Archive for December, 2014

Cruise Ships and Illness — it’s not a hospital

helocopterIf you are really sick in the middle of the Pacific Ocean on a cruise ship the treatment options are limited.  The mid-Pacific is international water — there is no Coast Guard and there is no hospital helicopter to pick you up.  The ship can only go 20 – 30 mph so going somewhere in a hurry is just not possible.

The doctors on the ship do what they can and over the past 10 years shipboard medical capability has improved.  But, there is no CAT scanner, there is no cardiac catheterization laboratory and if you hit your head and get a hematoma on your brain you will probably die.  Remember, you are on a vacation ship, not a hospital ship!

When a person is seriously ill and near a port (75 miles) a helicopter pick-up is possible.  Or, when the ship is in port an ambulance pick-up is possible.  Then what?  If you are in a third-world country the hospital you go to might not be much better than the ship.  If you are stable enough you might be able to take an airline flight home.  Otherwise, you might hire a med-evacuation flight — but plan to spend $50,000 unless you have insurance to cover it.

If you are seriously ill you can not stay on a ship — once the ship docks you will be taken to the closest hospital — even in  Guatemala.

The number of elderly people on cruise ships is huge.  The big cruise ships carry between 2,000 to 8,000 passengers.  During almost every week-long cruise on one of those ships someone gets sick and is taken off the ship, usually at port.  And, every year several people die on cruise ships.

Medical care on a cruise ship is very expensive.  Medications are very expensive.  A cast placed on a broken arm is very expensive.  If you are quite elderly or have significant health problems you need travel insurance and med-evac insurance.  Or perhaps, just skip the cruise instead.  Remember, regular health insurance or Medicare will not pay for cruise ship medical care.

Cruise ship doctors usually have experience with diarrhea, dehydration, colds, pneumonia, urinary tract infections, sea-sickness, cuts, bruises and broken or dislocated extremities.  The ships all have communication equipment and doctors can contact specialists anywhere in the world.

Despite access to a world of medical information the ship has limited medications and no major surgical capability.  In some respects, there is no need to do complicated tests because there is not much that can be done!  Why do a brain scan if you can’t do brain surgery!

So, caveat emptor — buyer beware.

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Direct Primary Care — where’s the quality?

greedydoctorHappy doctors seeing fewer patients and making more money — what’s not to like?  According to author David Von Drehle’s article “Medicine Gets Personal” in Time Magazine, Dec 29/Jan 5, the results are “intriguing”.

The story is about Qliance Health in Seattle founded by two doctors who were dissatisfied with fee-for-service medicine and all the associated paperwork.  So, they developed a model of care where the patient pays $65/month and receives all the primary care they need.  And, as a twist, they also agree to see Medicaid patients for the same cash amount (the details of the arrangement were not stated in the article).  Of course, insurance and medicaid pay for all other services like tests, x-rays, drugs, hospitalizations and specialists.

The doctors are happy because they have less oversight from insurance, don’t have to collect any data to prove they are delivering quality care, get steady income, treat patients over the phone to minimize visits, and are able to “run” their own business with no boss.  For the libertarian-minded physician it’s nirvana.

Piece-work is indeed a hard life as physicians and many in the garment industry know.  A monthly salary is much easier on the worker.  And, the salary model is not new in terms of primary medical care.  The physicians working for the National Health Service (NHS) in the UK have had this system since WWII.  However, the NHS found it was necessary to add financial incentives to get the doctors to do enough work.  And, they found it necessary to monitor quality since quality slips without oversight.

So, this “Direct Primary Care” is not new in the world.  In fact, it may be an important part of an Accountable Care Organization (ACO) as being tried the US.  But, physicians need to realize they need to be part of a large organization to ensure quality care.  The future for primary care is to be an employee, not a mom-and-pop store.  Most of doctor’s patients work as employees, is that so bad?

$65 per month would be too much to pay for poor quality care (the cost of poor care is always too high!)  So what does “Direct Primary Care” need to do for patients and payers to be confident quality care is being delivered?

  1. Measure and report quality in a transparent way — like on the office website.  And, keep it updated.
  2. Deliver patient-centered care and prove it.  Survey patient’s expectations and record whether the expectations are met with office visits.
  3. Report quality indicators other doctors must do like for diabetes, hypertension and smoking.
  4. Report primary care specific indicators regarding the most common diagnoses — skin conditions, joint pains and respiratory infections.
  5. Take a financial stake in what is prescribed or ordered.  Pay some fraction of the cost of all medications prescribed and all tests ordered.  They need to have some “skin in the game”.  (So there is a connection to the larger world of health care cost — ordering a $1000 MRI scan for every ache and pain must have some consequence).

