Ambulatory Surgery Centers — quality from the patient standpoint

ascwaitingPatient’s who have minor surgery at an ambulatory surgery center (ASC) don’t really know what to expect.  And, after the experience they often wonder  whether they received high quality care.  The basis for thinking the quality was good is usually the perception the staff was friendly and the fact the patient indeed survived to ride home in a car with a friend or relative.

There are more than just those 2 dimensions of quality.  What should an informed consumer watch for?  Or, more likely, what should family members who accompany the patient look for?  After all, the patient is a little anxious before surgery and often sleepy after surgery, mostly concerned about getting to the car.

Here is how a smooth high quality ASO interaction works:

  1. Primary care physician contacts the surgeon about the patient by phone or secure email to see what steps need to be taken for a possible outpatient surgery — like treatment of carpal tunnel syndrome.  And, the surgeon gets information about the patient’s other health problems.  Appropriate tests are ordered and an appointment with the surgeon is made within about a week.  All records are electronic and made available to the surgeon.
  2. The surgeon has a clinic visit with the patient.  The nature of the surgery is explained to the patient both verbally and with diagrams.  The surgeon states whether they feel the proposed surgery is reasonable under the circumstances and describes what the surgery entails from their standpoint.  But, no decision is made by the patient at that point.  The surgeon uses a shared decision making technique.  Meaning, the patient is given literature and internet links to review.  Also, a link to all previous patient satisfaction surveys about the same surgery are provided to the patient.   Plus, a packet with all the documents that must be signed.  Staff review the patient’s insurance and estimate for the patient ALL the out of pocket costs of the surgery (surgeons fees, ASC fees, devices, and drugs).
  3. Later, perhaps a couple of days later, the surgeon calls the patient, questions are answered and a joint decision is made about whether to proceed with the surgery.   Also, at some later time the patient talks to the anesthesiologist on the phone and can ask questions about anesthesia issues.
  4. If the patient wishes to proceed the necessary documents are signed (on paper or electronically) and an appointment for surgery is made.  The patient takes or sends the documents, including operative consent, HIPPA forms, etc, to the doctors office. The primary care records, the surgeons records and the documents are made available to the ASC.   No additional forms need to be signed or completed at the ASC.
  5. If there are questions about medication management or other medical issues another phone call or email is exchanged with the primary care provider.  The patient should never be a messenger asked to get information or ask questions about medications from the primary care provider.
  6. Required pre-operative examinations are performed by the surgeon or assigned physician assistants in a timely manner.
  7. The patient arrives at the ASC at the appointed time, no additional paperwork is needed.
  8. The patient is taken to a personal pre-operative room, not to a public waiting area — privacy of outpatient surgery is important.    All patient charting is done with a computerized system.
  9. The nurses, anesthesiologist and surgeon meet with the patient and family.  Any last minute questions are answered and post-operative instructions are discussed with the patient and persons taking the patient home.
  10. After appropriate preparation the patient is taken to the operating room and after surgery returned to a recovery room, hopefully the same room they started in.  The surgeon and anesthesiologist meet with the patient and persons taking the patient home to relate the outcome of the surgery and to repeat the post-operative instructions.  Written instructions with a follow up appointment date and time are given to the patient.  A phone number answered 24 hours per day is given to the patient for any problems or questions that arise at home.  Telling the patient to go to the ER for all problems is not acceptable.
  11. No patient should feel they are the last patient of the day and must leave because the ASC is closing.  The ASC must stay open for several hours to accommodate all needs of that last patient of the day.  Minor complications, like urinary retention, should be resolved by the ASC, not an ambulance transfer to the ER.
  12. The surgeon sends the operative report electronically to the primary care provider and sends a letter to the patient about the diagnosis and results of surgery.
  13. Later in the day or the following morning someone at the surgeons office contacts the patient to see how they are getting along, to answer questions and prescribe additional medications or treatments if needed.  The date and time of the follow-up appointment are again reviewed.  The patient is asked to participate in a patient satisfaction survey.
  14. The patient fills out the satisfaction survey on paper or on-line.
  15. The patient returns for the post-op visit with the surgeon as scheduled.  The final diagnosis is discussed with the patient and further instructions are provided.

Well, is that how your outpatient surgery went?  If yes or if no, leave a comment.  What was good at your ASC and what was bad?

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More Clinic Visits for Diabetics — use the phone

stringphoneJune 3rd 2015 Kaiser Health News reported the ACA seemed to cause more provider visits for management of diabetes “More Patients, Not Fewer, Turn To Health Clinics After Obamacare”.   This is both good and bad.

The “good”:  more attention to a patient’s condition is likely to result in better diabetic management, fewer complications, fewer hospitalizations and longer life.

The “bad”:  since clinic visits can be billed to insurance, clinics make appointments and make money for each visit.  The payment for visits rather than outcome is expensive and a known problem in US healthcare (fee for service).  Diabetes can be managed over the phone in many, if not most cases — but there is no money for the provider in that approach.  Phone care has a much higher value for the healthcare system and the patient; but, low-cost high-quality (high value) care is not getting the incentive.

