Archive for category Health care manpower

Annual Exam — not needed and may be harmful

wellnessexamDON’T GET AN ANNUAL EXAM.  The data are clear — see the recent article in the New England Journal of Medicine and the op-ed in the New York Times — perhaps you missed this counter-intuitive health advice?

aircraftmaintenanceMechanical devices need preventative maintenance.  The aircraft mechanic in the illustration prevents engine failure by checking and replacing parts before they go bad.  He knows the MTBF (mean time between failures) for the various engine components.  You would think this is how the human body works but THAT’S NOT TRUE.  You don’t take out an appendix like a spark plug just because they sometimes go bad — you fix it only when needed because surgery hurts and has complications.

One third of the US adult population get annual physical exams and primary care doctors spend 10% of office visits doing those exams.  Sound research shows the annual physical is not needed and worse yet, may be harmful because of false positives (tests that say something is wrong but later are proven wrong).  It’s the very essence of a false positive — an abnormal test in a healthy person!  You know where that leads:  “we need to do some additional tests or a biopsy” — just hope it’s not a brain biopsy.

The US healthcare system needs the wasted 10% of primary care time elsewhere.   It’s totally crazy — doctors doing unnecessary annual exams that clog up the appointment calendar and make it hard for people with actual  problems to get an appointment.  And, a large number of people have health problems who don’t see health care providers when they should (but that’s another story)!

Doctors like to do annual physicals — it’s nice to visit with patients and not have to make any hard decisions.  And, they make a lot of money doing the exams under the guise of “maintaining a relationship”.  But, the exams are not needed.

A proactive patient would make health care appointments as needed for the following:

  1. Annual flu shot
  2. Tetanus vaccination every 10 years.
  3. Cholesterol test every 5 years
  4. For women over 40 a pap smear every 3 years and a mammogram every 2 years.

Do you really need to have a health care provider tell you the following things, or is this list enough?

  1. DO keep weight in normal range (BMI below 25)
  2. DO walk 30 minutes every day
  3. DO wear seat belts
  4. Don’t use drugs or alcohol
  5. Don’t smoke
  6. DO Check blood pressure every year (automated checks are just fine)
  7. DO see a health care provider if you have a health problem.

Keep in mind this discussion is about an exam for nothing in particular — just a “check-up” — which you don’t need.  On the other hand, a patient needs visits with a health care provider to treat and monitor abnormal conditions.  You need routine visits to adjust blood pressure medications, to treat diabetes, to treat acne and to evaluate arthritis.

 

 

 

 

 

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Do Hospital Amenities Impact Quality Care?

Acccrystalchandelierording to a study at Johns Hopkins (2/1/15) improving hospital amenities improve patient satisfaction with the facility but otherwise do not improve satisfaction with care.  This is important for two reasons:

  1. Patients really can tell the difference — a crystal chandelier hanging in the hospital room does not make nursing care better!
  2. Patient satisfaction measurement is a powerful tool to assess medical care — if the patient’s expectations are met, it is likely good care is delivered.

The tremendous building boom for hospitals is strange given this bit of science  — are CEOs trying to improve quality by remodeling?   Now it seems clear CEOs should focus money and energy on improving hospital quality until the level of quality is very high then if there is money to spare consider improving the physical amenities.

Increasing the distance a nurse must walk to see patients results in decreasing nursing visits.  This seems simple enough, but the current trend in hospital remodeling is to eliminate rooms with multiple patients.  The trend reduces RN visits, increases the need for nursing assistants, increases hospital cost and may increase falls for elderly patients.

The hospital that looks like a nice hotel seems to be the desire of hospital CEOs.  This may be fine for obstetrics but may be wrong for geriatrics.   A multi-bed ward with 4 patients allows one nurse to check on 4 patients quickly.  4 times the number of nursing visits makes it much easier to prevent falls.  When nurses still wore those pointy white hats they had this figured out.

Progress marches on.  American health care quality is as low as many 3rd world countries but at least we have nice surroundings in which to suffer the complications.

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Fee for Counseling Service — another CPT code

cptwowWow, you could have had a CPT code and $60.  While fee-for-service is widely excoriated for excessive cost what is CMS doing?  They want primary care providers or someone to have another fee-for-service.  The fee is for “counseling” about lung cancer CT screening and “counseling” about weight loss.  Both things that are currently part of an office visit with no additional CPT code — just good patient care.

Both topics could easily be covered on YouTube in several languages but NO — lets do this the old fashioned way and spend a zillion dollars for each provider to reinvent the discussion each time.   CMS:  don’t be so lazy — make the patient education video and tell primary care providers the URL!  And, update the video every 6 months.

