qualityhealthcareplease

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Prescription Refill — a snarl of patient frustration

Patients dearly hate the hassle of requesting refills on medication prescriptions. Why?

  • The prescriber’s office takes days or weeks to respond (low priority).
  • The prescriber’s office requires an office visit, but can’t make an appointment until next month.
  • The patient fears running out of needed medication for asthma or migraine headaches or diarrhea.
  • The prescription has expired or did not have the expected refills.
  • A new insurance plan started
  • The insurance plan calculated the patient still had a day left on the previous refill and says to wait. (patient has something to do tomorrow besides rush to the pharmacy).
  • The person who answers the phone at the prescriber’s office can’t refill low-risk medications. So, a message is left for the physician who is out of the office and back-up physicians don’t do refills.
  • The prescriber’s office says to call the pharmacy while the pharmacy says to call the prescriber’s office.
  • The unnecessary visit to the ER just to get a refill.

It’s so easy for prescriptions to become “out of sync” with prescriber office visits. A cancelled appointment, a doctor’s vacation, a visit for an inter-current illness (a walk-in visit), an “as needed” medication that the prescriber forgot to re-prescribe at the last office visit etc. etc.

The pharmacy is also to blame by ridiculously refusing refills within a few days of running out of medication. And, waiting until the patient shows up at the window to say, “looks like the med is out of stock.”

It’s amazing more patients don’t require a mental health visit after trying to get refills.

According to a 2012 study only a third of primary care practices had a formal renewal policy. The big advantage for patients is quick turn-around for non-hazardous medications (like thyroid or asthma meds). Within the practice the amount of “churn” was less (fewer internal messages and delays). Plus, with a formal policy 100% of the patient charts were checked to verify the medication, allergies, last appointment etc. Another article actually listed medications safe for refill.

Solutions:

  • Give your prescriber a copy of the 2012 study
  • When ever you receive a prescription ask “how many refills and how often?” And, ask for 90 day supplies to minimize refills.
  • Keep a list of when each prescription will run out. Check it frequently and call the prescriber two weeks before the med is needed.
  • Ask your pharmacist if they have “grace” days which allow refills within a week of prescription expiration (use those pharmacies)
  • Know the difference between a refill (an existing prescription with active refills) and a renewal (a new prescription for the same medication)
  • Respect the guideline for prescribers to see patients at least once a year when a patient is taking medications. Keep up to date.
  • When a medication is taken “as needed” or PRN don’t hesitate to make an office visit to clarify when to stop taking or when to change the dose.
  • If a pharmacy is out of stock of a medication ask the pharmacy to transfer the prescription to another one that has the medication.
  • Always call the pharmacy before picking up a new medication to make sure they have it and that insurance will pay for it.
  • When you pick up medications don’t walk away from the pharmacy counter without looking at the medication and label to make sure it’s the right prescription (not some old one with the wrong dose). Pharmacies will not take medications back if you leave the store.
  • If you are notified your prescriber is leaving, check you prescriptions and call the office if you will run out of medications in a few months. Immediately make an appointment with someone new and have copies of your records transferred. Sometimes new appointments must wait for several months.
  • Your prescriber is responsible to maintain and monitor prescriptions — NOT the pharmacist and NOT the insurance company. If the prescriber’s office is not up to the task dump them and give them bad marks on Healthgrades.

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Tiers of U.S. Healthcare

A recent U.S. presidential-candidate debate included proposals on Medicare-for-all, care for illegal immigrants and private insurance: supposedly a three tier system. Exactly which existing tiers would be removed, which would be funded and how would the budget for care work?

Consider the layer cake of U.S. healthcare, as it exists. Start at the top where little figures of a bride and groom might stand. That is the highly-privileged care provided to members of Congress and many government employees (“Cadillac” health plans with a large percent government subsidized plus pre-tax perks). That insurance provides good care (not as good as the care in the French system, but pretty good).

