The Health Care Blog – Page 237 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Must Waiting Be Inherent To Medical Care?

Dec 1, 2018

By LISA GUALTIERI

“By the time you see the doctor, you’re either dead or you’re better,” my mother-in-law told me. She had to have multiple tests, all with long waits to get the appointments and the results, before her health insurer would allow her to make an appointment with a specialist.

“Waiting is the bane of the medical system,” a former student, an R.N., concurred. Advances in medicine and technology have improved medical outcomes, but have often resulted in more waiting at a time when every other aspect of life is speeding up. Waiting is a systemic problem exacerbated by advances in medicine and by health care reform.

Some of the ways we wait:

Wait to see if the symptoms go away or get worse. We all struggle with these decisions: do we need to be seen about the fever, back pain, or rash? Sometimes we wait because of denial or hopelessness; sometimes because of the cost or availability of medical care. I make decisions about when I need to see the doctor by asking myself if, under the same circumstances, I would take one of my children to the doctor.
Wait to get an appointment scheduled. I’ve made appointments for a sick child by channeling an old friend who could be relentless: “That is not acceptable. I need an appointment today.” Obnoxious but it sometimes worked. The rest of the time, though, the period between making and having an appointment can feel very long.
Wait to get to the appointment. Doctors and hospitals are more abundant in Greater Boston, where I live, than in other places, although traffic and parking can be problematic. Melody Smith Jones described a man’s six hour commute to see a doctor.
Wait to be seen by the doctor. It isn’t called the waiting room for nothing.Dr. Atul Gawande wrote in The Checklist Manifesto about people in the waiting room getting irate when he was running two hours behind on a hectic day. Being irate – or anxious or bored – is unlikely to increase the quality of physician-patient communication.
Wait in the examining room. At least in a waiting room you are dressed. If it is cold and you are wearing a paper or cloth johnny, distractions don’t work as well and examining rooms have fewer than waiting rooms.
See the doctor. Nowadays, as my mother-in-law recounted, you have to wait for the doctor to review your records before even looking at you. I find it surprising that physician rating systems give equal weight to wait times as they do to “communicates” and “listens”, when the latter are so much more important.
Wait in the lab. The selection of magazines is skimpier. You may be reviewing what you were told not to eat or drink: will that cup of black coffee skew the results?
Wait for lab results. If there are any non-routine reasons for testing, this can be interminable. I leave a lab asking when results will be ready and then I call. A former student told me about using Harvard Vanguard’sMyHealth Online. She said, “I love getting the lab results immediately online but I can see how those without clinical training could be overwhelmed or confused by the data and how to interpret them.”
Wait for the doctor’s interpretation of lab results. Lab results can be hard to decipher without clinical training, as my student said above. Even when I know results are available and the doctor has seen them, it can take many phone calls to obtain the doctor’s message via the secretary. Asking the doctor follow-up questions takes even longer. These are waits with a cell phone never turned off so you don’t miss the call.
Loop. You think you’re done but you may need to see a specialist, get a second opinion, or have more tests. As my mother-in-law pointed out, this process can be controlled more by insurance companies than by doctors’ availability. Another type of waiting also takes place now: waiting to get better. A friend bemoaned how she “couldn’t wait” for her black eye resulting from a fall to clear up because she was tired of people staring at her.

Requiem for the CLASS Act

Dec 1, 2018

By Trudy Lieberman

On Friday, the stepchild of health reform died at the hands of the Obama administration, and the obits for the troubled long-term care program were mostly similar recitations of why the administration was not going forward to implement that portion of the Affordable Care Act, how it was part of Ted Kennedy’s legacy, and how gleeful Republicans were at its demise.

The media amply quoted Senators Mitch McConnell of Kentucky and John Thune of South Dakota. Thune’s quote in The New York Times, “the Obama administration ignored repeated warnings about the financial solvency of this massive new entitlement,” gives a flavor of what they said.

The CLASS Act, short for the Community Living Assistance Services and Support Act, was a voluntary program where people could join a government plan to pre-fund some of the long-term care they might need in the future. Under the plan they would pay premiums during their working years. If they later became disabled and needed assistance, they would be entitled to a daily cash benefit of say, $50, that they could use to buy services such as a personal care attendant, home improvements that would let them stay in their house, or even to help pay nursing home costs.

Supporters saw the CLASS Act as a first step toward a national long-term care insurance program like those in other countries. Whatever its technical flaws, supporters argued that it would begin to solve the dilemma millions of families face—how to pay for a loved one’s care. Many politicians and the insurance industry weren’t keen on that idea since it could also be a first step to a publicly-financed insurance program (anathema to insurance sellers) and might cut into the market for long-term insurance, a product that has never really become a big seller primarily because of its high cost. The CLASS Act barely made it into the final bill.

