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CRAZY AMERICA: Health Insurance Covers Testing When You Are Well But Not When You Are Sick

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By HANS DUVEFELT

Insurance is the wrong word for what we have here. Our private health insurance system’s prioritization of sometimes frivolous screenings but non-coverage for common illnesses and emergencies is a travesty and an insult to typical American middle class families.

State Medicaid insurance for the underemployed has minimal copays of just a few dollars for doctor visits and medications. From my vantage point as a physician, it is the best insurance a patient can have. They cover almost everything and it is clear to me how to apply for exceptions or follow their step care requirements. I cannot say that about most other insurers.

Most employed people have the kind of commercial health “insurance” that covers an annual physical and certain screening tests at no cost, but requires people to pay the first several thousand dollars of actual sick care expenses out of pocket. This is, in my opinion, insane. It causes delays and omissions in diagnosis and treatment.

A shining example of this bizarre arrangement is the screening colonoscopy. It is free as long as it is normal. If a patient has a polyp removed, which if unchecked could turn cancerous, future health care costs for treating colon cancer are eliminated. But the patient gets billed for the early cure.

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The Art of Listening: Beyond the Chief Complaint

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By HANS DUVEFELT

A doctor’s schedule as typical EMR templates see it only has “Visit Types”: New Patient, 15 minute, 30 minute. But as clinicians we like to know more than that.

One patient may have a brand new worrisome problem we must start evaluating from scratch, while another is just coming in for a quick recheck. Those are diametrically opposite tasks that require very different types of effort.

Some visits require that test results or consultant reports are available, or the whole visit would be a waste of time. How could you possibly plan your day or prioritize appointment requests without knowing more specifically why the patient needs to be seen?

So, as doctors, we usually want our daily schedules to have “Chief Complaints” in each appointment slot, like “3 month diabetes followup”, “knee pain” or “possible dementia”. That helps everybody in the office plan their day.

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Health Professionals Are Tomorrow’s Health Journalists. Here is a Code of Ethics to Guide Us and Trump’s White House Doctor.

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By MIKE MAGEE

The patient/health-professional relationship is fundamentally grounded in science and trust, and involves the exchange of compassion, understanding and partnership. The Covid-19 pandemic has challenged this relationship by acutely increasing the nation’s burden of disease, creating new barriers to face-to-face contact, and injecting high levels of fear and misinformation.

Dr. Sean Conley, Trump’s White House physician, in his dodgy and evasive management of legitimate questions from the White House press corps regarding the President’s health, has made matters worse.

As this week’s report on an analysis of 38 million articles on the pandemic revealed, much of the misinformation our citizens have experienced can be traced to a single individual who lacks any health credentials – our own President Trump. Sarah Evanega, the director of the Cornell Alliance for Science and lead author of the report stated, “The biggest surprise was that the president of the United States was the single largest driver of misinformation around Covid. That’s concerning in that there are real-world dire health implications.”

The solution to that specific problem is only one month away – vote him out. But if Trump can be successfully sent packing, how prepared are our health professionals, in the face of these new and complex challenges? A President Biden health reform package will likely include expansion of health care teams, exponential growth of telemedicine, and increasing dependence on reliable information to advance personal health planning.

Today’s modern health professionals are tomorrow’s health journalists. What principles should guide them in their new and expanded role. As a guide, I offer the following:

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Physicians’ Communication Skills are Overlooked and Undervalued

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By HANS DUVEFELT

Interviewing celebrities can make you a celebrity yourself, and it can make you very rich. So there’s got to be something to it or it would be a commodity. The world of media certainly recognizes the special skill it takes to get people to reveal their true selves. 

At the other end of the spectrum of human communication lies our ability to explain and also our ability to influence. These three aspects of what we do—elicit, explain and influence—are far from trivial, and in my opinion quite fundamental aspects of practicing medicine. 

Eliciting an accurate patient history or administering standardized depression, anxiety, domestic abuse, smoking and alcohol screenings are commoditized activities in today’s healthcare. There is little time allotted and these tasks are usually delegated to non-clinicians. 

A complicated patient’s clinical history seldom lends itself to straightforward, structured EHR formats. It can be more like a novel, where seemingly unrelated subplots converge and suddenly make complete sense in a surprising last chapter. 

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Talking Politics in the Exam Room: A Physician’s Obligation to Discuss the Political Ramifications of Science with Patients

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By HAYWARD ZWERLING

I walked into my exam room to see a patient I first met two decades ago. On presentation, his co-morbidities included poorly controlled DM-1, hypertension, hyperlipidemia, and a substance abuse disorder. Over the years our healthcare system has served him well as he has remained free of diabetic complications and now leads a productive life. Watching this transformation has been both professionally rewarding, personally enjoyable, and I look forward to our periodic interactions.

At this visit, he was sporting a MAGA hat. I was confused. How can my patient, who has so clearly benefited from America’s healthcare system, support a politician who has tried to abolish the Affordable Care Act, used the bully pulpit to undermine America’s public health experts, refused to implement healthcare policies which would mitigate COVID-19’s morbidity and mortality, and who minimizes the severity of the coronavirus pandemic every day. Why does he support a politician whose healthcare policies are an immediate threat to his health and longevity?

My brain says, “You are the physician this patient trusts to take care of his medical problems. You must teach him that COVID-19 is a serious risk to his health and explain how the President’s public health policies threatens his health. You must engage in a political conversation.”

