication. Patients gravitated toward practices and doctors they resonated with.

In many of today’s medical practices, the doctors’ names aren’t on the front door, office letterhead or company advertisements; they’re often not even in the phone book. A group of employed doctors these days can consist of multiple personality types with disparate treatment philosophies and clinical styles. I once worked with a doctor who would give patients with upper respiratory infections half a dozen prescriptions while I would say “go home and get some rest; it’ll go away”. Not knowing what the two of us were like, patients could end up choosing the doctor whose style didn’t meet their needs.

I have worked with colleagues who view every laboratory abnormality as an ominous threat and pursue each one to the ultimate degree, making even the healthiest patients uncertain about their chances of survival. Some of the same doctors also insisted on seeing even patients with mundane medical conditions on a tight schedule in order to monitor them for unforeseen medical disasters. In today’s generic clinics, patients may not know if their new or covering doctor is a reassuring pragmatist or a consummate worrywart. Worse yet, they may be shuffled back and forth between doctors with opposite styles.

2) Training Differs

In Primary Care, we have MD’s and DO’s, Family Physicians, Internists and “Med-Peds” physicians. Each training is inherently different, further complicated by differences between schools, regions and countries.

Internists, trained to treat diseases of adults, are sometimes asked to treat children in the government-sponsored type of clinic I have spent most of my career in. They are also oftentimes faced with treating conditions in ophthalmology, otorhinolaryngology, gynecology and orthopedics – areas where they may have little experience. Their residency training may have been entirely urban and hospital based, but in today’s American job market, the demand and opportunities tend to be in more rural areas, particularly for visa applicant physicians from third world countries, where academic hospital medicine may be fairly similar to US healthcare, but where small town and rural medicine can be very different.

3) Culture Matters

As an immigrant physician with English as my second language, I had to work at speaking comfortably with rural American patients, many of whom were of French-Canadian origin. It must be a bigger challenge for physicians from further away than Sweden. Language is only the beginning. How different cultures view life events and medical conditions can vary greatly. I am told that the Japanese don’t have a word for hot flashes and that in Tibet, most people aren’t familiar with the notion of depression.

People in this country often talk about how doctors need to be sensitive to minority patients’ culture. Less is said about minority physicians’ familiarity with the American majority of patients; whether we are from Sweden, Japan, Tibet or India, we each have a learning curve for understanding those we are here to serve as personal physicians.

I remember one internal medicine physician from a Muslim country who found out that his American employer expected him to perform routine gynecological exams including Pap smears on his female patients. Not only had he never been trained to do any of it, he also had to wrestle with overcoming what his his entire upbringing had told him was improper.

4) What is a Good Doctor?

The industrial view of healthcare imagines that it consists of standardized processes that are easily measured: What is the average blood sugar, or glycohemoglobin, of Dr Andersson’s and Dr Singh’s patients? Their pneumonia immunization rate? How many of their heart failure patients are on a beta blocker? How many seniors have had a fall risk assessment? How many obese patients have an obesity action plan documented in their medical record?

Nobody talks about this, but all those quality indicators make less difference for individual patients’ longevity and for entire populations’ health than healthy lifestyles do. For individual patients’ health as it relates to healthcare, accurate diagnosis of new symptoms can amount to an all-or-nothing disparity between health and disease, even between life and death.

Some of the most basic measurements of physician quality are surprisingly irrelevant: Beta blocker therapy in heart failure patients only increases average survival 6-12 months, it takes 50,000 pneumonia vaccinations to prevent one pneumonia death, and prostate cancer screening, once a basic minimum requirement for men’s health care, is no longer even recommended.

My uncle had waxing and waning paralysis of his left arm, but his doctors never checked his carotid arteries, and soon thereafter he had a stroke. My aunt had a cough for well over a year, but because she never smoked, her doctor didn’t order a chest x-ray until it was too late and her lung cancer was inoperable. This happened in Sweden, where the average life expectancy is the 6th highest in the world, 3 years more than 32nd ranking USA. It could have happened anywhere, because doctors are people, each one different, and the real quality of their work cannot be measured, let alone regulated.

