Archive for June, 2013

Hospital Re-Admissions — the revolving door

revolving door

Hospitals have ignored the obvious problem of patients returning to the hospital soon after discharge.   Decades of re-admissions have enriched hospitals — same charges over and over.  Now re-admissions for heart attacks, heart failure and pneumonia lead to Medicare penalties.  The problem is widespread and as always worse in some parts of the country.

Pneumonia Readmissions

The above graph comes from a an excellent Medicare study.  It show a high rate of re-admission after pneumonia in some areas (dark blue).  It should come as no surprise that some hospitals have been able to quickly drop the re-admission rate by 20% (because they were not trying very hard before).

Why did hospitals not care?

  • Re-admissions were profitable
  • Avoiding re-admission was considered an outpatient problem
  • It was the patient’s fault for not taking the medications they were prescribed at discharge (no matter what the cost).
  • Hospitals have no control over outpatient doctors.

What changed?

  • Dr. Donald Berwick cared.  He was the administrator of Medicare who initiated the penalties.
  • Hospitals purchased doctor practices — so now they really do control the outpatient doctors and thus assume a greater responsibility.
    •  Over 75% of cardiologists work for hospital systems
    • Over 50% of primary care work for hospital systems
    • Many health systems operate visiting nurse services.
  • Hospitals have no excuse for failing connecting discharged patients with primary care (they own primary care)
  • Hospitals have no excuse for failing to engage patients in heart failure clinics (they own cardiology).
  • Hospitals must take an interest in what medications are prescribed at discharge — the right medications and generic medications if possible.

What can patients do to cut the odds of re-admission?  According to a report by Jason Kane of PBS there are 7 things a patient can do:

  1. Work with the hospital to plan ahead (days before discharge)
  2. Understand your illness and ask questions about your health care
  3. Have a written discharge plan
  4. Understand your medications
  5. Don’t go it alone
  6. Follow through with follow-up care
  7. Find out how good the care is in your community for patients leaving the hospital.

A word of caution:  just because you have been re-admitted, it does not mean you need to be on hospice care — indeed that will stop re-admissions but perhaps not the way you want (dead patients don’t return).

Your ace in the hole:  strong primary care.  The hospital team MUST communicate with primary care — make sure they do.  A quick follow-up appointment and several short interval appointments will help to get back on track with the management of chronic illnesses.  If you were just in the hospital for a heart attack, congestive heart failure or pneumonia (or other chronic conditions) an appointment in 6 months is totally inappropriate.

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Clinic Pharmacist — great idea

Pharamcist pictureWow — a pharmacist called me before a visit with a new doctor to review my medications.  What a great idea.

This clinic has a pharmacist on staff to discuss medication issues with patients.  And, that pharmacist calls all new patients to review ongoing medications, record them in the medical record and make recommendations that the new doctor will review at the upcoming visit.   Recommendations like problems with drug interactions, newly available generics, less expensive alternatives and contraindications.

That same pharmacist arranges refills and responds to drug questions on the clinic Internet Portal.

What a great service.  Discussion of medications by physicians is usually too brief.  And, any input from the pharmacist is usually after the fact so physicians are not too happy to call the patient and admit a problem with prescriptions they just wrote.

Sometimes great ideas just need a SHOUT-OUT. This idea is super — an actual partnership between a prescriber and a pharmacist.

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Drug Side Effects — could it be the medication?

Dino xing

 The physician who does not carry a smart phone to look up drug side effects is a dinosaur soon to be extinct.

Drug side effects can be common, rare,  severe or mild.  But, the number of reported drug side effects is so large the human brain can not remember them all.  When a patient has a symptom or abnormal lab finding it is imperative to answer the question “could it be the medication?”  An additional step is to check for drug interactions between all the medications a patient takes — easy on a smart phone or computer.

Prescribers may recall the side effects that were listed when a drug first went on the market — but quietly pharmaceutical companies discover more side effects which are later added to the product literature in fine print.

