Archive for June, 2012

Low Value Health Care — The Equation

The “Sick in America Poll” shows 33% of people who were sick in the past year believe they don’t get a good value for health care.  One way to look at “value” is the following equation:

V = B / P

Value = Benefit divided by Price

If a person wishes to cross a river there might be 2 ways to get across.  $5 to go across a bridge or $2 to go across a tightrope.  If the benefit (getting across the river) is the same then the best value would be to use the tightrope.  But, low risk,  no need for training and convenience are actually part of the benefit for the bridge — which is indeed the best value.

In health care the “value equation” runs into problems.  What if a person only has $2 (the unemployed).   What if a person does not know about the bridge (poor health literacy).  What if a person does not need to cross the river but pays a fee just in case (insurance).  What if a person pays tax for the bridge (taxation).  What if the bridge is in disrepair so a person falls (cost of poor quality).  What if a person will not live long enough to get across the river (quality adjusted life years).  Health care economics is indeed complicated.

There is also a “funnel theory” of health care which says that despite theoretical complexity there are only a few solutions to come out.

  1. Deliver evidence based healthcare
  2. Stay within a budget
  3. Eliminate waste
  4. Maximize quality
  5. Minimize cost
  6. Be fair
  7. Know the value of life

Finally, the “Marcus Welby” theory of health care is dead.  That is to say, the doctor who knows everything, treats a few patients (with lots of drama) and bills enough to have a great lifestyle is now off the air.  Cost is now the king, and Americans must work within a system to meet budget requirements.  Corporations live under the same constraints, so must health care.

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Poor Communication – The black hole.

High percentages of sick Americans site poor communication of results, poor communication between doctors, and poor communications after hospitalization.

WHY x 5
WHY:  Many times providers verbally communicate but patients don’t remember.  Sometimes, providers intend to communicate but they forget.
WHY:  Providers feel that communication is part of the job they get paid to do.  They feel that the time to write down results or call or is not needed since the patient could just call the office if there was a question. Providers sometimes feel that a normal test does not require communication.
WHY:  Providers do not put a high priority on calling results.
WHY: Providers believe a call to their office is not difficult.  Only a small percent of patients will call for results.  Results done at hospital may not be available to office nurses.  It takes a lot of time to call another provider.  Hospital data may not be automatically sent  to the office.
WHY:  Providers really don’t know how long it takes to get results on the phone.  Most do not have a system to make sure communications get done. It is difficult to justify the cost of such a system since billing has already been done.  Using the Internet would be efficient but is not secure without special software.

Communication is a 2-way street.  Providers need to be more explicit about results and follow through if they say they will call or send results.  Patients should ask who to call in the office about results not currently available — they should be willing to use electronic means of getting the information if available.  Electronic medical record (EMR) companies need to focus on tagging information that needs to go to the patient and always integrate a patient portal with EMR products.

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Care Not Meeting Expectations – Where do the expectations come from?

The “Sick in America Poll” shows 45% believe the quality of healthcare is a very serious problem.   Quality is always based on a comparison with “something else”.  In the past it was difficult to compare health care with “something else”.  But now, a patient can look on the Internet for a world of comparisons (where health care does not look so good).  Or the patient will just ask a relative.

Quality is sometimes undercut by the providers themselves.  Rather than just say “an annual blood count is not supported by medical evidence”  too many doctors just say “insurance won’t pay for it.”   Rather than say “eating too soon after surgery may cause nausea”, too many nurses say “the doctor won’t let you eat.”  Rather than say “it is usually a safe drug but watch out for a rash” the pharmacist says nothing and passes out a huge list of side effects.  Where is the teamwork?  It is a set up for failure and poor satisfaction.