Employers and bureaucrats may think a doctor is a doctor is a doctor. My aunt, for one, doesn’t think so anymore.

It’s Time We Talk: Why Should Doctors Treat the Well and Nurses the Sick? – Part One

THREE PROVIDERS IN MAINE

Mary Hunt is a busy family physician with a full caseload. A twenty-five year veteran with an Ivy League medical degree and a residency training at an eastern seaboard tertiary care center, she has seen a lot, but she never jumps to conclusions or takes shortcuts. This makes her run late sometimes, but her patients don’t mind; they know she provides top-notch medical care.

Mary’s schedule is filled weeks in advance, and she seldom sees patients for acute illnesses. The bulk of her work is chronic disease management. Her EMR inbox is filled with prescription requests, results of standing lab orders, consultant reports, records from the emergency room, inpatient hospitalist service and the local walk-in clinic. Her office visits the past several years have become more and more scripted with checklists for the different quality measures from her Medicare Accountable Care Organization, NCQA and all the other agencies that measure her performance.

Almost every night after supper, Mary logs on to her EMR from home to finish office notes, go through results and answer “medical calls” from her medical assistant and her office case managers.

Megan Brown has been a nurse practitioner for two and a half years. She considers herself lucky to have Mary Hunt as her supervising physician. For the first two years after her graduation from her Masters program at the local branch of her state university, Dr. Hunt co-signed her chart notes and had weekly tutoring sessions, but now she is only available if Megan feels she needs help.

Megan has a small panel of patients of her own, but mostly she sees “acutes” down the hall from Dr. Hunt. She hates to interrupt the doctor because she sees how busy she is, but never feels put down for needing help managing a case. She often sees presentations that are unlike anything she has encountered in the four and a half years since she started nurse practitioner school. Before then, as a nurse, she was never exposed to the diagnostic process; she was more focused on assessing patients for comfort versus discomfort and for carrying out existing treatment plans.

Rhonda Smart has been a nurse practitioner for a decade. Before that, she was an emergency room nurse, which helped prepare her for a career as an independent frontline clinician. She has worked at a shopping mall urgent care center for three years now. She sees a fairly interesting variety of patients, but is starting to feel a little stale, because she rarely gets to hear how her patients make out. She sends her reports to the local primary care physician offices, but they never give her any feedback or updates. She does her shift and goes home and rarely spends much time with the other nurse practitioners who work at her clinic. She has no mentors and no peer group to share difficult cases or career conundrums with.

THREE QUESTIONS:

Is Mary Hunt doing what we want doctors to be doing in a way that is sustainable for her and her patients?

Is Megan Brown our best choice for first responder for undifferentiated medical symptoms and conditions?

Is Rhonda Smart growing in her profession or will her medical acumen shrink as she continues to work in the isolation of her storefront clinic?

It’s Time We Talk About Who Should Do What in Healthcare Teams

 

“Team based care” is one of today’s buzzwords without real substance, because unless the payment systems change, only the physician members of the “team” can bill for their work.

Few people seem to be concerned with the simple but essential question of how physicians spend their time and how medical offices are paid. As a primary care physician who doesn't do any major procedures, and who in 2014 is essentially paid fee for service, I should bill around $400 per hour – $7 per minute, to put it bluntly – for my employer to stay afloat and for me and our support staff to stay employed.

Physician review and oversight of the team’s efforts, which is a medical and medicolegal necessity, is an unreimbursed activity. So, how much enthusiasm do the healthcare experts really expect to see for schemes that have computers, apps and non-physicians gather information for physicians to act on without seeing the patient – and thus, without the clinic collecting a fee?

But also, taking a medical history, for example, is not necessarily a simple task that can or should be delegated to team members with little or no training for it. Just like employers who interview prospective new employees themselves, or at least have a seasoned Human Resource professional do the job, doctors do more than just ask questions and record the answers. They pay attention to the person’s posture, attitude, facial expressions and willingness to provide the information.

Would a journalist have someone else interview a politician and then feel he could write a credible feature article based on the other person’s notes?

