Archive for category Poor Coordination of Care
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!
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:
Hospital medication errors are very frequent. A commonly quoted figure is one error every day of a hospitalization. Meaning: wrong drug or wrong dose or wrong time or missing dose.
Consequently, it should not come as a surprise the instructions patients are given when they are sent home have frequent errors. Patients may be taking medications before they are hospitalized, so in addition to new medications those pre-existing medications need to be considered (a process called “medication reconciliation”).
You may ask: how can this be goofed up? A person has medications at home, the doctor writes a new prescription just before going home, the prescription is filled by the local pharmacy, and the prescription is taken in addition to the same medications as before. What could be more simple?
The answer is: there is plenty of room for error! What if:
- the new medication is actually a generic duplicate of a brand name home medication
- the new medication has severe interactions with a home medication
- the home medication dose is listed incorrectly
- the new medication prescription and the discharge instructions don’t match
- a new medication prescription was omitted
- a doctor outside the hospital is unaware of the new medication and prescribes something that interacts badly
- the patient get an allergic reaction to the new medication but the prescriber is not available to help
- the patient forgot to mention some of the home medications
- unnecessary brand name drugs are prescribed that are not covered under the outpatient insurance plan
- the prescriber forgot to tell the patient to stop some of the home medications that were causing symptoms prior to hospitalization
NOT SIMPLE AT ALL.
Yet, hospitals and prescribers often don’t take much time to get the medications right at discharge (there is a big push to get the patient out the door as soon as possible). Here is an actual example from 2 weeks ago:
A patient was admitted from a care center with an accurate list of medications. The admitting nurse transcribed the list into the medical record but made a mistake on one dose. The physician’s plan was to reduce the does of another medication which seemed too strong but the patient was not taking any medications by mouth at that point so no medication orders were written. A few days later the patient was ready to leave the hospital.
Unfortunately, a different physician discharged the patient rather than the one that admitted the patient. The nurse’s list of home medications was used to generate the discharge medication instructions — no new medications were ordered. But, the transcription error of the nurse was included with the instructions and the plan to reduce the dose of another medications was forgotten. Two major errors. The family actually realized the errors but the nurse the family informed forgot to call the doctor so no change to the list was made so the care center followed the flawed instructions.
So what went wrong?
- Duplicate lists of home medications were collected but the transcription error was not detected because the lists were not compared.
- The list of medications used during the hospital stay was not marked as equal to or changed from home medications.
- The planned change in home medications was not made because there was no place to put such a reminder for discharge in the hospital chart.
- The prescriber did not review the medications with the patient or family personally.
Worse yet, although errors happened there was no plan to change the system to prevent similar errors in the future.
So, as a patient or family member what can you do?
- ALWAYS bring multiple copies of an accurate list of home medications to the hospital — give a list to anyone that asks to review the medications.
- Expect the attending physician to review the discharge instructions with the patient or appropriate family member — if this does not happen immediately complain and make that expectation known. Good physicians plan ahead and sometimes do this review the day before discharge!
- Use one of the copies of the home medication list to compare to the discharge instructions. Make sure to understand ANY changes. And ask — does the new medication, if any, interact with home medications?
- Find out who to call if questions or problems with the medications arise after getting home — get a name and phone number. Often the discharging nursing unit will take the call and find the right person.
Elisabeth Rosenthal reported “Patients’ Costs Skyrocket; Specialists’ Incomes Soar” in the New York Times today 1/19/19. She particularly targets one of the most popular specialties for US trained physicians, dermatology. Good hours, great pay, and compared to other specialties, easy to learn.
A highly trained thoracic surgeon can only do 2 bypass surgeries per day but a dermatologist can to 20 lesion removals per day and make almost as much money. Patients choose to go to a dermatologist when most primary care doctors can just as easily solve the problem at a fraction of the cost (like benign skin lesions, sun related pre-cancers, and acne). And, when infection sets in on the weekend the dermatologist’s answering machine says to go to the emergency room ($300 co-pay).
She describes a situation where a woman had a facial skin cancer removed at a cost of $26,014. The astounding cost was the result of a dermatologist removing a lesion and then being unable or unwilling to close the wound — but still billing for the procedure. And, the patient also received bills from the doctors that actually fixed the problem (perhaps they should have billed the dermatologist). Sadly, a bad system is more profitable than a good system.
It is easy to see why the patient and Ms. Rosenthal believe there is a problem with US healthcare. Because, THERE IS A PROBLEM!
Rather than complain about the problem, what is the solution? It is not rocket science. The dermatologist, surgeon, operating room personnel and anesthesologist all need to be employed by an accountable care organization (ACO)– that way there is just one predetermined fee for taking care of the whole patient for a year. If the system does the work correctly they make some money, if they goof-it-up (as in this case) they lose money. The incentive should be to do good and efficient work. Not to make money by making mistakes.
