Archive for category Health Information Fragmentation
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.
- It sets the allowed price for hospital and medical provider services
- It pays 80% of the “allowed” price leaving 20% for the individual or a “medical supplement”.
- Limits participants to one insurance company or organization
- Has lower premiums
- Wraps Medicare and a supplement together
What about Medicare For All
- 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.
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)
A good patient portal is wonderful; a bad patient portal is a waste of time. A recent post by Dr. Yul Ejnes suggested portals may not be patient centered and don’t get much use.
An alternative view is that all patient portals NOT are the same. Some have great features and are supported by the providers offering them. Other portals are not much more than advertising — generally something a patient does not revisit. Sadly, many businesses have the latter type of portal — no wonder people don’t flock to medical portals.
Check out your health care provider’s portal. If it does not really provide a benefit then TELL THE PROVIDER, complain, and say other providers do a better job.
Admittedly, a poorly functioning provider office will likely have a poorly functioning portal. Just because the portal lets you send a message to the nurse or provider is no guarantee the response will be helpful.
Large vertically integrated health systems or ACOs have the best chance of a good patient portal. The portal needs monitoring and rules for providers — rules that require questions to be answered the same day. And, that the portal will display lab results within 48 hours, regardless of whether the provider has or has not seen the results. Responses from nurses need to be monitored for accuracy and timeliness — the lazy but profitable response to just make an appointment is not adequate. Integration of pharmacy functions is essential.
Here is a checklist of possible portal features — how does your provider’s portal stack up?
- Responses to online requests take less than 24 hours
- Ask a medical question
- Ask medication related question
- Make a follow up appointment
- Make a same day urgent care appointment
- Get refills on a chronic medication
- Get a message from your provider about test results
- Report drug side effects or drug allergies
- Send a picture of a skin rash.
- Diabetics can send blood sugar results
- Asthmatics can send peak-flow measurements
- Look at your list of medical diagnoses both active and inactive
- See a list of current medications and the diagnosis for which they are prescribed
- Links to drug information about the drugs on the medication list
- Review the providers notes
- Review any test, x-ray or consultation report
- Your provider can send questions to specialists and forward the response to you
- You can print your lab, pathology and x-ray reports
- See your most recent medical summary including past medical history, social history, family history, medications list allergies — and be able to print the report if needed for consultations or to take on trips.
- Request a summary of billing and payment information — including when bills are sent to insurance and when payment is received.
- Pay your bills on-line
- Links to reliable on-line information sources about tests, treatments, drugs, immunizations and diseases. Include a symptom checker — a computerized diagnosis based on symptoms — something to discuss with your doctor.
- Provider office provides training to use the portal.
A provider might say: “I’m not paid for running a portal or answering questions”. That is very true for many providers in the US health care system. But, in systems without fee-for-service billing then portals are a huge driver of efficiency. If a patient’s questions or problems can be resolved via the portal so much the better for both the provider and the patient. The handwriting is on the wall — fee for service is going to go away — the efficiency of portals will be a strong driving force.
Laura Landro of the Wall Street Journal published the article: “Image Sharing Seeks to Reduce Repeat Scans” on April 1, 2013. Ms. Landro reported on an academic project to store x-ray pictures on the Internet called the “Imaging Sharing Project” (image share news release). The idea is to have patients own a secure copy of their personal x-rays. By having this storehouse of x-rays in the “cloud” they can be given to any health care provider or hospital as needed.
Any patient who has had to take x-ray images from one provider to another understands the problem. The provider handed the disk of images may or may not be able to look at them because of incompatible ways of recording the material. Of course, this means another visit to the provider (or worse, a repeat x-ray and unnecessary x-ray exposure).
Storage of images is nothing new. But, the concept of the patient owning the images is indeed something new. It allows a patient to seek a second opinion without all the hassle of getting the disk. This is a real asset to a patient who keeps copies of their own medical information. The typed radiologist report is usually very brief and does not allow for alternate interpretations.
The difficulty transmitting images is partly intentional. Radiologists fear someone else far away could be a business competitor. It would be very bad for local radiologists if patients always wanted their brain CT evaluated by some expert in Boston or London.
Cancer patients will find this service very helpful. If a woman has an abnormal mammogram she can pick the oncologist or surgeon and then share the images with them. If she has a mammogram at a different facility she can share the older image for the purpose of comparison.
People who move from city to city would still retain easy access to x-ray images. The US population is much more mobile than in the past so this is very important.
The Image Share project is not available everywhere. There is a commercial product called LifeIMAGE. It is a great idea so hopefully the idea will spread. It would be a step forward if all insurance programs and x-ray offices were required to provide this as a benefit. If you know of other similar products please leave a reply.
An expert is someone who has succeeded in making decisions and judgments simpler through knowing what to pay attention to and what to ignore.
(Edward de Bono)
There are about 50 common types of medical and surgical specialists. The list runs from allergists to vascular surgeons. So, in the big picture of health care where do they fit? Do they add to health care quality? Are their services cost-effective (as you might evaluate a drug or device)? When should a patient see a specialist (or not)? Why are specialists happier than primary care doctors?