Bucking the Established

Dec 1, 2018

By DR. WES

“Out with the old, in with the new!”

Who’s your doctor? Do you have one?

If you have one, you aren’t that interesting to them any longer because you’re “established.” This is not the fault of your doctor, but because of government rules for paying doctors: “new patient” visits pay better than “established patient” visits. “New patients” have a much better chance of needing new procedures, so they are even more special. Add to that the fact that more and more patients are going to need to become part of the “system” soon, and “new patients” quickly achieve the health care value trifecta.

Sorry. Those are the rules.

The higher payments made by insurers and government agencies for new patients was meant to offset the longer amount of time and cognitive challenges of dealing with a new patient that enters the doctors office. There is no question that there is more work to do when a new patient enters a medical facility: entering demographic data on a computer, actually taking a set of vital signs, performing a careful history and physical. But thanks to the explosion of ancillary health care assistants, imaging studies, the availability of the internet, and a constant push to do more in less time, doctors work differently today than they once did. Much of the data gathering is accomplished before the patient enters the office, imaging studies and baseline testing often occurs before a patient is even seen (remember those tests “required” for “quality” care?). Furthermore, because limitations for the frequency of testing has been imposed by government regulators, health care systems leap at the opportunity to “direct” doctors to order tests the moment the test might be needed. As such, “new patients” become particularly valuable to health care systems compared to “established” ones.

The Meaningful Use Song (with Apologies to Gilbert & Sullivan)

Dec 1, 2018

By MARGARET POLANECZKY, MD

As billing compliance leader in my department, I’ve been charged with getting my colleagues on board with Electronic Medical Record Meaningful Use. (What does meaningful use have to do with billing? It’s complicated, but the codes up until now have been reported along with billing codes, so it sort of fell into my lap. Lucky me…)

Generally, meaningful use refers to using the EMR in a way that harnesses its immense power to store and retrieve data in a way that makes sense and potentially improves clincal outcomes- by checking for drug interactions in real time, for example, or to track blood sugars, blood pressure or other data, or to allow for electronic prescriptions and shared data between clinicians using common language.

Specifically, when we say “meaningful use” these days, we are referrring to the list of meaningful use standards developed by CMS – a very specific list of 25 objectives, along with defined quality measures (like percent of women getting mammograms) that will be used to report and track health outcomes in practices using EMRs.

CMS is offering financial incentives to medical practices to use their EMR in a meaningful manner this year. We will be reporting data starting in October 1 to CMS, and must meet 20 of the 25 meaningful use objectives and report outcomes on chosen quality measures to qualify for the incentive payment. In addition, we are reporting separately to the government on the use of electronic prescribing, and face possible penalties for docs who are still stuck on paper. In time, our outcomes on the quality measures will be reported to the public on the CMS website.

Does Meaningful Use Improve Clinical Outcomes?

That’s the 20 billion dollar (the amount 2009 Hi-Tech Act allocated to the meaningful use incentive program) question. We really don’t know as yet whether or not EMR use itself favorably impacts patient care. Some studies say EMR usedoes not improve health outcomes, but more recent studies of diabetes care and in low resource areas have suggested that EMR use may be beneficial.

We also have no idea if docs who attain meaningful use are better docs than those who don’t. Despite this, the CMS website will have clear implications as to the outcomes of doctor’s practices in terms of standard quality measures. It’s a bit worrisome to me, especially since so many of the outcomes are driven by patient compliance (a word I know a lot of my readers don’t like, but there it is…) Not to mention the thorny issue of using mammogram screening in women over 40 as an outcome measure when we just decided that it is no longer recommendedto routinely perform it in everyone. (Don’t get me started on that issue again…)

Overall, I think meaningful use is a step in the right direction

I do see meaningful use as an attempt to rein in the wild, wild west of EMR development to try to create some standardized functionality and communication. It’s also a way to begin to corral the freestyle and autonomous EMR use that has evolved among early EMR users, who did what they needed to do to get their work done during the evolution of the EMR around them, but who now need to step back and reassess how well (or not) they are using this powerful tool that has been foisted upon them.

But my god, this whole process has been painful.

And so damned complicated, I needed a song to keep it straight. Ergo that parody up there, which actually covers all 25 meaningful use requirements as defined by CMS. (or at least as I see them…)

Of course, I could have just learned the Meaningful Yoose Rap. But please… me singing rap?

Margaret Polaneczky, MD, is a board certified obstetrician-gynecologist and Associate Professor of Clinical Obstetrics and Gynecology at Weill Medical College of Cornell University in New York City. Her blog, The Blog That Ate Manhattan, started out as a food blog and eventually evolved to cover food, medicine, her life and her opinions, and an occasional silly song. This post originally appeared at TBTAM.