The care of diabetics is further compromised by the pharmacy.  A key piece of equipment for a diabetic is a glucose meter.  The manufacturer almost gives away the meter so they can make huge profits by selling the disposable test sticks.  The sticks are not interchangeable, not generic, sold in small lots, each lot sold with a co-pay, each lot requiring a visit to the pharmacy, and the use of gasoline to make the trip.  If you don’t have much money the speed-bump turns into a mountain.

The solution:  every few years mandate a generic test stick that manufacturers of glucose meters must support.  “Uncouple” the meter maker form the test stick maker.  And, sell the sticks in lots that last for at least 90 days, and that are sent to the patient by mail.   Adjust the payment to providers so that they must contact diabetics by phone to adjust medications at least 2 times per month in order to bill for a medium or high level clinic visit.  Also, each provider must obtain patient satisfaction data to prove the adequacy of service.

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Addendum:  Here is a link to an interesting court case about glucose meters

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Warning: Price could cause ulcers — CMS drug data

purplepillThe purple pill tops the list of the most expensive drugs for government health programs in 2013.  No, your first reaction to blame the government is wrong — the drug is prescribed by health care providers — and, the government is prevented by law from negotiating drug prices.  Why is this a problem? –there was a perfectly fine OTC generic substitute available in 2013 at only 6% of the cost.

WHAT???  Prescribers wrote prescriptions for a drug that could have been substituted by an equivalent drug and saved 94%.  OK, at the margins of the argument, at the fringes of reality, at the level it makes no clinical difference, big pharma says it might not be a perfect substitute.  A good example where the “perfect”  is the enemy of the very good.

But, how could prescribers and patients have the wool pulled over their eyes? — fantastic marketing.  And, by the way, if you take this drug, send me your name, address, social security number, and bank account number,  I have a nice bridge to sell you.brooklinbridge

The magnitude of the problem became crystal clear when CMS published prescription data.  The following data is widely reported from CMS as the spending on drugs through Medicare’s Part D prescription-drug program in 2013:

Rank Brand Name Generic Name Number of Claims Cost in Billions
1 NEXIUM ESOMEPRAZOLE 8,192,362 $2.53
28 OMEPRAZOLE OMEPRAZOLE 32,250,368 $0.64

Omeprazole is a very good substitute for Nexium for heartburn and reflux.  Despite the cloud of industry generated studies many pharmacists say the two drugs have equal effects.  As the table above shows omeprazole was prescribed 4 times as often as Nexium but the providers who chose Nexium created a vastly larger and unnecessary cost.  Why Nexium is even be on the Medicare Part-D formulary is a mystery.  Who pays the bill? — taxpayers, of course, and the patients who paid a co-pay higher than the full cost of an equivalent.

In 2015 Nexium became an over the counter drug (OTC) and just as you might suspect it now costs about the same as OTC omeprazole — about $32 for 56 pills (at Costco) rather than $300.

Where is the oversight?  Where is the cost control?  Why is US healthcare so expensive?  Need more examples? Just look at the other medications on the list.

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Switch to Generic Medications — no problem!

genericmedSwitching from a brand name medication to an available generic medication is safe, easy and will likely save you a lot of money.  Thanks to the work of the FDA, generic medications in the United States are quite safe.  Patients in the US take more generics than in other countries.

When a patient starts a new brand-name drug (e.g. Lipitor) there is a risk of a side effect or allergy to the active ingredient.   But, when a patient switches to a generic medication (e.g. atorvastatin) the patient already knows the active ingredient agrees with them so the chance of a reaction is as close to zero as medical science can make it.

Prescribers are well aware that some generic medications may come in different forms (tablets or capsules) and different strengths — this is not a problem, the prescription just has to be adjusted to match what the patient needs.  Most care providers are quite willing to make the change to help lower the cost of treatment — patients tend to take medications they can afford!

The Wall Street Journal had a story today based on the opinion of a “pharmacist-economist” who has been a lead author on only one paper in the past 20 years and who thinks tablets and capsules of the same medication are distinct entities (yes, but it makes no practical difference).  The WSJ is clearly interested how the switch to generics affects the economics for big pharma — it would not be good and the stocks could go down — such a disaster.  However, if you have stock in a brand-name company you could use your stock dividends to pay for the drug.

The new bio-similar drugs and even some old drugs (like warfarin) may have a slightly different effect that depends on some minor manufacturing quirk.  Prescribers are well aware of these peculiar drugs and can easily make adjustments and do tests as needed.  Fortunately, small manufacturing differences for the vast majority of drugs is a distinction without a difference for the patient.

This principle needs to be considered in everyday terms.  The table salt at restaurants may come from separate and  distinct sources — it really makes no difference to the customer — salt is salt!  Marketing departments want you the think a generic is like coal and a brand-name is like diamond — intellectual garbage.

