Archive for August, 2012

Preventive Health — Just the Right Amount

Preventive health is like the story of the 3 bears.  Too much results in excessive testing, too little misses widespread problems.  Prevention needs to be studied by experts to get just the right amount.  Above all, prevention is aimed at diseases the health care system can actually improve for a large number of people.  The worst case scenario for prevention is to check everybody (huge cost) for an incurable rare disease (no benefit).

Diagnosis of a disease is different from prevention.  Prevention is what is done when things are otherwise OK.  If a person has a heart attack lots of tests and treatments may be needed — this is not prevention.  If a person is doing well and has a cholesterol level checked it is a preventive measure.  Checking the cholesterol level is intended to find a condition unknown to the person.  Furthermore, if high cholesterol is found there is a proven treatment which is beneficial to reduce heart attacks.

What are good preventive measures for Americans?   Research has lead to several conclusions which have been assembled by the US Preventive Services Task Force (USPSTF).   The recommendations are available on the Internet.  The recommendations are clear yet many people do not get the recommended preventive measures.  Sometimes it is just as simple as asking your health care provider a question about prevention and the problem is solved.  But, asking this type of question can cause anxiety.  Actors have a script and sometimes patients need a script also.  How do you ask a provider a question about something seen on the Internet.  Take your choice:

John Wayne:  “Listen doc, I hear an ultrasound is a mighty good idea.  You got a good reason to the contrary?”  (John puts his hand on his hip and smiles)

John Modern:  “Doctor, I was searching the Internet about disease prevention and found some government recommendations.  It looks like a previous smoker at my age should  get an ultrasound to check for aneurysms.  Do you think an ultrasound is a good idea? (John puts his hand on his insurance card and smiles).

Based on the recommendations from the USPSTF here are some very good questions.  Feel free to write your own script.

Man, age 65-75 who has smoked:  Should I have an abdominal ultrasound?
Adult:  At least once a year I drink 4-5 alcoholic drinks in a day, is that a problem?
Pregnant woman:  Do I have iron deficiency anemia?
Man age 45-79:  Should I be taking an aspirin a day?
Woman age 55-79: Should I be taking an aspirin a day?
Pregnant woman:  When should I have a urine culture?
Adult: Is my blood pressure OK?
Woman with family history of breast or ovarian cancer:  Should I have BRCA testing?
Older woman with family history of breast cancer but no problems with blood clots:  Should I be taking medicine to prevent breast cancer?
Woman, over 40:  Should I get a mammogram at least every 2 years?
Pregnant woman:  Can I get counseling about breast feeding?
Woman:  Should I get a pap smear at least every 3 years?
Women:  Should I be checked for Chlamydial infection?
Adult:  Should I have my cholesterol checked?
Adult age 50 or older:  How often should I be checked for colorectal cancer?
Child 6 mo to 5 years:  Should they be taking a fluoride supplement?
Adolescent:  Do you think my child could have depression?
Adult:  Do you think I might have depression?
Adult with BP over 135/80:  Do you think I might have diabetes?
Woman of childbearing age: Should I take a folic acid supplement?
Newborn:  Did my baby get eye medication against gonorrhea?
Women with multiple sex partners:  Should I have a test for gonorrhea?
Adult or child with high lipids:  Should I have instruction on a special diet?
Newborn:  Does my baby have good hearing?
Newborn:  Does my baby have sickle cell disease?
Pregnant woman:  Do I have hepatitis B?
Adolescents and Adults with risky sex behavior:  Do I have AIDS?
Newborn:  Does my baby have a thyroid problem?
Baby age 6 – 12 months:  Does my baby need iron supplements?
Adult:  Am I overweight and do I need counseling or behavior interventions?
Child:  Is my child overweight and do they need behavior interventions?
Woman age 60 or older:  When should I be checked for osteoporosis?
Newborn:  Has my baby been checked for PKU disease?
Pregnant woman:  When do I get checked for Rh incompatibility?
Person with sexually transmitted disease:  Can I get behavioral counseling?
Smoker:  What can be done to help me stop smoking?
Pregnant women:  Do I get checked for syphilis?
Person with risky sexual behavior:  When do I get checked for syphilis?
Child, age less than 5 yrs:  When should my child’s eyes be checked?