How truthful and accurate are the answers our patients give in the mandated depression screenings our medical assistants administer in our clinics? How many patients just barely even tell their doctor their innermost feelings and thoughts?

The reality in medicine is that the licensed professionals need to do the bulk of patient interacting and decision making, because that is what they are trained to do. Other team members need to be part of the process by preparing for visits, facilitating the plan that is outlined in the medical record, fielding questions and carrying out standing orders. I don't advocate for less involvement by support staff, but actually more. For example, I feel the front desk staff needs to know which patients and which types of symptoms require more time and which ones require less, in order to be able to schedule appointments intelligently and make the best use of physicians’ time. I also think each provider’s primary nurse or medical assistant should read all office notes after they are completed, so that if a patient calls back with a problem the medical assistant has an immediate awareness of how this patient can best be helped.

Similarly, if a patient is fit into the day’s schedule, a team member who reads the chart in order to make sure pending reports are available and who scans the phone messages and other things that have happened since the last visit can help the physician “hit the ground running”. Also, making sure at check-in that the patient doesn't have an immediate and different concern that may change the plan for the day avoids wasting everybody’s time in the visit.

Team members in a primary care office who know the patient and know what usually happens in typical situations are invaluable. Most primary care offices don't have team members with professional licenses that allow them to make clinical judgements, but just by being facilitators and advocates, they can easily double a physician’s productivity.

Which team effort moves the care forward most efficiently? Having medical assistants give depression screenings and smoking cessation counseling or making sure everything needed for the visit is available? Patients with urinary symptoms need to have a urine test, wound care visits must have all necessary supplies at hand and hospital follow-ups must have not only the discharge summary but also the consultations and all test results available, or the practice loses $7 for every minute of wasted physician time. It may seem mundane to today’s healthcare visionaries, but such efforts keep the doors open.

There is a strange cliché in use here, “working to the top of your license”. This has been used to justify letting support staff take over screening and education duties. It has not been applied to freeing physicians from clerical tasks like entering data that used to be done by transcriptionists.

I am not afraid to clean exam rooms after my visits are done, or anything else that keeps the office flow going. But I get a little frustrated when non-medical people opine that taking histories, doing physical assessments and counseling patients is so easy that anyone can do it. Sure, I can wire a three-way light switch and solder a copper pipe, but electricians and plumbers do it better, faster and neater. That isn't something for me to be embarrassed about – they have more experience doing it, just like I have more experience taking medical histories than nurses and medical assistants, because it is what I do for a living.

I do support making use of special talents; we once had a medical assistant who was a natural motivator. She took courses in motivational interviewing and became our smoking cessation counselor. But a blindly applied “working to the top of your license” is also known as “the Peter principle” – push everyone to their limit, where they can no longer do what is asked of them.

I don't know if I am just less aware of this in other “industries”, or if this is something unique to non-medical policymakers’ vision of medicine: There is less and less respect for professional training, skill and experience. If this were declared as a social experiment or an “equalization” effort, I would understand (after all, I grew up and trained in a Socialist country), but that is not quite what I hear.

My next topic in this series will be doctors, nurses and nurse practitioners – who should do what?

It’s Time We Talk About What Healthcare Really Is: Public Versus Personal Health

 

The general debate about how healthcare should be organized, measured, evaluated and paid for is about as useful as arguing about whether all food should be served hot, cold or room temperature.

Healthcare can be so many things these days, that I’m not even sure we agree on the definition of healthcare. We certainly have seen disagreements on what we expect our insurance policies to cover. This is an especially thorny question as we in the United States spend twice as much as any other country, and yet are worse off than the other industrialized nations in infant mortality, life expectancy and chronic disease burden statistics.

OBESITY AND SMOKING ARE NOW QUALITY INDICATORS, BUT ARE THEY TRULY THE DOCTOR’S RESPONSIBILITY?