The bottom line:

  • Lung Cancer CT Screening:
    • Don’t do it if the patient can’t have surgery
    • Don’t do it until the patient has 30 pk yrs accumulated (number of packs per day times number of years)
    • Don’t do it if the patient is less than 55 or over 80 years old.
    • Don’t do it if the patient quit smoking more than 15 years ago.
  • Weight-loss counseling:
    • Say in a loud voice “you weigh too much” then say “eat less”.  (that was not so hard!)
    • Doctors have been doing this for decades without sustained  results.
    • There are 20,000 books about diets to loose weight without sustained results.
    • This is not going to work — at least be honest.

Follow the money:  

Counseling fees for CT scans is an incentive to do the CT scans.   The primary care provider makes money, the x-ray office makes money and the radiologist makes money.  A better idea is to have the radiology office pay the primary care provider for the counseling out of CT revenue so this is a no-sum-gain.  Better yet — make it a provided service under an ACO plan!

Counseling fees for intensive weight-loss is an incentive for lots of repeat visits or a referral.  The Primary care provider makes money (and changes from a primary care provider to a specialty provider).  The incentive reduces the pool of available visits for primary care with little if any benefit to the vast majority of obese people.  A better idea is not to add another CPT code.  If the patient needs more time — make another appointment!

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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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Shorter Medical School — manpower planning

medicalschoolA practicing physician can look back to answer the question:  what time was wasted during training?  In other words, what was not applicable and forgotten.  The answer is about 50% of college, 40% of medical school, 20% of residency and  20% of specialty training.  Altogether the inefficiency of training (wasted years) adds to about 3 years for primary care and 4 years for a specialist.  Wasting years of time  is bad for students and bad for the US health care system.

Freedom to choose a type of practice seems to be the basis for US training.  Consequently, the training is designed for maximum student choice.   Required courses cover all the basics until far into training when finally a choice dawns.

The illusion of choice is the student never knows what practice is like, does not know what care givers are actually needed and assumes they can practice anywhere.  Sometimes they choose just based on potential income — since they do have to pay off student loans.

Some would say:  the student paid for training so they are entitled to choose.  The fact is they pay a very tiny fraction of training cost, which society reimburses them many times over.  Reimburses with a salary after medical school, reimburses by taxes going into Medicare and Medicaid, reimburses from insurance premiums paid by individuals and business.  Society is paying for health care providers in aggregate.  Health care has become a utility.

Given the utility nature of healthcare providers, why should health-care students have full choice of  specialty, location or fees?   A proper utility should provide uniform service and access where needed.

The problem:  a disconnect between the demand for manpower and the product of training.

A solution:  The pay-forward system.  Openings for health care training should be presented before college.  The student makes a decision very early.  Education can be focused and much shorter.  The options might be: nursing, primary care, laboratory medicine, surgical specialties, anesthesiology,dermatology, radiology, hospital care, or medical specialties (with a similar manpower guided choice a few years later).   In exchange for participating in the new system, education is free to the student — paid for by reducing the salary over the career of the provider.  But, there is an obligation to practice what and where manpower demands indicate.

The advantage of focused training is the ability to go into productive work in less time:

Dermatology:  6 years (vs. 12 years)

Primary care:  7 years (vs. 11 years)

Cardiologist:  8 years. (vs. 14 years)

Neurosurgery:  12 years (vs. 18 years)

Those students who perceive the need for a more broad education could spend several years in college pursuing whatever they want before committing to the health care track.  One would expect some students would not make the grade needed in the health care track — they may want to fall back on another career possibility.

The University is helped by moving health care training away from other majors.  The new track would allows majors in chemistry and biology to concentrate without the competition of pre-med students who do not intend to work in those fields.

The best part is the results of training program yield the providers needed. And, the providers practice where there they are needed — without crushing debt.

 

 

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Training Doctors — choked by tradition

towerGrand poobahs, long robes, ivory palaces, exulted wise men — is it the Arabian Nights?  — no, it’s graduate medical education in the US.  Finally, a voice of reason — coming from the Institute of Medicine (IOM).  The surprising report released 7/29/14 says doctor training is not meeting the needs of the country.

The problems:  $18 billion per year going to academic medical centers without adequate accountability.  Money lavished on the Northeast fails to trickle down to community training programs elsewhere.  Self-serving training of an academic workforce but not main-street primary care.

The US has never had a coherent plan to train doctors — academic medical centers have been making decisions that should have been made by ordinary people, people who don’t like waiting lists.  A huge manpower shortfall has been expected for a long time.   The IOM expert committee is calling for big changes to the system.  The hope of the country, West of Harvard, is that Congress will follow the recommendations — the report is not asking for more money (which would be a stake in the heart) just a rational use of funds to meet obvious needs.

A primary care doctor does not need to go to Harvard to be a very good doctor and the US does not need to support super specialty programs at the expense of towns lacking a doctor.  The cost savings by diverting  funds to community training programs could be huge, possibly training 2 or 3 physicians instead of one in Boston.

Funding of training needs to be tied to providing service where service is needed.  What better way to train doctors for Iowa (or other areas needing doctors) — train young people in the communities where they live.

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