Archive for June, 2015

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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