The next tier is the “CEO” or “rich guy” healthcare. They have so much money they don’t need insurance. They just buy what they want at big name hospitals with private suites staffed by nicely dressed doctors in suits and young nurses with little pointed hats. The motto is “whatever you want”. CT scans of everything happen at least once a year and heart tests proceed just because “you can’t be too careful”. And, heavens, the food you like is on your diet. Rating of care: poor.

The next tier is a hodgepodge of layers or “options” offered by many insurance companies like Blue Cross, UnitedHealthcare, Aetna etc. These are mostly provided through an employer group plan. And, sometimes purchased individually at a higher cost if the person is part-time or retired before age 65. Some plans have high deductibles and high co-pays that financially make care difficult to obtain. Some closed panels of providers limit where a person can obtain care and limit the options for moving or travel. The insurance companies scrape off 15% of the icing (administrative fees). Rating of care: fair to good.

Next is the Medicare tier divided into several layers including Medicare with a supplement (fee-for-service) and Medicare Advantage (per-capita). Rating of care is good with a plus for lower cost compared to the higher layers. Unfortunately, Medicare does not negotiate drug prices according to laws supported by drug companies. Rating of care: good.

Next are decorations of socialized medicine. These include the Veterans Administration, Indian Health Service and various levels of military healthcare (Tricare). Rating of care: good.

Next is Medicaid. A State run and federally supported insurance for the poor. It is limited by budgets and willing providers. Rating of care: fair if you qualify, but many who need care don’t qualify for a variety of reasons.

Finally, the bottom layer. The layer for those with no insurance and no funds. All States require emergency rooms to provide care to “stabilize” a mental or physical illness. Anyone can obtain health care in the U.S. based on this nearly insane model where people wait until they are really sick to receive care in the most expensive setting. The bills, which none in this layer can pay, are astronomical and serve only to further bankrupt the unfortunate. Rating of care: poor with no connection to a primary care provider or mental health follow-up.

In conclusion, the recent superficial debate about healthcare seems to hinge on hot-button issues like rich insurance companies, greedy drug companies and desperate immigrants who become sick. Of course healthcare costs money — only a politician would say otherwise. The healthcare system we have or will have is exactly what we plan.

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Medicare For All — what does that mean?

Bernie Sanders popularized the idea of US national healthcare during his 2016 campaign. He described the idea as “Medicare For All”. That was a genius idea since most Americans have a family member with that program for seniors. In fact, with its 44 million participants it represents a very large, although incomplete, national healthcare program. It is very popular among seniors since it reduces insurance premiums dramatically.

There are two major versions of Medicare: Standard and Advantage.

Medicare Standard

  1. It sets the allowed price for hospital and medical provider services
  2. It pays 80% of the “allowed” price leaving 20% for the individual or a “medical supplement”.

Medicare Advantage

  1. Limits participants to one insurance company or organization
  2. Has lower premiums
  3. Wraps Medicare and a supplement together

What about Medicare For All

  1. What about premiums or supplements or services? (the specifics need to be chosen, not guessed at.) It’s like a dream house, but without a drawing or a list of deliverables.

The Choices

This is really the nuts and bolts of a national plan no matter what you call it. And, if the current providers sense they will make less money, the self-serving complaints will be very loud. Who will complain if patients don’t get a better deal — not very many people. That’s because not very many people understand healthcare. So, what do you as a consumer want?

☐ Same old insurance, high drug prices and poor quality
☐ Premiums paid via payroll deduction
☐ Premiums paid via annual income tax
☐ Allow supplemental insurance for non-covered items (like plastic surgery or special drugs)
☐   Profits for drug companies limited to 5%

All covered medications available for $10/month
☐ All approved hospital days available for $400/day

☐ Out of pocket annual expenses limited to $5000/year
☐ Approved child medical care is free
☐  0.5% of premiums for research
☐ Regional claim processing (by current insurance carriers, limited to 5% profit)
☐ Limited list of available medications, generics are required where available, brand name drugs are selected by the plan
☐ 30% of provider payments linked to quality and quantity measurements
☐ Medical school tuition paid in exchange for 5 years of service in designated (poorly served) areas
☐ Mental health service included same as other health care (includes PhD psychologists)
☐ Maternity care, including midwife care at home when safe