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The Rise of the Midlevel Provider

Several recent articles have commented on the shortage of physicians.  In particular, the Atlanta Journal-Constitution reported “The number of physicians in the U.S. grew from 737,764 in 1996 to 954,224 in 2008, a 29 percent increase, according to a 2011 American Medical Association report. But the number of physician assistants went from 29,161 to 73,893 and the number of nurse practitioners from 70,993 to 158,348 in the same period. That’s an increase of 153 percent and 123 percent, respectively.”

The US healthcare system is adjusting to the difficult and expensive problem of training new physicians (MD and DO) by training midlevel providers (nurse practitioners or physician assistants).  The midlevel providers must go to college and then have 2-3 years of additional training as opposed to the additional 7-10 years for physicians.

The midlevel providers are a welcome addition to the health care workforce.  They fit an interesting gap not well filled by physicians.  They provide more face to face time with patients, they provide excellent health care education for patients, they tend to follow evidence based guidelines more closely than physicians and they excell at routine type patient interactions.(see examples below).  Physicians will always have the advantage in diagnosis of illness and complex problem solving due to the nature and duration of their training (some claim this advantage fades as midlevel providers gain  experience in their area of practice over several years)

So, how should patients take advantage of the growing number of midlevel providers?  Seek providers (MD and DO) that are part of organizations that include midlevel providers in a ratio of about 1 – 2 midlevels to 1 MD or DO.  Look for a team approach to patient care where the midlevel providers do a lot of the routine visits but the MD and DO providers are on the front line for acute or new problems.  This type of a setting helps to improve access to care — better access hopefully means longer visits, better education and higher satisfaction.  If a patient calls a primary care provider’s office for an appointment with a new problem it should be with the MD or DO.  In the course of a routine visit if a problem clearly needs a specialist the midlevel should be able to make the referral just like an MD or DO.

Examples:

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Indigent Care and Accountable Care Organizations

Some Americans just don’t have access to health care.  That statement is hard to understand for many people.  Just get in the car and drive to your doctor’s office.  Or, if you don’t have a doctor where you live then move somewhere else!  People without money may not have a car and may live with relatives who don’t want to move.  It is reminiscent of what Marie Antoinette said about people who did not have bread “Let them eat cake”.

The majority of Americans do have access to health care so why worry about those who do not?  There are three reasons for concern; 1) we don’t like our fellow man to suffer  2) the care for people with poor access is terribly expensive once they do get medical attention.3) we have a system of care for the indigent which is very expensive and does not work well.  Poor people who live in the Mississippi Delta get health care like a third world country and sometimes not even that good.  In fact, a health care system copied from Iran is being used in Mississippi to try to improve access to care.

Just as an experiment, try to make an appointment with a doctor and say you don’t have insurance.  Voila, no appointment.  What if you have a sinus infection and can’t get an appointment with a health care provider?  You go to the emergency room.  Even though you have been admitted many times for heart failure you can’t get an appointment with a doctor so you run out of medication — back to the emergency room.  You have a growth on your breast but can’t get an appointment.  So when it smells bad you go to the emergency room.

One measure of poor quality preventive care and follow up care is the rate of emergency room visits and re-hospitalizations.  Some communities do very poorly by this measure.

When looking at the health care system as a whole providing good access to care is a way to save money.  But, in America we have lost track of those cost savings.  If a hospital, in good faith, tries to prevent readmissions for everyone, poor and rich, they lose income. The community benefits and taxpayers benefit but the organization controlling the situation is penalized.

There is some hope in the idea of an Accountable Care Organization (ACO).  That proposed system of care matches a population to an organization of hospitals and providers for care.  A certain amount is paid per person per year to the ACO (similar to insurance but without the middleman).  The ACO hospitals become overhead expense rather than cash cows and primary care providers that keep patients healthy are golden.  At least the incentives are aligned favorably for Americans but whether the idea will work is yet to be tested on a large scale.  If poor people are included in the ACO, access to care should be improved and cost may come down.  Additionally, an ACO can be held accountable for quality — since health care providers work for the ACO considerable pressure to deliver a quality product can be applied, especially if customers get to choose which ACO to join.

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