Here are some real life examples:

  • A patient who takes several blood pressure medications is hospitalized with another episode of abdominal pain due to pancreatitis.  $10,000 worth of tests find no cause.  The patient is sent home and told it must have been due to a gall stone that passed undetected.    WRONG — it was due to the side effects of the blood pressure medications.  Medications changed, problem solved.
  • A patient takes a new oral anticoagulant and needs a heart procedure.  The blood test shows a low platelet count.  $10,000 worth of tests give no clue.  A bone marrow biopsy is proposed.  WRONG –The patient finds an internet site shows the new drug may cause a low platelet count.  No bone marrow test is needed.  Medication changed, problem solved.
  • A patient gets sunburned easily and friends comment on a suntan even in the winter.  The medical diagnosis:  fair skin.  WRONG — the blood pressure medication causes photosensitivity.  Medication  changed, problem solved.

No matter whether the drug side effect is rare or common, if it happens to you it is 100%.   Pharmaceutical companies rate the frequency of certain side effects.  Indeed, this is helpful to health care providers — they figure out a diagnosis by mentally sifting through possibilities based on likelihood.   Right lower abdominal pain is most likely appendicitis but surgeons well know there are other causes.

From a patient standpoint sometimes it is enough just to know that a drug could possibly be the cause of symptoms.  If those symptoms start right after a drug was prescribed it does not take a rocket surgeon to figure out the problem.

Drug side effects are not behind every symptom.  Such thinking could be very dangerous.  To hesitate to see a doctor about chest pain because it could just be a drug side effect would be crazy.   Also, there are unavoidable side effects — you might not like the side effects of a medication but sometimes there is no alternative (like medications to prevent organ transplant rejection).

The proactive patient should always check for possible side effects of their medications and discuss the findings that match symptoms with a health care provider.   Just searching the drug name and “side effects”  almost always gets the list you need.  Another source is patient reported side effects.  Several web sites are available — this one is sometimes helpful eHealth.me

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The $9,000 Colonoscopy — lighting the way for profit

TheScopesOnYou (4)

$3,500 is the amount US insurance companies pay  for a screening colonoscopy that takes 30 minutes.   In some states a $9,000 charge is routine.  In the country of  Switzerland the cost is $655 using the same techniques and the same scope from Japan.  This sad story of price gouging was reported in detail by the New York Times on Sunday June 2, 2013.

Key points about high charges from the Times’ article include:

  • Adding charges for an unnecessary anesthesiologist
  • Adding facility fees by calling colonoscopy a surgery
  • Adding huge fees for biopsies that take only minutes
  • Repeating colonoscopy too frequently

If it was just colonoscopy that was the cause of the problems with high cost in the US  it would be an easy fix.  But, the pattern of prices having no basis in actual cost is a systemic problem of huge proportions.

In other walks of life people would not tolerate the abuse.  We would complain bitterly if a garage mechanic charged for someone to hold his light, or added a fee to use the garage space,  or tacked on a charge to check tire pressure  or wanted to recheck the muffler every 3 months.

Why do people tolerate unreasonably high medical prices?  Because people do not understand health care.  Because insurance shields them from the need to understand.  And, because we think 10 years of training is needed to do many procedures, which is absolutely not true.

Surgeons and gastroenterologists study many things but if colonoscopy was separated out, the total training time for that procedure itself  is probably only a few months.  A trained physician assistant or nurse practitioner could easily do a screening colonoscopy at much lower cost and with equal safety.  The manpower drain from gastroenterology to do screening colonoscopy  is astounding and the only reason they do it is the high reimbursement.

Keep in mind, it is not people causing the problem.  The fault is with the warped system of care and reimbursement we have devised.

To fix the problem the US system of payment must change to be more like other advanced countries.  That means  either the prices for procedures are set nationally (the French way) or large conglomerates of doctors and hospitals are paid to provide all necessary care to people on a per capita basis (the ACO way).

Numerous publications are reporting on the problems in our health care system.  The New York Times, The Wall Street Journal and Time Magazine have had lead articles on the subject.

The problem of high cost will need government action to make a significant change since no business is large enough to force the issue alone.   It is easy to be pessimistic — but, there is a tipping point coming.  When consumers realize lower-cost  higher-quality health care is possible they will want it.

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