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Urinary Retention — 1 in 10 men over 70

urologybillboardOne ER visit is a red flag — more ER visits for the same problem become an example of  poor quality health care.

Urinary difficulty is something older men don’t like to talk about.  But, 1 in 10 men over the age of 70 will end up in the emergency room with urinary retention — an uncomfortable situation where they can not pass urine.  Urologists are aware of this frequent problem — see the billboard story.  It is a serious problem;  in third world countries it may be fatal.

The usual cause is enlargement of the prostate preceded by symptoms of slow and frequent urination.   Sometimes there are few symptoms until a painful inability to pass urine forces a rush to the emergency room.

The usual medical approach is to insert a tube (a catheter) into the bladder to relieve the pressure, start a medication to help urination, and 3 days later to remove the catheter.  50% of men can then pass urine adequately (for a while).  The quality issue is that 50% have a recurrence within a week — so is another ER visit the answer?

A friend of this blogger landed in the ER a total of 4 times with urinary retention.  Why is the ER the center of after-hours treatment for this problem — once identified as an issue why is the health care system making it a recurring emergency?

The solution is Urologists need to own the problem and provide adequate patient care 24 hours a day once a catheter is removed.  Yes, own the problem, not turn off the phone and let the ER solve it.  Does that mean the urologist must be at the clinic 24 hours a day?  No, but there must be an arrangement for immediate care — no waiting in the ER, no ER charges, no secondary consultations.  An arrangement with a 24 hour urgent care center may be enough but some back-up plan and patient education are essential.

The majority of men with urinary retention end up having a surgery to ream-out the prostate (TURP).  According to healthcare-salaries.com a suburban US urologist makes $500k to $1M each year.  This is another example of the decoupling of cost and quality caused by involving multiple providers with no common financial risk.

A proactive patient who has a catheter removed should ask the urologist “what is the plan if this does not work?”  and “is there some alternative to the ER since you have already evaluated me?”.  At least find out how to get in touch with the on-call urologist!

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The Most Powerful Treatment — walking

Moderate fitness is the most powerful treatment to prevent disease.  And, moderate fitness is easy to obtain.  Just walk 20 minutes a day.  People get very little extra benefit from more exercise than that!  The graph shows moderate fitness lowers your risk of death by about two thirds — and the extra years you get will have better quality.

The benefit of moderate fitness exceeds that of not having the following conditions:

  • smoking
  • high blood pressure
  • high cholesterol
  • family history of heart disease
  • overweight
  • pre-diabetes

So what worries you more?  Being a couch potato or having any of those conditions?  The couch potato is the worst.  This is not to say you should continue smoking — it means you need to BOTH exercise AND stop smoking.

The average American watches 5 hours of TV per day and many think the lack of activity it causes increases the death rate.  Just skip one TV show and walk instead to reverse the trend.

fitnessanddiseaseMany people say “I don’t have time” to walk 20 minutes a day.  The real question is “are those other things consuming your time really more important?”  If you are dead not much else matters.

A good primary care provider should ask you about your level of exercise and fitness at every visit.  A lack of fitness is the most severe health problem in the United States.  Health providers almost always check you blood pressure when in fact your level of activity is more important — let’s keep this in perspective.

Here is an absolutely wonderful YouTube video about fitness:

http://youtu.be/aUaInS6HIGo

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The Perils of Over-Treatment — diabetes and hypertension

excessToo much treatment is dangerous just like too little treatment.  Treating blood pressure too early or too aggressively increases the risk of death.  Treating elderly patients with diabetes with too much medicine increases episodes of low blood sugar that damage the brain and leads to broken bones from falling.

In 2014 the national guidelines for blood pressure treatment were changed to allow a higher blood pressure.  Similarly, a recent study found increased mortality for elderly patients treated too strongly for diabetes.

This is not rocket science.  Imagine a blood pressure medication that could lower the blood pressure to any level.  Knowing that zero blood pressure means you are dead, it stands to reason there is a point where treating blood pressure goes from helpful to dangerous.  Same for blood sugar.

Sometimes this problem is called “treating the test“.  In essence prescribers just look at the numbers and write a prescription, but ignore symptoms of weakness or spells of altered consciousness.  Hypertension and diabetes are good examples but this happens with lots of other conditions.

Examples of over-treatment include treating a sore throat with antibiotics, treating mild asthma with oral steroids, or treating an elevated lyme serology test with antibiotics.  It takes time to make a correct diagnosis and time to explain treatment to patients — some health care providers simply don’t take the time to do either.

Most drugs have a “therapeutic windowopenwindow.  As long as the window is open the patient gets benefit.  But, the window closes due to side effects and advanced age.

If a person is over 80 or in poor health excessive medical treatment is a substantial risk.  In this group even the thought of a low cholesterol diet is foolhardy.   It’s all about risks and benefits.

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