This solution is extremely easy yet extremely unpopular with hospitals, surgeons, anesthesiologists, pathologists, radiologists, ophthalmologists and dermatologists. The reasons are obvious — they make less money and must follow quality guidelines. Given the low quality and extreme high cost of US healthcare is that really a problem? A few more articles by Ms. Rosenthal and a few thousand letters to congress might help. Sadly, one industry lobbyist equals one journalist in this battle.
By the way, the lesion at the top is a benign seborrheic keratosis — harmless, but gladly removed by dermatologists ($250).
The cause of hospital readmissions is not a secret. Patients are readmitted to the hospital because the patient, physician or both are too optimistic about the patient’s situation: too optimistic about the patient’s social problems, too optimistic about the strength of primary care, or too optimistic about the possibility of surgical complications.
It feels better to be Optimistic than the alternative. It feels better to the patient to be going home. It feels better to the doctor to believe all is well. But, the data about readmissions suggest the feelings are not always accurate. Perhaps we should be optimistic there are ways to find and correct the reasons for readmission. Providers need to focus on solving more problems before discharge, not just the problem of sending the patient out the door. Providers need to follow a discharge check list, just like a pilot getting ready for takeoff – not just be optimistic the plane will do just fine.
Rehospitalization is often attributed to fragmentation of health care. So, what constitutes a non-fragmented (smooth) transition from hospital to home? The following is the basis of that preflight checklist:
- The hospitalization is long enough to make sure the patient is stable.
- Providers anticipate the day of discharge:
- the likely date of discharge is discussed at least twice
- on the day of admission
- when the patient is feeling better, at least 48 hours before actual discharge
- patient questions are answered
- minimize medication complexity
- absolute minimum number of meds
- simplify dose schedule (don’t mix intervals)
- educate about new medications
- explain and write down
- the reason the patient was hospitalized
- the final diagnoses
- the name of surgery performed
- the complete list of medications including
- home meds discontinued
- home meds continued at same or different doses
- new meds (make sure they are generic or on the insurance formulary)
- why each medication is needed
- financial problems addressed (can medications be purchased?)
- home social situation reviewed
- obtain home monitoring equipment (glucose meters, scales, blood pressure checkers)
- send needed prescriptions to the patient’s pharmacy electronically
- the likely date of discharge is discussed at least twice
- family engaged, discharge plans discussed with family
- visiting nurses called if needed
- primary care providers called and discharge summary faxed same day
- discharge instructions reviewed verbally and in writing with patient
- follow up appointments made
- specialty care as needed
- primary care within one week
- transportation arranged
- phone follow-up next day by discharging provider
What indicates high risk for rehospitalization?
- Intensive care stay
- Living alone
- Previous readmissions
- Lack of insurance
- No primary care provider
- Smoking or other substance abuse
- Congestive heart failure
- COPD or asthma
- Insulin dependent diabetes
- Surgical wound drainage
- Weakness or falling
- Over 15 lb wt loss
- No phone at home
- No transportation (except ambulance)
Rehospitalization may be foreshadowed during a hospitalization. Health care providers sometimes fail to notice wound drainage, night time confusion, low grade fever, shortness of breath, leg swelling, anxiety, or comments about the cost of medications. The errors of omission can be reduced by minimizing provider changes and hand-offs — so patients do not “fall through the cracks”. Providers should take a second look at labs, vital signs and nursing notes before giving the green light for discharge.
Sarah Needleman of the Wall Street Journal was the author of “Rx to Avoid Health-Law Fines” which appeared August 8, 2013. She reported on new companies that help hospitals reduce hospital readmissions by printing sensible discharge instructions and also by predicting the chance of readmission to help focus resources on high risk patients.
Discharge software is expensive and probably not more effective than a good checklist of risks. Most importantly, hospitals must have action plans for each high readmission risk factor (like no transportation or no phone).
The Robert Wood Johnson Foundation published “The Revolving Door: A Report on U.S. Hospital Readmissions” in February 2013. The report puts a strong focus on fragmentation of care, being a root cause of rehospitalization. The fragmentation can be significantly reduced by strong primary care, doing close follow-up after discharge, engaging additional social services if needed, extensively using the phone to communicate with patients who have chronic illness.
A good idea: phone follow up. Many primary care providers complain that post hospital phone calls are an unreimbursed expenses (so they don’t make the calls) — hospitals should consider paying a fee to primary care for phone calls during the month after discharge.
Another good idea: the hospitalist outpatient check. Some hospitalist groups actually have a discharge follow-up clinic for patients who had a long hospitalization or who have rehospitalization risks. The visit is usually a couple of days after discharge and is focused on solving problems before they become big problems and also to make the transition to a new or existing primary care provider.
