Posts Tagged poor quality

Health Care Lobbying — it’s not for quality


Health care lobbyists are not your friends.  They do not promote quality health care, instead they promote health care business profits.  If only hundreds of millions of dollars could be spent on lobbying for health care quality, on health care access, and on lowering health care cost then the US might not be last in the quality ranking for industrialized countries.  The data below are from the Center for Responsive Politics.  The table shows the amount of money spent for lobbying in 2015 for various industries.   Any wonder why we don’t see much change?

Industry Total (millions) X = 10 million $
Pharmaceuticals &
Health Products
Insurance $118 XXXXXXXXXXX
Oil & Gas $97 XXXXXXXXX
Business Associations $96 XXXXXXXXX
Electronics Mfg &
Electric Utilities $88 XXXXXXXX
Misc Manufacturing &
Health Professionals $73 XXXXXXX
Securities &
Hospitals &
Nursing Homes
Telecom Services $64 XXXXXX
Air Transport $60 XXXXXX
Education $56 XXXXX
Defense Aerospace $56 XXXXX
Health Services &
Real Estate $52 XXXXX
Civil Servants &
Public Officials
Commercial Banks $46 XXXX
TV/Movies/Music $45 XXXX
Automotive $43 XXXX

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Urinary Retention — 1 in 10 men over 70

urologybillboardOne 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 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!

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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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Care Not Meeting Expectations – Where do the expectations come from?

The “Sick in America Poll” shows 45% believe the quality of healthcare is a very serious problem.   Quality is always based on a comparison with “something else”.  In the past it was difficult to compare health care with “something else”.  But now, a patient can look on the Internet for a world of comparisons (where health care does not look so good).  Or the patient will just ask a relative.

Quality is sometimes undercut by the providers themselves.  Rather than just say “an annual blood count is not supported by medical evidence”  too many doctors just say “insurance won’t pay for it.”   Rather than say “eating too soon after surgery may cause nausea”, too many nurses say “the doctor won’t let you eat.”  Rather than say “it is usually a safe drug but watch out for a rash” the pharmacist says nothing and passes out a huge list of side effects.  Where is the teamwork?  It is a set up for failure and poor satisfaction.

An academic view of quality health care is provided by the Institute of Medicine (a government organization).   They have defined six attributes of health care quality:

  1. Safe: Avoiding preventable injuries, reducing medical errors
  2. Effective: Providing services based on scientific knowledge (clinical guidelines)
  3. Patient centered: Care that is respectful and responsive to individuals
  4. Efficient:  Avoiding wasting time and other resources
  5. Timely:  Reducing wait times, improving the practice flow
  6. Equitable:  Consistent care regardless of patient characteristics and demographics

The Institute of Medicine is concerned with finding that “something” for the quality comparison.   Unfortunately, the Institute of Medicine did not list system assets such as “reasonable cost” or “sound  management” or “continuous improvement” or “reliable care” or “high national ranking”.   The goal is good, the means to the goal is lacking.  An old business saying is “measure to manage.”  Americans need to know how the health care system is being managed, at the speed of the stock market, not at the speed of academic reports.  We need to see the ticker tape for cost and quality.  If the system is not being managed well then get a new manager.

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