Many years ago there were no specialists. Doctors delivered babies, set broken bones and used leaches. Treatment of war wounds with amputation heralded surgery as a specialty in the latter part of the 19th century. As time went by other specialties came into being mostly because specialists were the conduit from research to clinical practice. As medical information was more widely available specialists simply had more experience with uncommon or difficult problems. Specialists led the way for new treatments . Pulmonary doctors treated consumption (TB). Cardiologists studied EKGs. Obstetric specialists invented forceps for difficult births. Now there are at least 50 varieties of specialists.
The specialist world is divided between procedural (surgical) and medical (expert advice) specialists. A cardiac surgeon is a good example of a surgical specialist. An endocrinologist is a good example of a medical specialist. Some specialists do a little of both like cardiologists who do heart catheterization procedures and provide expert advice for treatment of heart disease. Medical research has exploded to such an extent specialists still maintain an edge by focusing on smaller and smaller areas of expertise.
One might be led to believe every condition should be evaluated by a specialist. But, there is good evidence to the contrary. Based on Medicare data: Areas with more specialists spend more on health care for Medicare beneficiaries but see no improvement in the quality of care, mortality, or patient satisfaction. The foundation of modern American medical care is being questioned. What went wrong? Is it Kryptonite? How can this be?
There are two answers to what went wrong. First, knowledge about a disease does not always lead to cure but always runs up the bill for tests. Second, medication and surgery do have complications that can be serious to the point of shortening a person’s life. In aggregate the specialty world “hit the wall”. The positives could not offset the negatives.
The foregoing indictment of specialists really put the wind to the sails of primary care. In fact, treatment of most common ailments is well established with what are called “evidence based guidelines”. Quality, safety, cost-effectiveness, and patient satisfaction thus depend on a good process to implement the known guidelines rather than special knowledge. Until recently primary care providers had the lowest job satisfaction of any provider group. Now, with a new sense of importance and purpose they seem to be personally happier.
The specialty world is fighting back by addressing cost-effectiveness. Cardiologists have devised cost-effective strategies for treatment of heart attacks (evidence based guidelines) with dramatic improvement in survival. Oncologists are following guidelines for treating many cancers and engaging hospice at a more appropriate time. Gastroenterologists have found they can prevent colon cancers by following evidence based guidelines for doing colonoscopy. The world’s specialists are not all on board with the idea of being cost-effective. Those who do procedures are still criticized for doing them too often (if you have a hammer everything looks like a nail).
THE BOTTOM LINE:
- If you have health problems then have regular visits with a primary care provider. They usually do have good advice about going to specialists.
- Do your homework. Search the Internet about your problem. If there are ideas you find then discuss them with your primary care provider.
- There is still some “ego” challenge for a primary care provider to ask for help in difficult situations. The simple question: “Do you think a specialist could help us with this problem?” is usually well received.
- If you have a life altering problem or are hospitalized more than once for the same disease a visit to a specialist is certainly reasonable.
- If you do go to a specialist make it clear you want your primary care provider kept informed. Likewise, make sure the primary care provider communicates with the specialist (sends periodic updates) and follows the recommendations primary care actually requested.
28% in the Sick in America Poll saw a health care professional who did not have all of the relevant medical information. Many patients think all health care providers are linked together by computers but this is absolutely not the case. The experience at an airport where a gate agent can look up your ticket and alternative flights — even from other airlines — is really spectacular. Unfortunately, American health care is not at that level of connectedness. If one doctor orders an x-ray the results go to that doctor. If the second doctor is in the same health system there is a chance the result will be in the system database. If the second doctor is elsewhere the doctor will not have the result unless the patient takes some action or has the result in a notebook. The situation is dangerous. The patient thinks the doctor has the information. The doctor does not have the information and orders duplicate tests or potentially unnecessary procedures.
- From the patient standpoint: keep a notebook of all significant tests and procedures and show it to any new providers. When making an appointment tell the scheduler about recent tests — there is a chance the office will endeavor to get the results. Admission to a hospital is frightening and is made worse by each new health care person ask the same questions over and over (suggesting poor communication between the admissions nurse, the hospitalist, the surgeon, the anesthesiologist, etc.) The questions get asked because the providers have not looked at the record or because the previous provider has not had time to enter the information. Really well organized hospitals minimize this repetition so choose your hospital accordingly.
- From the provider standpoint: Unless it is an emergency, try to have a staff member contact the patient before the visit and review any recent health care events. That staff member should check for data from those previous events and have the data available for review prior to the provider visit. Most outpatient providers have about 4 employees dedicated to them (nurses, schedulers, insurance filers, and record keepers). One of them should be tasked with collecting data for the visit. You might say the provider fee does not cover data tracking, but how silly does it sound to bill for saying we don’t have the needed information? When the patient is asked to come back for a second visit to review the missing data the patient may smile, but as the poll shows, they know poor organization when they see it. When seeing a patient in the hospital review the record before questioning the patient. It is reassuring to patients to have a provider review the information in the record with them and ask “is that correct?”
- From the American health care system standpoint: other countries do a better job of reducing health care data fragmentation. In England there is a system wide (NHS) computerized medical record. In France each patient has a smart card that contains the medical and billing record. Nobody knows for sure what the current cost of data fragmentation might be but it is certainly huge. Perpetuating an inefficient system wastes money and talent.