The White Coat

Dec 1, 2018

By DINOSAUR MD

I have not worn a white coat since I opened my own practice more than twenty years ago.

Not that I had anything against white coats in principle. I wore my short white one in med school with pride, and the longer one in residency too; their pockets filled to bursting with the 4 x 6 inch six-ring binder emblazoned with my name in gold, courtesy of Burroughs-Wellcome, the long-defunct pharma giant, which had presented one to each medical student in the US for many years, as well as assorted pens, note cards, alcohol wipes, hemoccult cards, and so forth. I even had a tiny teddy bear pinned to my lapel, my own way of personalizing the impersonal.

When I went out on my own, though, I made the conscious decision not to wear one. I confess that all these years later, I don’t completely recall my thought processes on the subject. It seemed pretentious, especially since I was the only doctor in the office and therefore not easily confused with other staffers. Little kids were scared of them, held the common wisdom. I decided that I wanted to project a warmer, less formal tone now that I was out on my own and could do whatever I wanted. Don’t get me wrong: I took pains to remain quite professional. I wore skirts, hose, and heels (sensible low ones, of course) at all times.

Patients noticed, and often commented. My explanations were accepted. It was my style, and I’ve always been comfortable with it. Even when a broken foot 10 years agoled me to begin wearing slacks instead of skirts, I never even considered wearing a white coat.

A SOCIAL Approach to Health Reform

Dec 1, 2018

By Richard Reece, MD

Every Sunday, I read the Sunday NYT in search of ideas for a blog. Today is no exception. I found the idea in Thomas Friedman’s column, “The New IT Revolution,” in which he holds forth as follows,

“The latest phase in the IT revolution is being driven by the convergence of social media- Facebook, Twitter, LinkedIn, Groupon, Zynga- with the proliferation of cheap wireless connectivity and Web-enabled smart phones and “the cloud” – those enormous server farms that hold and constantly update thousands of software applications, which are then downloaded (as if from a cloud) to make them into incredibly powerful devices that can perform myriad tasks.”

The SOCIAL Acronym

Friedman then goes on to quote Marc Benioff, founder of Salesforce.com, who describes this phase of the IT revolution with the acronym SOCIAL.

• S is for Speed – This means physicians and patients can find anything and everything about health care (and each other),

. O is for Open – This means physicians are out in the open and can no longer hide their results or reputation.

• C is for Collaboration – This means physicians must organize among themselves or affiliated hospitals or into loosely coupled teams to take on the new challenges posed by society in general and health reform in particular.

• I is for Individuals – This means anyone – physicians, patients, and entreprenuers – as individuals can reach around the globe to start something or collaborate or consolidate to improve care – faster, deeper, and cheaper – as individuals.

• A is for Alignment – physicians with each other or with supportive health organizations to make sure all your ships are sailing in the same direction.

• L is for Leadership – This means physician leaders are going to have to mixs top-down and bottom-up forces – from public and private sectors – to provide what is best for themselves, patients, and society.

Is the Era of Off-Label Promotion Over?

Dec 1, 2018

By MERRILL GOOZNER

The question arises in the wake of yesterday’s news that the government and GlaxoSmithKline settled a string of lawsuits charging the company with illegal promotion of prescription drugs for unapproved uses. The $3 billion settlement represented just a small fraction of the sales to patients for whom the off-label prescriptions either caused harm or did little or no good.

Glaxo’s chief executive Andrew Witty, in a prepared statement, assured the public that his company has “fundamentally changed our procedures for compliance, marketing and selling in the U.S. to ensure that we operate with high standards of integrity.”

Judging by the number of seminars and conferences over the past few years designed to help companies meet the legal requirements for promoting drugs, there would certainly appear to be a lot more attention being paid these days to staying within the law. There have been 165 settlements between the government and drug companies over the last two decades, and the more recent settlements — $2.3 billion from Pfizer and $1.4 billion from Eli Lilly — have achieved blockbuster status (a word usually reserved for drug sales above $1 billion). While that is affordable for the highly profitable industry, settlements of that size do tend to capture the attention of top company officials and begin to tip the risk-reward ratio for illegal activity toward better compliance with the letter of the law.

Cold Hard Facts or Cold Hard Doctors?

Dec 1, 2018

By Andrew Robinson

I was first diagnosed with leukemia while travelling on a vacation in 1994. I had a persistent respiratory infection so I went to a local emergency room to get an antibiotic. I had the usual tests, including a blood test. A doctor came into the room where I was waiting and introduced himself as an oncologist. He told me that the blood test showed that I had “a terminal and incurable form of leukemia” and “less than five years to live.” Just like that. He also added that I didn’t need to rush back to New York, as there was nothing to be done.