An academic view of quality health care is provided by the Institute of Medicine (a government organization).   They have defined six attributes of health care quality:

  1. Safe: Avoiding preventable injuries, reducing medical errors
  2. Effective: Providing services based on scientific knowledge (clinical guidelines)
  3. Patient centered: Care that is respectful and responsive to individuals
  4. Efficient:  Avoiding wasting time and other resources
  5. Timely:  Reducing wait times, improving the practice flow
  6. Equitable:  Consistent care regardless of patient characteristics and demographics

The Institute of Medicine is concerned with finding that “something” for the quality comparison.   Unfortunately, the Institute of Medicine did not list system assets such as “reasonable cost” or “sound  management” or “continuous improvement” or “reliable care” or “high national ranking”.   The goal is good, the means to the goal is lacking.  An old business saying is “measure to manage.”  Americans need to know how the health care system is being managed, at the speed of the stock market, not at the speed of academic reports.  We need to see the ticker tape for cost and quality.  If the system is not being managed well then get a new manager.

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Health Information Fragmentation – Where’s the result?

28% in the Sick in America Poll saw a health care professional who did not have all of the relevant medical information.  Many patients think all health care providers are linked together by computers but this is absolutely not the case.  The experience at an airport where a gate agent can look up your ticket and alternative flights — even from other airlines — is really spectacular. Unfortunately, American health care is not at that level of connectedness.  If one doctor orders an x-ray the results go to that doctor.  If the second doctor is in the same health system there is a chance the result will be in the system database.  If the second doctor is elsewhere the doctor will not have the result unless the patient takes some action or has the result in a notebook.  The situation is dangerous.  The patient thinks the doctor has the information.  The doctor does not have the information and orders duplicate tests or potentially unnecessary procedures.

  • From the patient standpoint:  keep a notebook of all significant tests and procedures and show it to any new providers.  When making an appointment tell the scheduler about recent tests — there is a chance the office will endeavor to get the results.  Admission to a hospital is frightening and is made worse by each new health care person ask the same questions over and over (suggesting poor communication between the admissions nurse, the hospitalist, the surgeon, the anesthesiologist, etc.)  The questions get asked because the providers have not looked at the record or because the previous provider has not had time to enter the information.  Really well organized hospitals minimize this repetition so choose your hospital accordingly.
  • From the provider standpoint:  Unless it is an emergency, try to have a staff member contact the patient before the visit and review any recent health care events.  That staff member should check for data from  those previous events and have the data available for review prior to the provider visit.  Most outpatient providers have about 4 employees dedicated to them (nurses, schedulers, insurance filers, and record keepers).  One of them should be tasked with collecting data for the visit.  You might say the provider fee does not cover data tracking, but how silly does it sound to bill for saying we don’t have the needed information?  When the patient is asked to come back for a second visit to review the missing data the patient may smile, but as the poll shows, they know poor organization when they see it.  When seeing a patient in the hospital review the record before questioning the patient.  It is reassuring to patients to have a provider review the information in the record with them and ask “is that correct?”
  • From the American health care system standpoint:  other countries do a better job of reducing health care data fragmentation.  In England there is a system wide (NHS) computerized medical record.  In France each patient has a smart card that contains the medical and billing record.  Nobody knows for sure what the current cost of data fragmentation might be but it is certainly huge.   Perpetuating an inefficient system wastes money and talent.

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Excessive Waiting – You call that a schedule?

35% had to wait for an appointment with a doctor longer than thought reasonable.  Scheduling services is a difficult task in any business.  Restaurants have numerous employees that have to be scheduled in the face of day to day changes in business and generally do quite well.  Airlines schedule flight crews, aircraft and thousands of passengers every day with remarkable success.  However, a health care facility that runs on schedule is quite unusual.  The providers feel so much is unexpected they can’t follow a tight schedule (but on paper they create a tight schedule).  There are many reasons for this phenomenon but no excuse.  Schedulers can be tasked to optimize provider time or patient time and usually the former wins.

