Archive for category Patient-Centered Care
June 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.
Addendum: Here is a link to an interesting court case about glucose meters
According 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:
- Patients really can tell the difference — a crystal chandelier hanging in the hospital room does not make nursing care better!
- 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.
Happy 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?
- Measure and report quality in a transparent way — like on the office website. And, keep it updated.
- Deliver patient-centered care and prove it. Survey patient’s expectations and record whether the expectations are met with office visits.
- Report quality indicators other doctors must do like for diabetes, hypertension and smoking.
- Report primary care specific indicators regarding the most common diagnoses — skin conditions, joint pains and respiratory infections.
- 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).
You smoked 2 packs a day for 20 years. Your doctor orders the low-dose CT screening (above). Your doctor says you have a lung nodule, now what? That’s a lot to think about but before anxiety builds too much you need to know that of all the people with a nodule on their first scan 19 times out of 20 it is NOT lung cancer.
By asking some questions it is possible to work through the complicated logic of what to do next.
What if I am that unfortunate 1 out of 20?
If you know for sure the nodule is cancer you would get that nodule removed. Sure it’s a big surgery, hurts for weeks (sometimes longer), in the hospital for several days, and tons of risks the surgeon will recite. No walk in the park but the odds of a cure are better at an early stage. Lung cancer is a killer so it is easy to conclude: get rid of that nodule
What if that nodule is a bad type called “small cell” cancer?
Most specialists agree that chemotherapy is the treatment of choice. Surgery for small-cell cancer is not helpful and may actually shorten your life. A biopsy before surgery may help to avoid surgery for this type of cancer.
What if I am one of the lucky 19?
If all 19 get surgery there would be a lot of discomfort only to be told after surgery the nodule was just a scar or a harmless irritation. Biopsy or follow-up x-rays are sometimes helpful to avoid surgery.
What if I get a needle biopsy of the nodule?
A shot of numbing medicine, a long needle between the ribs, a tiny bit of tissue removed, and finally the pathologist sends a report. Such biopsies are 95% accurate. The wheel of fortune lands in one of 5 major categories:
- No cancer found
- Small-cell lung cancer
- Non-small-cell lung cancers
- Squamous cell carcinoma
- Large cell carcinoma
- Other cancers (much less common)
- Something which is not cancer
A needle biopsy answers critical questions. If it shows non-small-cell lung cancer surgery is the next step. If it is small-cell cancer the next step is chemotherapy. If it is something else, like tuberculosis, then entirely different treatment is needed. If it is “no cancer found” then you are back to square one — meaning a nodule is present and the cause is unknown (possibly a cancer that was missed by the needle).
I am willing to take some risk to avoid procedures.
We started this discussion with a 1 out of 20 chance of cancer. Is there some way to improve on the accuracy of that prediction? 1 out of 20 does not sound so good. But, if the odds of cancer in your situation are 1 out of 100 that would be more favorable.
Improved risk assessment
Canadian Annette M. Williams, MB and others reported in the New England Journal of Medicine in September 2013 an improved mathematical prediction method. Most pulmonary doctors and radiologists can readily provide the statistic. Basically, if the calculated risk score is below 5% then the chance of cancer is about 1 out of 100 .
If the risk is low you might just choose to get a CT scan every few months. If the size of the nodule does not change for 2 years then it is harmless. One sure thing, cancers grow. No growth means no cancer. But, if the nodule does grow you could change the plan and get the biopsy or surgery — there is a risk to letting a cancer grow for a few months (it could spread) but there are risks to biopsies and surgery as well.
If the cancer risk is high you might want to go ahead with a biopsy.
The above are the outlines of nodules 1) round 2) lobulated 3) irregular and 4) spiculated. Cancerous nodules can take any shape but tend toward the spiculated (spiny) form.
The improved statistical method is based on a few details about the nodule. Sex (women are more likely to have malignant nodules), size (the larger the nodule the more likely it is malignant), location (upper lobe nodules are more likely malignant) and spiculation (see diagrams).
If you want to calculate the risk statistic yourself, have a calculator and know the details listed above then click this: Calculate Risk. But, be warned, this calculation only applies to people who have a risk for cancer to begin with, not the incidental nodule found in a lifetime non-smoker or someone who only smoked a few years.
The forgoing material is intended as education, not a substitute for the evaluation and advice of your health care provider. If it seems helpful print it and take it to your provider for discussion. Medical care changes with time so always get up to date information.
Your medical history is very important because health care providers use that information as the foundation for medical decisions. Who has more interest in the accuracy of your information than you do?
You might say: writing the medical history is the doctor’s job. You are right. But, have you actually looked at the product of that work? — most people have not. Patients who read the doctor’s version of a medical history are astounded by the number of errors and the amount of missing information. To be fair, health care providers are goal oriented — as they hear the medical history they make diagnoses and once a diagnosis is made the details become less important.
Health care providers absolutely love a new patient that hands them a concise medical history. They love it because:
- They save time
- The information is more accurate and complete than usual
- They can take notes directly on the paper
- It is an aid to write their own version or enter data into a computer
The do-it-yourself (DIY) medical history is great for patients because:
- You don’t need to repeat it on forms, just write “see attached Medical History”
- You can print a copy when you see a new doctor or specialist
- You can take a copy to the emergency room
- You can keep it up to date with a wordprocessor
- You can store it on your computer or “in the cloud”
- Your health care visits can focus on current problems not old records
As helpful as this DIY medical record seems there are some important points:
- The record must be constructed the way health care providers expect — otherwise they will not read it or use it.
- The record must be concise — try to get it on one page (not more than 2 pages)
- You must not omit diagnoses or include any self-made diagnosis
- Avoid duplication — if you include something in one section do not put the same information in another section.
- This is not a test. You can “cheat” by copying from the medical history created by one of your health care providers. After all, it’s your medical history. Make sure you get copies of any “History and Physical” done by your providers.
When you see a new health care provider you should take 2 things:
- A copy of your DIY medical history.
- A small piece of paper with the 3 concerns you want to talk to the provider about
Now, to the nuts and bolts of the DIY medical history. Here are the categories:
- Identifying information: Name, Date of Birth, Address, Phone number
- Past Medical History:
- various diagnoses with dates of any hospitalizations and causes
- recent blood tests, x-rays or other tests with results (or attach report)
- Past Surgical History: name of surgeries with date, surgeon, and hospital
- Childhood illnesses: birth defects or serious illnesses when a child
- Obstetrical History (women): pregnancies and outcome, number of children
- Psychiatric History: depression problems etc. and list of hospitalizations
- Family Medical History: just parents, siblings and children
- Social History:
- where you live, with whom, occupation, when retired etc.
- habits including smoking and alcohol consumption
- advance directives (living will, 5 wishes etc.)
- drug names, strength, how often taken, for what
- pharmacies with phone and fax numbers
- Drug Allergies
- Drug Intolerances or side-effects, what drug and when it happened
- Food or Inhalant allergies
- Immunizations: which vaccines and when
- List of current health care providers: primary care, pediatrician, ob/gyn, and specialists
- Prefered hospital in case hospitalization needed
- Emergency contacts: names, relationship and phone numbers