☐ Primary care provider available for all persons
☐ Physicians and surgeons are salaried (not paid by number of services)
☐ Same day service for urgent problems
☐ Clinics open nights and weekends
☐ Massive increase in numbers of physician assistants and nurse practitioners with tuition paid in exchange for service

☐ Video visits with providers via Internet if desired
☐ Hospitals paid according to diagnosis (DRGs)
☐ Regional specialty hospitals (5% for growth and development)
☐ Local general hospitals
(5% for growth and development)
☐ Providers all use the same secure medical record
☐ Annual adjustment of payment levels based on a budget

☐ Ongoing and up-to-date quality measurements on all services
No need for malpractice suits — immediate compensation for injuries instead
☐ Strong quality system capable of sanctioning administrators and providers (important!! may need lawyers here)

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Privatize the VA? Pay more for less.

free-vector-veterans-administration_089530_Veterans_Administration

Should the US privatize the Veterans Administration hospitals and clinics?  Let’s put the assumptions in the question on the table:

  • Bureaucracy is bad
  • US health care is good
  • The US is in continuous war
  • Treating the wounded is too expensive

This blog is about healthcare, not geopolitics, yet the temptation to see war as a disease is difficult ignore.  Let’s not go there.  Instead, compare the VA system with the proposed replacement.

VA Healthcare Private US Healthcare
  • Lower drug prices due to negotiation by the system
  • Expertise with PTSD, alcoholism, tobaccoism, drug addiction, low income, amputations and poor literacy.
  • Group sessions with people having a military background
  • Funding is always in doubt
  • Managed as a system, although management is only fair.
  • World healthcare rank is unknown, but is likely better than the US as a whole.
  • High drug prices due to lack of negotiation at the system level
  • Primary care is unequipped to deal with social and psychiatric problems (not in the usual five-minute visit that is profitable)
  • Group treatments with people who might dislike the military.
  • No limits on costs and profits
  • Highly influenced by the biggest lobbying efforts in the US
  • Not managed as a system
  • World healthcare rank is 26th.

Would a veteran actually want private healthcare?  Perhaps veterans living a long distance from a VA facility would choose private care.  But, if VA facilities are close who would want to enter a private system that is hugely expensive, not focused on war injuries, poorly managed, and has low quality ratings?

The real answer to the initial question is that private US healthcare needs to improve tremendously.  If and when that happens then the need for the VA would naturally disappear.  And, by the way, less war would help.

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US Healthcare — a foolish consistency

foolishconsistency

Ralph Waldo Emerson is not usually associated with healthcare.  However, his famous quote about consistency may apply.  The US healthcare system seems to be quite consistent, in a bad way.

The Perspective section of the September 7, 2017 edition of the New England Journal of Medicine featured an opinion article by Eric Schneider and David Squires.  The essence of the article is to point out the US healthcare system has a lot of potential, receives lots of money, discovers great treatments and has some institutions that really deliver good care.  The authors suggest with a change in focus US healthcare could be number one in the world.  Yet, it is not.  And, it maintains a poor rating CONSISTENTLY.

The authors state key strategies for improving healthcare:

  1. Timely access to care (preventive, acute and chronic)
  2. Delivery of evidence-based and appropriate care services.

They note several things that stand in the way of delivering care of any type:

  1. Cost of care (US is number one)
  2. Administrative burden (US is number one)
  3. Disparities in the delivery of care (US rates very high)

In any large US city the profusion of stand-alone emergency rooms is testament to the failed notion of high-cost rescue treatment rather than low-cost prevention or ongoing monitoring and early intervention.   The US tends to invest in high-cost drugs, treatments and surgeries and under-invests in primary care and social services.  The failure to adjust the focus of healthcare efforts has become a financial train wreck.