  • For patients:  a primary care clinic should be able to see a patient with an urgent problem the same day, a bothersome problem within a few days and all patients who request within a week.  If that is not what you find then check out other clinics.  Be willing to see any one of the provider team for urgent problems.
  • For providers:  constantly monitor the delay between appointment time and provider appearance time and adjust the master schedule accordingly.  Providers should work as a team.  A pool of providers needs to have open slots for urgent visits and other providers need to have uninterrupted time for scheduled visits.  The future is with patient self-scheduling, like booking a seat on an airplane – check what is available and book a time slot on the Internet with no phone calls!

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Poor Coordination of Care – Who is in charge?

23% of sick Americans felt  “no one doctor understood or kept track of all the different aspects of their medical issues.”  At present there is only one solution.  The patient needs to keep a notebook of information about their health.  This should include an up to date health history, medications, allergies,copies of significant tests, x-ray reports and lab tests.  After office visits ask for copies of results and after hospitalizations ask for copies of the discharge summary for the notebook.  The impediments to sharing of information are tremendous:

  • No nation-wide patient identification number
  • No common way to store health information
  • No way to search all sources of health data
  • Patients moving or changing doctors or changing health systems
  • Name changes, identity theft, undocumented aliens
  • Poor communication to and from a primary care providers
  • Lack of pharmacy integration into databases
  • Strict privacy rules
  • Separation of outpatient and inpatient providers

Nobody knows who to trust with their health information.  If such a trusted place for information could be found then American’s health information could be electronically stored there with access controlled by the patient.  This probably will not happen soon so patients should:

  • keep a health information notebook
  • get a primary care provider
  • try to stay in a health system that has a good information system
  • support the idea of trusted regional or statewide health information systems

Health care mergers and acquisitions are increasing but the merging of information systems sometimes does not follow.  Perhaps such joining of health care systems should have legal requirements to merge the patient data systems as well.

Despite the dim hope of information sharing on a large scale there are things providers can do.

  • Give patients copies of important medical information either on paper or electronically
  • Always send information to the patient’s designated primary care provider.
  • Always give the patient an updated list of medications they should be taking, not just the medications prescribed that day.
  • Encourage the patient to bring the medication list to every health care encounter.
  • Make it clear to the patient who is in charge at all times.  Hand-off of care means a positive, certain, provider to provider communication and not just a whisper in the wind.
  • Make it easy for other providers to contact you.

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Inadequate Face Time – 5 minutes is not enough

Nearly 7 in 10 Americans want their doctor to spend more time with them and talk about more than just the problem at hand.  No doubt 5 minutes is not enough time for a health care visit.  Remember, just like the taxi driver, the meter is running.  Both providers and patients need to be better prepared for a visit.

  • On the provider side all data should be reviewed before the visit – not during the visit.  And, the least expensive provider should be engaged, based the nature of the visit.  Simple problems (e.g. well baby checks, blood pressure checks, and acne) should be addressed by physician assistants or nurses. Health care literacy needs to be assessed — some groups need a lot of attention by a nurse, some groups should be getting information from the Internet — giving the patient an Internet link for education saves time.  If the provider’s skill is well matched to the problem more time is available for the visit itself.  The provider should always ask “any other questions?”
  • On the patient side any patient should come to a provider visit with a written list of just 3 issues they want  to be addressed then check them off as a response is obtained.  For example:  1) my cough 2)my knee pain and 3) any less costly alternatives to my current medications.  A person should think about the issues and look in a book or on the Internet before the visit to be able to ask reasonable questions.  A visit to a surgeon is a little different.  It is always focused a single problem and the surgery to fix the problem.  The three issues usually are 1) the chance surgery will fix the problem 2) the reasonable alternatives and 3) what will the surgeon do to prevent complications (a good answer is to follow hospital protocols and use a surgical safety checklist).
  • Visits need to be on time and on task.
  • Patients are more satisfied with a provider visit if there is “discussion of broader health issues” as the poll indicates.  This finding corresponds to other work indicating America has a large problem with health literacy.  People need reliable health information and they certainly don’t get it on TV (“miracle ___ cure”, ”ask your doctor if you need ___”)

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Lack of Access to Care – The Wallet Biopsy

One of the most telling statistics comes from the 516 people who were sick enough to be hospitalized overnight but did not have insurance at some time during the year.  40% did not get the care they thought they needed compared to 10% for those with insurance.