A few months later, I sat in an office in New York of an oncologist who specialized in my form of leukemia. His manner was soft-spoken and warm. He told me that although there was no cure for my disease, there were a number of relatively mild chemotherapies that were effective in extending patients’ lives for many years, and that given developments in research, during the additional time there may well be a cure for my illness.

It turns out that the second doctor was correct. Five years after being diagnosed, bone marrow transplants became available for people my age with chronic leukemia. I had a transplant and a few years after that there was no longer any sign of the disease.

When I inquired with physician friends about my experience with the first doctor, they spoke of doctors’ fear of instilling in patients “false hope.” In my interactions with many cancer patients, I have yet to hear of any patient who felt they were given false hope. But there were many instances of patients, like myself, who were filled with “false despair.”

Now, I can’t imagine how difficult it must be to be an oncologist, to have to tell patients that they have a terminal illness, to see them go through brutal chemotherapies, to see them die. According to one estimate, during the course of their career, an oncologist will break bad news to their patients almost 20,000 times – from first diagnosis to the news that death is near. Yet, many doctors who approach this task in a cold-hearted manner seem to justify themselves with a “tell it like it is” philosophy. Easy for them, devastating for us.

Medical science readily acknowledges the placebo effect – that many patients who believe they are getting an effective medicine show improvement in their condition even when they are in fact not getting the medicine, but are instead receiving a harmless substitute. If the effect of a patient’s positive expectations can so profoundly affect his health, what then is the impact when a patient is, from the outset, given the difficult news about having cancer in a manner that so discourages his spirit?

Most lay people know the fundamental maxim of Hippocrates to physicians throughout the centuries: “First, do no harm.” This has always been understood to have to do with the medicines and treatments that physicians prescribe. In this day and age it applies equally to how doctors talk to and act toward their patients.

Andrew Robinson was a successful New York trial attorney when he was diagnosed with leukemia and told he had less than five years to live. That was more than 15 years ago. He is the founder and CEO of Patient2Patient, a company that develops disease specific guides to help patients learn how to locate and use medical information and resources on the Internet. This post first appeared at Prepared Patient Forum.

New Physicians, Rethink Your Career Path Before Your First Job

Dec 1, 2018

By Melissa Byington

I recently came across an online discussion started by a graduating resident who was looking for advice on how to combat burnout. While the replies that followed offered all sorts of ideas, everyone seemed to agree that a rigorous schedule and stress and strain on work-life balance is par for the course.

Somebody even quipped that when practicing medicine, you can enjoy two of the following in any combination: 1) live where you want; 2) earn what you want; and 3) specialize in what you want, but it’s not possible to enjoy all three.

While many physicians would agree with that belief, I’d like to suggest considering locum tenens – this option proves that enjoying all three is possible.

Locum tenens is a highly respected practice alternative that offers physicians a full spectrum of professional opportunities in every type of practice across the country. Hospitals and healthcare facilities use locum tenens to cover for planned or sudden staff vacancies, and to strategically prepare for the highs and lows of patient demand. It’s become an especially attractive alternative for new physicians; among other things, it offers the opportunity to:

· Gain real-world experience and build skill set

· “Road test” different practice settings, options and locations so you can make informed decisions about which is right for you

· Get an insider’s view of practice management and economics

· Enjoy a flexible schedule so you can take time off to travel or pursue interests outside of medicine

· Fill in the gap between residency and fellowship

· Pay off medical school loans before making more financial commitments

· Spend more time practicing medicine and forgo the politics

Don’t gamble with your career

Practicing medicine as a locum tenens buys you time to find your dream job while building up your CV. By working at a variety of practice models, you are demonstrating the ability to adapt to all different practice settings which can give you an edge over competing job candidates when the time is right.

If locum tenens interests you, it’s well worth your time to research healthcare staffing firms to help you find and prepare for job opportunities. Key considerations should include the company’s breadth of resources and contacts, as well as its reputation for integrity and customer service. Of course, pay is important but it’s only part of the picture; you want to be covered from travel and housing to licensure, credentialing and malpractice. A good resource to help you get started is the National Association of Locum Tenens Organizations (NALTO), an industry organization that ensures the fair practices and collaboration of physician staffing organizations.

Locum tenens is a career choice that puts new physicians in the driver’s seat. The work-life balance that eluded your predecessors is now within your reach—yes, you can have it all!

Melissa Byington is president of the locum tenens division of CompHealth, the nation’s leading provider of temporary and permanent physician staffing. She is also a current board member and past president of NALTO.