The authors of the above article present four prescriptions for US healthcare:

  1. Improve access to care
  2. Increase investment in primary care
  3. Reduce the administrative burden
  4. Make healthcare more equitable, so all people can receive good healthcare

However, those lofty goals require something else.  The US must stop the foolish consistency of accepting poor health care, of paying too much for healthcare and believing great inventions automatically lead to great healthcare.

Perhaps the Emerson quote is too painful.  An Albert Einstein quote may be better:

“The world we have created is a product of our thinking;  it cannot  be changed without changing our thinking.”

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Physician Shortage — no end in sight


The above chart is from data just released from the National Resident Matching Program.  This is about doctors who completed medical school and now according to their preferences are matched with training programs in various specialties.  This is for the first year of residency, but it should be noted physicians may branch out to other specialties later in training.  Internal medicine is a good example since those physicians branch out to later be general internists, hospitalists, cardiologists, pulmonologists, gastroenterologists, diabetologists, and nephrologists among others.

The point of this chart is to show how the shortfall in US physicians is being filled by foreign physicians.   The foreign physicians are good doctors, in fact, some of the best in the countries they come from.

The obvious question is WHAT IS WRONG WITH THE US PHYSICIAN TRAINING PROGRAM?  It obviously is not keeping up with demand.  Thousands of US students desperately want to go to medical school, but there is no place for them.  Certainly, cost is a definite issue — many who would like to go to medical school just can’t secure the funding or don’t want to go into debt for hundreds of thousands of dollars.  So, the inadequacy of US medical training is resolved from afar.

Other countries, like the UK, solve this problem by offering aspiring doctors the funds to go to medical school in exchange for becoming a specified type of doctor and practicing (for a number of years) in a specified location.  It seems to work.

Attracting good doctors from other parts of the world sounds attractive but it’s not so nice for those other countries losing the doctors.  The US has a significant physician shortage which is getting worse.  Since the US does not have a healthcare system it is not possible to respond to the shortage.  The free market system fills the lucrative specialties in the nice locations leaving the non-urban communities to go without or hopefully attract a foreign medical doctor.  In many rural communities there are no US trained physicians.

US healthcare quality is at the bottom of industrialized countries.   Access to healthcare declines in large part due to a shortage of providers.  Since there is no organized healthcare system no resolution is in sight.  It’s staggering to realize even Cuba has more doctors per capita than the US.  The discussion and legislation so hotly debated currently seems oblivious to the shortage of physicians for which insurance is no solution.

 

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Healthcare Standstill — poor prognosis

So, what’s the problem with US healthcare?  What’s the fix?  What’s the medication for the ailing health system?

Start over.  Begin again.  Throw out the mess.

Usually, complicated problems are solved incrementally by finding each small problem and fixing each one until the huge problem is resolved.  This approach has failed healthcare in the United States.  The evidence is overwhelming.

  • rising cost
  • declining health
  • inability to train enough workers
  • high infant mortality
  • inability to control drug costs
  • focus on cost instead of health
  • fragmented improvement efforts

THE UNDERLYING PROBLEM IS THE US DOES NOT HAVE A HEALTHCARE SYSTEM:  NO SYSTEM TO CORRECT, NO SYSTEM TO MEASURE, NO GOALS TO MEET, NOBODY WHO IS ACCOUNTABLE.

The measure of a healthcare system is an average.  It’s not whether one guy is cured from leukemia but whether the average baby survives, the average citizen can get a doctor appointment, can purchase medications, and can have surgery if needed.

Sadly, if you are a legislator every problem looks like a financial problem — you can pay more or pay less.  You tried the first option so now you want to try the second option.

Supply and demand economics does work  But, it just has to be applied the correct way.  If the salary paid to a lawmaker is dependent on improving health in the country then the economic theory would work fine.  It does not work fine when complicated treatments are marketed to a population with low health literacy (and that includes the President and Congress past and present).

The reason Medicare-for-all seems so appealing is because it is a system.  Perhaps it’s not as good as the systems in other countries, but it’s the system we know.  It’s time to stop complaining about cost and complexity.  DO SOMETHING and KEEP IT SIMPLE.

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