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Penalty for Failure to use EMR — CMS doing the right thing for patients


Physicians scoff at rules requiring them to use electronic records and now they must pay the penalty.

Melinda Beck reported in the Wall Street Journal 12/18/14 “Medicare to Cut Payments to Some Doctors, Hospitals”.  Of the 893,851 physicians in the US, Ms. Beck reports 257,000 will be fined 1% of their Medicare fees for failure to adequately use an electronic medical record.

For example, the technically challenged doctors have failed to use electronic prescriptions, favoring instead marginally-legible  hand-written prescriptions.  And, they undoubtedly harmed patients by not taking advantage of allergy and interaction checks that are part of electronic prescribing.

AMA president-elect Steven J. Stack is reported as saying he was “appalled” by the government action.  Every physician, obviously excluding Mr. Stack, was informed 5 years ago that fines would be imposed in 2014 by Medicare if physicians that bill Medicare fail to use electronic records in a meaningful way.

Why would a rational physician choose not to use an electronic record…?

  • Because North Korea might hack the system
  • Because the government told them to use an EMR (they give orders, not take them)
  • Because they will be retiring soon and won’t need to learn about computers (the real reason)
  • Because they will need to pay for a system to help patients
  • Because young physicians want the systems, older physicians say no to all this newfangled stuff.
  • Because a an electronic record might be used in court against them.

There you have it — a detailed explanation.  Appalling, don’t you agree?

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Global Health Care — an edX course

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So you think your health system is bad?  There are countries where doctors and nurses leave due to the risk of death (their own), countries where health care workers can’t make enough money to pay for their own hospital care, countries that don’t keep medical records, countries where doctors must see at least 100 patients per day and countries where a patient purchases the number of questions they want a doctor to ask — one question is typical — and at very low cost!

As the author of this blog I decided to try an online learning course from edX titled “Improving Global Health: Focusing on Quality and Safety” presented by faculty at Harvard.  Overall it is a good course.  I am sure everybody who takes the course finds different parts interesting depending on where they live and their background in health care quality and system organization.

Below are the things I found interesting from a US healthcare perspective:

  1. Errors and harm caused by health, especially in hospitals, is high everywhere.  The big categories are hospital acquired infections, adverse drug events, falls with injury, surgical complications, pressure ulcers and deep venous thrombosis.  Significant harm happens in about 10 to 15% of hospitalizations.  Errors in medical/surgical management are considered preventable.
  2. Countries have different standards of care.  And, countries have different legal systems.  The most interesting concept is to eliminate malpractice suits by having a compensation board and strong quality improvement.  Thus, patients get compensation much faster and the health care system improves to mitigate errors.  Accountability for errors becomes part of the quality improvement process, not the legal system.
  3. In most countries hospital and outpatient care seem to be in different silos, much to the detriment of patients who transition between the two.
  4. The PLAN-DO-STUDY-ACT cycle is critical to quality improvement.
  5. “If you can’t measure it, you can’t improve it“.  But, high tech and computerized methods are not always needed.  In low and middle income countries the use of simulated patients (in the US called secret shoppers) and text messaging questions by cell phone can collect hugely important data with a minimum of cost.
  6. Management practices of business in general are more effective than the business practices in healthcare.   The same principals apply and need to be followed.  For example, managers not meeting expectations need to be changed.  Just like measurements of healthcare quality there are measurements of business quality.  A culture of blame is a big problem.
  7. Patient-centered care is critically important.  There is a very strong statistical link between patients who feel their needs are being met and almost all other technical measures of quality.  Simply asking patients what they expect is a huge first step that is not being done my a majority of providers.  Dignity, respect and putting effort into meeting expectations is the essence of patient-centered care.  One measurement of patient-centered care is waiting time — waiting time for making an appointment, waiting time in an office, and waiting for surgery.
  8. Universal healthcare is highly desirable and some countries do a better job than others.  The key features are:  enrollment (signing up and getting a health card), universal coverage (the funds to pay for care — like insurance), and finally effective application of the coverage.  The last element is actually “quality” healthcare.  Having a health card is not enough.  Having insurance is not enough. Effective care is a combination of prevention (population-centered) and patient-centered care within the financial constraints of a system.
  9. Politics is present in all forms of health care.  But, the focus for patients, providers and the news media should be on the gap between care that is reasonably possible and care that is actually delivered.

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