  • The well insured:  Access is usually not a problem.  But, if the patient does not have an established place for care before an illness it may be difficult to get a timely appointment for evaluation or hospital follow up.  Some patients with Medicare will run into the “our practice is not taking any more Medicare patients at this time”.
  • The under-insured:  Major health issues are usually resolved.  But, not having the money for the expensive drugs prescribed at hospital discharge is a problem.  Not being able to find an outpatient healthcare provider when covered by Medicaid (title 19) is a huge problem if no provider was established prior to a hospitalization (your appointment might be in 6 months).  High dollar deductibles and lack of drug coverage can overwhelm someone on a tight budget.
  • The uninsured:  Serious issues are usually resolved at the hospital.  For example, some uninsured pregnant women show up at the hospital just hours before delivery.  The babies are delivered but with more complications since they did not get prenatal care.   Uninsured care generates a huge debt which is often not paid directly.  The debt is offset by cost shifting to insured programs.  (In political terms this is often called “the safety net”)  When a person is making an appointment and the scheduler asks “what insurance do you have?” the answer “none” will often not lead to an appointment.  Most health care providers and pharmacies have an astronomical fee for someone paying cash.  The high fees originated back in the old days of “usual and customary charge” paid by insurance companies.  Now the tables have turned — the insurance company dictates what they will pay, which is not what the hospital or doctor charges.  Unfortunately, the uninsured will be expected to  pay more than Medicare, more than insurance companies and more than Medicaid.


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High Cost of Care – Bad and Getting Worse

Four in ten Americans report that within a year illness caused a severe family financial problem.  Americans obviously have not solved the problem of rising health care cost.  During the past 50 years insurance seemed like the answer.  If insurance premiums were the same as 20 years ago who would complain? The situation has changed.  Now some can not afford insurance and almost no one can afford the cost of catastrophic illness. Businesses that provide insurance to employees are strained, so insurance  deductible levels are higher.   Pooled risk (insurance) has concealed the lack of health care cost control for a long time — hindsight is great.  Now we wish we had paid more attention.

According to the Kaiser Family Foundation  31% of the healthcare dollar is spent on hospital care and 20% on physician and clinical services.  Furthermore, major drivers of health care cost are:

  • Technology and prescription drugs
  • Rise in chronic diseases
  • Administrative costs (currently 6% for medicare and 30% for private insurance)

The “where” we spend more money and “why” we spend more money are interesting facts but do sick people feel a lot better as a result?. America spent $2.6 trillion in 2010 but the “Sick in America Poll” very clearly shows dissatisfaction.  The World Health Organization ranks U.S. health care at number 37 just after Costa Rica.  In simple language, Americans are not getting a good bang for the buck.  The phrase “drivers of health care cost” might be associated with the image of someone driving a car, following a map and getting good mileage.  Erase that image.  Replace the word drivers with “culprits” to get the right picture.  We spend too much for technology and prescription drugs, we spend too much on chronic disease and we spend too much on administrative cost.  The philosophy of each category needs to change to help solve the financial problems:

  • Technology and prescription drugs:  the current philosophy is “safe and effective”, the new philosophy needs to be “safe and cost effective”
  • Chronic disease:  the current philosophy is treat the same as acute disease, the new philosophy is prevent, treat early, follow-up to prevent progression.  Also, exercise more, eat less sugar and remove nicotine from all products.
  • Administrative costs:  the current philosophy is to “manage complexity”, the new philosophy needs to be “keep it simple”.  Reasonable efficiency demands 94% of premiums for all public and private insurance should be used to pay for care.   By some estimates 30% of all health care cost is related to “paperwork”.

The current US health system is perfectly designed to deliver high cost low quality care with an ocean of paperwork.  What a mess.  Fortunately, there are islands in the paperwork ocean where low cost high quality care is delivered.   There is hope. 

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