The lines have blurred between public and personal health, and there have even been a couple of role reversals between medicine as we were trained to view it and what we used to think of as public health. For example, ancient physicians like Hippocrates put great emphasis on nutrition advice in sickness and health, but during my lifetime the government started telling us how many glasses of water to drink and what nutrients are good and bad for us. This was when the beginning obesity epidemic was blamed on high fat intake several decades ago by someone in the government. Since then, fat consumption has decreased steadily while obesity rates have increased. In a clever reversal of its stance, the government has now lobbed the ball back in the physicians’ court, since the official strategy misfired so profoundly. And they have cleverly built in a punitive mandate to make sure they don’t get handed back the responsibility for the epidemic they fueled with their ignorance. How?

Medicare now demands that physicians document a follow-up/action plan for every single obese patient they see. Is that really a priority for the individual doctor-patient encounter? Especially since there are no truly effective medical treatments for obesity. It is best treated with diet (higher fat, lower carbohydrate) and exercise. Or is it perhaps something better handled in the public health arena again, this time with better science behind it? When there is talk of shortages of primary care doctors as the baby boomer generation enters their senior years, as we struggle with high hospital readmission rates, and as we wring our hands over lack of access in primary care and inappropriate emergency room utilization, should we turn sick patients away because we are busy counseling even our most unwilling patients one by one on the dangers of soft drinks and breakfast cereals?

Similarly, smoking has been viewed as a public health problem, but it has now become a yardstick in healthcare, too. Doctors will now fail their quality metrics for any diabetic patient that smokes, regardless of their blood sugar, cholesterol and blood pressure control. Is that a fair and realistic way to measure physician performance? Will it cause “noncompliant” diabetics to lose access to care? I worry that it will.

Even gun safety has been put on the physicians’ shoulders. The Maine Medicaid well child visit templates have gun safety as a prescribed topic to cover. What the political parties have failed at, we are now supposed to do as an add-on item in our fifteen minutes with our patients. Interestingly though, a 2011 Florida law, which was upheld in a legal challenge this year, specifically prohibits physicians from asking their patients about gun ownership. So why is healthcare defined differently at the opposite ends of US Route One?

ARE IMMUNIZATIONS HEALTHCARE OR PUBLIC HEALTH?

Obvious Public health activities such as immunizing against contagious diseases were traditionally done by doctors’ offices in this country. In Sweden, where I trained, physicians in primary care did not usually administer childhood vaccines. Instead, publicly funded nurse-run clinics handled immunizations and routine screenings of infants and young children.

The difference I see between immunizations given in a government run clinic and in a physician’s office is that physicians, by nature of their training, tend to be patient focused and sometimes will support their patients’ decisions about forgoing immunizations, for example some of the newer, less studied vaccines that have much less than 25 years of study (it took about that long to find out if post menopausal estrogen decreased heart attack risk as it had been speculated – it actually increased it).

Now national pharmacy chains are giving adult immunizations with forceful promotion and obvious profit motives but physicians, who in some cases are losing the revenue from giving the shots, are still required to spend their time keeping track of who got what shot.

THE DIFFERENCE BETWEEN PUBLIC AND PERSONAL HEALTH

Public health puts the individual second and societal health, finances or well-being first. Doctors, just as in the example about immunizations above, have traditionally had an obligation first to their own patients. The more we are expected to be public health officials, the more our relationship with each patient may be challenged. We are also getting sucked into a pseudo-accountability that is more political than scientific. Just like we are measured by how many of our heart disease patients are on beta blockers and how many diabetics are on ACE inhibitors, both of which are considerations with some controversy and many exceptions, our public health and common-sense recommendations are now measured in absurdum. Even when it comes to what we say behind closed exam room doors to patients who drink too much or exercise too little, we are being measured as if we are the only ones on the planet who can tell our patients these things.

By holding physicians accountable for many of the global ills of our society, from obesity to smoking, alcohol use, distracted driving and sedentary lifestyles, we have entered an environment where others are doing or being considered for the jobs we were trained to do: Pharmacists treating hypertension, nurses dosing blood thinners, Nurse Practitioners seeing our sick patients at Walmart or CVS clinics. This will be the topic of my next post in the series “It’s Time We Talk…”

 


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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