Archive for category Coordination of care
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|
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.
Patient’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:
- 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.
- 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).
- 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.
- 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.
- 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.
- Required pre-operative examinations are performed by the surgeon or assigned physician assistants in a timely manner.
- The patient arrives at the ASC at the appointed time, no additional paperwork is needed.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- The patient fills out the satisfaction survey on paper or on-line.
- 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?
One ER visit is a red flag — more ER visits for the same problem become an example of poor quality health care.
Urinary difficulty is something older men don’t like to talk about. But, 1 in 10 men over the age of 70 will end up in the emergency room with urinary retention — an uncomfortable situation where they can not pass urine. Urologists are aware of this frequent problem — see the billboard story. It is a serious problem; in third world countries it may be fatal.
The usual cause is enlargement of the prostate preceded by symptoms of slow and frequent urination. Sometimes there are few symptoms until a painful inability to pass urine forces a rush to the emergency room.
The usual medical approach is to insert a tube (a catheter) into the bladder to relieve the pressure, start a medication to help urination, and 3 days later to remove the catheter. 50% of men can then pass urine adequately (for a while). The quality issue is that 50% have a recurrence within a week — so is another ER visit the answer?
A friend of this blogger landed in the ER a total of 4 times with urinary retention. Why is the ER the center of after-hours treatment for this problem — once identified as an issue why is the health care system making it a recurring emergency?
The solution is Urologists need to own the problem and provide adequate patient care 24 hours a day once a catheter is removed. Yes, own the problem, not turn off the phone and let the ER solve it. Does that mean the urologist must be at the clinic 24 hours a day? No, but there must be an arrangement for immediate care — no waiting in the ER, no ER charges, no secondary consultations. An arrangement with a 24 hour urgent care center may be enough but some back-up plan and patient education are essential.
The majority of men with urinary retention end up having a surgery to ream-out the prostate (TURP). According to healthcare-salaries.com a suburban US urologist makes $500k to $1M each year. This is another example of the decoupling of cost and quality caused by involving multiple providers with no common financial risk.
A proactive patient who has a catheter removed should ask the urologist “what is the plan if this does not work?” and “is there some alternative to the ER since you have already evaluated me?”. At least find out how to get in touch with the on-call urologist!
Snowbirds: watch out for high medical costs in Florida, Texas, Arizona and California. According to Elisabeth Rosenthal in the New York Times 2/1/15 “Patients Find Winter Havens Push Costs Up”. She points out providers in Florida are the worst offenders — the same place notorious for Medicare fraud!
Ms. Rosenthal highlights one patient from New York wintering in Florida who had a checkup for his pacemaker but did not have any new symptoms. Many in-office tests were ordered by the substitute cardiologist — tests the patient’s regular cardiologist said were unnecessary.
To be very blunt: cardiologists, and other providers, who order in-office tests make a lot of money from those tests. Many studies show providers who profit from tests do more tests than providers who don’t profit from tests. A medical license is not a license to take advantage of patients or Medicare — profit motivation seems to blind some providers to this distinction.
The lure of profit is made greater by a patient not having any new symptoms, not having any record of previous tests, and not having plans for follow-up visits. It is like the patient has a sticker pinned on their back: “TEST ME”. The choice for the cardiologist is simple: either pay the nurse to spend time getting out-of-town records OR make money by repeating tests. Make money, right!
- If you are on vacation and have a sudden health problem your best bet is an urgent care center. They can send you to a specialist, if needed.
- If you have health problems and will be spending several weeks or months away from home:
- Talk to you primary care provider: they may want you to call in and give a report on the phone (diabetes is a good example). If so, no office visit may be needed while away.
- Get enough medication to last the trip. Or, get prescriptions with refills at WalMart or Target and have the prescription transferred to a store near your winter location.
- Identify a doctor to see in your vacation area before you leave. Ask friends or other people who winter in the area for a recommendation. Call the distant provider office and get a FAX number so records can be sent.