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Measuring the Effectiveness of Cost-of-Care Conversations

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By NELLY GANESAN, JOSH SEIDMAN, MORENIKE AYOVAUGHAN, and RINA BARDIN

With support from the Robert Wood Johnson Foundation, Avalere assesses opportunities to normalize cost-of-care conversations through measurement.

Cost continues to pose a barrier to accessing healthcare for millions of Americans. Research has shown that conversations addressing costs among patients, caregivers, and the clinical team can help build a more trusted relationship between patients and clinicians.

Avalere has partnered with Robert Wood Johnson Foundation (RWJF) since 2015 to work toward normalizing cost-of-care (CoC) conversations in clinical settings, including identifying barriers and facilitators to engaging in conversations about cost. CoC conversations can be defined as discussions that address any costs patients and families might face, from out-of-pocket (OOP) to non-medical costs (e.g., transportation, childcare, lost wages). To that end, Avalere collaborated with the National Patient Advocate Foundation to explore the feasibility of patient-centered measure concepts to support quality improvement, increase satisfaction, and improve outcomes. This issue brief highlights the challenges associated with measurement in this space alongside alternative solutions to encourage CoC conversations in practice.

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Doctors Urge Caution in Interpretation of Research in Times of COVID-19

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September 9, 2020

To:      

American College of Cardiology

American College of Chest Physicians

American College of Physicians

American College of Radiology

American Heart Association

American Society of Echocardiography

American Thoracic Society

European Association of Cardiovascular Imaging

European Society of Cardiology

European Society of Radiology

Heart Rhythm Society

Infectious Disease Society of America

North American Society of Cardiovascular Imaging

Radiologic Society of North America

Society of Cardiovascular Magnetic Resonance

Society of Critical Care Medicine

Society of General Internal Medicine

Society of Hospital Medicine

Dear Society Leadership:

We are a group of clinicians, researchers and imaging specialists writing in response to recent publications and media coverage about myocarditis after COVID-19. We work in different areas such as public health, internal medicine, cardiology, and radiology, across the globe, but are similarly concerned about the presentation, interpretation and media coverage of the role of cardiac magnetic resonance imaging in the management of asymptomatic patients recovered from COVID-19.

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Meaningful U’s

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By HANS DUVEFELT

Meaningful Use was a vision for EMRs that in many ways turned out to be a joke. Consider my list of Meaningful U’s for medical providers instead.

When electronic medical records became mandatory, Federal monies were showered over the companies that make them by way of inexperienced, ill-prepared practices rushing to pick their system before the looming deadline for the subsidies.

The Fed tried to impose some minimum standards for what EMRs should be able to do and for what practices needed to use them for.

The collection of requirements was called Meaningful Use, and by many of us nicknamed “Meaningless Use”. Well-meaning bureaucrats with little understanding of medical practice wildly overestimated what software vendors, many of them startups, could deliver to such a well established sector as healthcare.

For example, the Fed thought these startups could produce or incorporate high quality patient information that we could generate via the EMR, when we have all built our own repositories over many years of practice from Harvard, the Mayo Clinic and the like or purchased expensive subscriptions like Uptodate for. As I have described before, I would print the hokey EMR handouts for the Meaningful Use credit and throw them in the trash and give my patients the real stuff from Uptodate, for example.

I’d like to introduce an alternative set of standards, borrowing the hackneyed phrase, with a twist. MEANINGFUL U’S for medical providers:

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I Cured My Patient, But What Was His Diagnosis?

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By HANS DUVEFELT

He cancelled his followup appointment because he was feeling fine. He didn’t see the point in wasting a Saturday to come to my clinic when he had lawns to mow and chores to do.

Less than two weeks before that he was sitting on the exam table in my office, again and again nodding off, waking up surprised every time his wife prodded him. The stack of printouts from the emergency room illustrated all the normal testing they had done.

He had experienced a brief episode of numbness in the left side of his face and felt tired with just a slight headache. When I saw him the headache was a bit more severe in the back of his head and down the right side of his neck. But his neck wasn’t stiff.

His blood sugar was 87, normal for most people, but this man had a history of diabetes although his blood sugars had steadily improved over the past year. I told him to stop all his diabetic medications although I don’t think he took notice. His wife said she would make sure he stopped them.

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Medical Education Must Adapt to Support the Broadening Role of Physicians

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By SYLVIE STACY, MD, MPH

As a physician and writer on the topic of medical careers, I’ve noticed extensive interest in nonclinical career options for physicians. These include jobs in health care administration, management consulting, pharmaceuticals, health care financing, and medical writing, to name a few. This anecdotal evidence is supported by survey data. Of over 17,000 physicians surveyed in the 2016 Survey of America’s Physicians: Practice Patterns and Perspectives, 13.5% indicated that they planned to seek a nonclinical job within the subsequent one to three years, which was an increase from less than 10% in a similar survey fielded in 2012.

The causes of this mounting interest in nonclinical work have not been adequately investigated. Speculated reasons tend to be related to burnout, such as increasing demands placed on physicians in clinical practice, loss of autonomy, barriers created by insurance companies, and administrative burdens. However, attributing interest in nonclinical careers to burnout is misguided and unjustified.

Physicians are needed now – more than ever – to take on nonclinical roles in a variety of industries, sectors, and organizational types. By assuming that physicians interested in such roles are simply burned out and by focusing efforts on trying to retain them in clinical practice, we miss an opportunity promote the medical profession and improve the public’s health.

Supporting medical students and physicians in learning about and pursuing nonclinical career options can assist them in being prepared for their job responsibilities and more effectively using their medical training and experience to assist various types of organizations in carrying out missions as they relate to health and health care.   

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