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.
One winter afternoon Mr. C was at his health club enjoying a workout on the StairMaster. Suddenly, he began to have a nosebleed. In the past, any nosebleed would go away with some pressure but this was different, the bleeding just would not stop. Driving his car was out of the question. Fortunately, another health club member offered him a ride to the ER. On the way they passed an urgent care clinic but did not stop. They were concerned the urgent care clinic might not be able to stop a nosebleed. The towel he used to catch blood was getting very red and he was a little frightened by the thought of bleeding to death.
Holding his nose with the towel he checked in to the ER and was quickly taken to an ER room. After 20 minutes a nurse evaluated him and took his blood pressure. His nose continued to bleed and 30 minutes later a doctor arrived. He put drops of epinephrine in the nose followed by a nasal pack. The bleeding stopped, he was given an antibiotic pill (ciprofloxacin), he rested a few minutes then his wife took him home. A few days later his wife removed the packing as directed. Problem solved — at least the bleeding problem.
He eventually got a statement from his Medicare (MC) supplemental insurance company.
|epinephrine 4 drops||$204.60||$0 *||$204.60|
|ciprofloxacin 500mg||$50.82||$0 *||$50.82|
* Medicare would not cover (“allow”) the medication because the medication was categorized as an outpatient charge. What Medicare does not allow supplemental insurance will not allow either. So, the patient has to pay.
Wholesale prices of medications are as follows:
epinephrine 1 mg/ml (0.1%) 1 ml ampule $2.55 (charged 80 x cost)
ciprofloxacin 250 mg 2 tablets $0.45 (charged 110 x cost)
See the reference on nosebleeds (epistaxis).
Could there have been another way? Less waiting and less cost? Perhaps. Consider the following alternative scenario:
A patient had a nose bleed for 5 minutes at which point he called his on-call primary care provider (PCP). The patient was instructed to go to an urgent care center. Waiting was minimal since bleeding is a big deal at the urgent care center (at the ER there are bigger things going on). The treatment at the urgent care center was the same as the ER except a prescription for ciprofloxacin was given to him which he picked up at the 24 hour pharmacy ($0.50). The charges and out of pocket expenses for the urgent care visit were as follows:
|epinephrine nasal||$20 (est)||$0||$20.00|
It is important to note there is no “facility” charge at the urgent care. Only hospitals can charge for use of the facility. Ostensibly, this is to offset the costs of maintaining higher staff levels to be ready for really big emergencies. In effect, by going to the hospital ER the patients with minor problems subsidize the patients with major problems.
The bottom line: At your next visit with your PCP discuss how they want you to handle minor and major emergencies. In general, if you feel you have time, call your PCP’s office (even at night because someone is on call) before going to the emergency room. Use urgent care centers rather than the ER if possible. Don’t accept a facility dispensed medication to take at home if there is a nearby 24 hour pharmacy. If your PCP is aware of an urgent problem they will likely follow up when needed.
23% of sick Americans felt “no one doctor understood or kept track of all the different aspects of their medical issues.” At present there is only one solution. The patient needs to keep a notebook of information about their health. This should include an up to date health history, medications, allergies,copies of significant tests, x-ray reports and lab tests. After office visits ask for copies of results and after hospitalizations ask for copies of the discharge summary for the notebook. The impediments to sharing of information are tremendous:
- No nation-wide patient identification number
- No common way to store health information
- No way to search all sources of health data
- Patients moving or changing doctors or changing health systems
- Name changes, identity theft, undocumented aliens
- Poor communication to and from a primary care providers
- Lack of pharmacy integration into databases
- Strict privacy rules
- Separation of outpatient and inpatient providers
Nobody knows who to trust with their health information. If such a trusted place for information could be found then American’s health information could be electronically stored there with access controlled by the patient. This probably will not happen soon so patients should:
- keep a health information notebook
- get a primary care provider
- try to stay in a health system that has a good information system
- support the idea of trusted regional or statewide health information systems
Health care mergers and acquisitions are increasing but the merging of information systems sometimes does not follow. Perhaps such joining of health care systems should have legal requirements to merge the patient data systems as well.
Despite the dim hope of information sharing on a large scale there are things providers can do.
- Give patients copies of important medical information either on paper or electronically
- Always send information to the patient’s designated primary care provider.
- Always give the patient an updated list of medications they should be taking, not just the medications prescribed that day.
- Encourage the patient to bring the medication list to every health care encounter.
- Make it clear to the patient who is in charge at all times. Hand-off of care means a positive, certain, provider to provider communication and not just a whisper in the wind.
- Make it easy for other providers to contact you.