- If your primary care provider thinks you need a health care visit while you are away then make an appointment and have your records sent before you leave home — also take a paper copy!
- If tests or surgery are recommended then call your regular doctor’s office to see if they agree.
- Give any provider you see your regular provider’s name, address, phone number and FAX number (a business card is good). Request that results of visits, tests or hospitalizations be faxed or sent to them — and make sure it happens. Fill out a release of information form while you are at the office or other facility.
Doctors have long complained they don’t get paid to solve problems over the phone. Now primary care providers (not specialists) can charge $40 per month for something called “Chronic Care Management.” (CCM)
If you have several long term and serious conditions like diabetes, congestive heart failure and chronic obstructive pulmonary disease then Medicare will pay $32 per month and you or your supplemental insurance will pay the rest for this service. Many supplemental insurance plans have deductibles and co-payments — so many, if not most patients will be paying an extra $8 per month.
Who actually does all the work? The office nurse. The doctor supervises the decision making.
You will have to sign a consent for CCM in order for the doctor to bill you each month, so it is important to know what to expect. Some doctor’s offices will make the service helpful but in other offices you may never know where the money is going.
If you can’t tell you are getting CCM then simply stop the service — revoke the consent with a letter “Dear Doctor, effective at the end of this month please stop “Chronic Care Management”. I will continue visits as usual.”
In general, CCM is a good thing. Here are some of the problems it solves: Without CCM many doctors just don’t take the time to coordinate services except as part of an office visit — if you go to the emergency room the primary care provider would not act on recommendations until you actually go for an office visit. If your visiting nurse suggests some course of action then you go for an office visit. If you want to see a specialist you first go for an office visit. If you get discharged from the hospital and need physical therapy you go for an office visit before it will be ordered. With CCM the doctor gets $40 per month to coordinate care without always going for a face-to-face visit.
The minimum requirement for the provider is to spend at least 20 minutes per month working on your case without seeing you in person. Here is a list of things providers of CCM are required to do (at no extra charge) and thus things you should expect:
- Transitional care management: meaning admission or discharge from some medical service or facility (like giving orders for physical therapy after hospital discharge or providing full medical records to a rehab facility)
- Supervision of home healthcare. The provider gives orders for home care with lists of medications, duration of treatment and goals of treatment.
- Hospice care supervision.
- Provide a limited number of end-stage renal disease services.
The provider must have 5 capabilities and use those capabilities as needed:
- Keep your records in a computer
- Create a care-plan — an outline of goals and actions the provider will follow to meet those goals. Like “keep blood sugars in control — by weekly phone contact”. The provider should give you a copy of the plan — it should be specific to you and not a standard form applicable to anyone.
- Provide phone access to talk to a someone associated with the office 24 hours per day (they should be able to look at your computer record). Provide office visits as needed (presumably same day for urgent problems and within a week for non-urgent problems)
- Facilitate transitions in care. Like provide prescriptions and orders for therapy after discharge from a hospital or providing medical information to specialists for each visit. Or, keeping orders for home oxygen up to date. Or, immediately sending outpatient medical records to the hospital where you are admitted.
- Coordinate care. This does not mean providing all care, it is not a wall around you. If you need to see a specialist the provider makes sure all your medical data is transmitted to that specialist and makes appointments for you. And, follows the instructions of the specialist (as medically reasonable). Engages therapy such as home visits by nurses, physical therapy, occupational therapy or social service. And, makes efforts to meet the care needs outlined by those therapy services (as medically reasonable).
CCM does not eliminate office visits but it makes sure loose ends are dealt with and it obligates the provider charging CCM fees to provide access to someone that can look at your chart 24 hours per day. It also means the ER can call the primary care provider office and get up-to-date medical information about you in an urgent situation.
Disclaimer: the rules and fees for this program are in a state of flux. What is true today may not be accurate tomorrow. So, discuss the meaning of CCM with your primary care provider. Give them a copy of this article as a place to start a discussion. Here are some additional helpful links: