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Does My Doctor Trust Me (and Does It Matter)?

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By JESSIE GRUMAN

Source: The Edelman Trust Barometer 2011

Members of the  American public are frequently surveyed about their trust in various professionals.  Doctors and nurses usually wind up near the top of the list, especially when compared to lawyers, hairdressers and politicians.  Trust in professionals is important to us: they possess expertise we lack but need, to solve problems ranging from the serious (illness) to the relatively trivial (appearance).

How much professionals trust us seems irrelevant: our reciprocity is expressed in the form of payment for services rendered or promised, our recommendations to friends and families and repeat appearances.

So I was surprised to read an article in the Annals of Family Medicine describing a new scale to measure doctors’ trust in their patients.  This scale, based on input from focus groups and validation surveys of physicians, was developed for research purposes on the grounds that trust is a “feature of the clinician-patient relationship that resonates with both patients and clinicians.”

Hmmm. I hadn’t really thought about trust being a two-way street in my relationship with the doctors and nurses who take care of me.  But given the push for us patients to become actively engaged in our health care, it’s not surprising that questions would arise about how dependable we are as partners. And it is a sign of the times that as clinicians increasingly face incentives to deliver evidence-based medicine and are held accountable for our health outcomes, our trustworthiness as partners has become professionally, if not economically, important to them.

While this new scale is only a research tool, its creation nevertheless raises interesting questions about how traditional notions of trust in medicine are changing in the new clinician-patient relationships that the media urges us to forge. So let’s examine it as a reflection of the idea of physicians’ trust in their patients.

Here are nine of the 18 items of the trust scale.   Clinicians are asked:Continue reading…

Remember: Technology is but a Tool

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By JOHN MOORE

Yesterday, Chilmark Research participated in the CRG conference, Driving Change Through Managed Care IT from Provider Payments to Quality, which was held in New York City. Despite having a title that no one will be able to remember, the overall theme of the event and presentations therein gave one a bird’s eye view into what payers are thinking as we march forward with healthcare reform and the digitization of the healthcare sector.

A common theme that repeated itself numerous times over the course of the day was the lack of business process maturity in the healthcare sector. Meg McCarthy, EVP of Innovation at Aetna was the first to make this statement citing this issue as arguably the number one challenge for this industry sector to overcome. (McCarthy provided some interesting details on the Medicity acquisition but we’ll save that for a later date.)

Later that day, Jessica Zabbo, Provider Technology Supervisor at RI-BCBS gave a very detailed presentation on her company’s experiences working with providers on the adoption and use of EHRs. Over the last several years RI-BCBS has done a couple of small pilots. In both cases a defining parameter of success was business process maturity. For example, the company did a Patient Centered Medical Home (PCMH) pilot that coupled pay for performance metrics (P4P) with EHR use. Basically P4P measurements were to be recorded and reported through the EHR. One of the key lessons learned was that P4P program success was highly dependent on the EHR being fully implemented and physicians comfortable with its use (process maturity). But in a Catch-22, to successfully incorporate P4P metrics into the EHR requires a very deep understanding of practice focus and workflow. Without that understanding, failure of the P4P program is almost certain.Continue reading…

Oregon Death with Dignity Act vindicated

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To no one rational’s surprise, a study confirms that those few Oregon patients (400 over 10 years) who chose legal physician assisted suicide in case of terminal illness had a better quality of death than those who didn’t. Sadly because those attacking it aren’t rational, this won’t end the debate–but if you’re terminally ill you have better choices in Oregon (and Washington & Switzerland).

ACOs: Unicorn breeding rules emerging

Mark Smith, the President of the California Health Care Foundation, jokes that ACOs are like unicorns–mythical beasts that no one has yet seen. Well today Politico reports that–just like the Kennel club certifying a new breed of dog–CMS is about to come out with 1,000 pages of regulations telling us what an ACO is and what it can and can’t do. Should be fun.

The Cost of Apples

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By SAMUEL YANG

Up until last May, my experience of medical costs was limited to the $100 per month premium I contributed towards my employer-sponsored insurance and the nominal co-pays associated with well-child checkups and generic prescriptions. There was never any hesitation in seeing a doctor or filling a prescription. That all changed when went I back to school.

I blindly signed up for the school-recommended family insurance and naïvely assumed myself, my wife, and my two young children would receive whatever health care we needed at a relatively small co-pay. The upfront premium of $10,000 was high, but I believed that this would cover whatever life threw at us. However, two experiences woke me up from my ignorance: my wife’s endoscopy and a visit to the pediatrician.

In July, my wife was sent by her doctor to get an endoscopy to determine the cause of her stomach pain. In the weeks following her procedure, we started receiving statements from our insurance company.

The statements declared that we were responsible for the full amount. We received the following explanation from our insurance company, “We don’t cover preexisting conditions.”

As we argued with the insurance company, the hospital bills started trickling in: $1200 from the outpatient center, $200 from our family physician, $400 for the anesthesiologist and $200 from the lab. We received six bills demanding $2600 for one procedure. As I examined the bills I was shocked by the redundancy—why is the cost for the anesthesiologist not included in the outpatient center bill? Why do I need to pay my family physician twice (the initial visit and the follow-up) for a procedure she ordered us to do? Besides feeling hung-out-to-dry by my insurance company, I felt taken advantage of by the medical system. It seemed as if everyone in that hospital wanted to include something for our visit. Continue reading…

Potassium Iodide Pills

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By DEREK LOWE

Well, the nuclear crisis in Japan seems to be causing a run on potassium iodide (KI), and not just in Japan. If news reports are to be believed, people in many other regions (such as the west coast of the US and Canada) are stocking up, and some of these people may have already started dosing themselves.

Don’t do that. Don’t do it, for several reasons. First, as the chemists and biologists in this site’s readership can tell you, it’s not like KI is some sort of broad-spectrum anti-radiation pill. It can protect people against the effects of radioactive iodine-131, which is a major fission product from uranium. It does that by basically swamping out the radioactive iodine a person might have been exposed to, keeping it from being taken up into the body. Iodine tends to localize in the thyroid gland, and that uptake and local concentration is the real problem. An unfolded newspaper will shield you just fine from the alpha particles that I-131 gives off, but not if it’s giving them off from inside your thyroid. Correction: I-131 is a beta/gamma emitter – my apologies! The point about not wanting it in your thyroid, of course, stands. . .

And this is why potassium iodide won’t do a thing to help with the other radioactive isotopes found in nuclear reactors. That includes both the uranium and/or plutonium fuel, as well as the fission products like strontium-90 and radioactive cesium. Strontium-90 is a real problem, since it tends to concentrate in the bones (and teeth), and it has a much longer half-life than I-131. Unfortunately, calcium is so ubiquitous in the body that it’s not feasible to do that uptake-blocking trick the way you can with iodide. The only effective way to deal with strontium-90 is to not get exposed to it.Continue reading…

A Normal Pregnancy Is a Retrospective Diagnosis

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By J.D. KLEINKE

The names in this article have been changed to protect the privacy of all individuals involved.

If every medical specialty has its homily for indoctrinating new members, “a normal pregnancy is a retrospective diagnosis” is the cynical soundbite for obstetrics. It is a patronizing and alarmist statement, meant to distance weary practitioners, terrify patients, silence objections from families, and establish the first defensive perimeter in the legal fortress that defines obstetrical practice in the US.

It is also the perfect, if inadvertent expression of how little obstetricians really know – and how limited the specialty is in its ability to test and expand that knowledge – thanks in part to the visceral fear inspired in patients by statements like “a normal pregnancy is a retrospective diagnosis.”

This homily serves as the opening taunt to one of the more quietly rebellious obstetrician/gynecologists (OB/GYNs) in my new book, Catching Babies. For reasons I’ll explain momentarily, the book began as an expose of the practice of high-risk obstetrics, but it quickly morphed into a novel, an ensemble drama about the brutalization of OB/GYNs during their residency training.

Continue reading…

A Growing Chorus on the RUC

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By BRIAN KLEPPER

Yesterday on Kaiser Health News, Barbara Levy MD, the Chair of the AMA’s Relative Value Scale Update Committee (or RUC), published a glowing defense of the RUC’s activities. Her article extols the work of the 29 physician volunteers who, “at no cost to taxpayers…generously volunteer their time,” “supported by advisers and staff from more than 100 national medical specialty societies and health care professional organizations.” She fails to mention that the physicians’ and organizations’ efforts to craft the RUC’s recommendations have direct financial benefit to the physicians, specialty societies and health care professional organizations whose representatives dominate the RUC proceedings.

She points to the openness and transparency of the RUC’s proceedings, noting that “the general public is able to comment on individual procedures, and processes are in place to ensure that input from all stakeholders is considered by CMS. Finally, the AMA ensures transparency of the process, making the data and rationale for each RUC recommendation publicly available.” This, from an immensely influential Committee that refuses to share the identities of its members except by their societal affiliation, that keeps its proceedings private, and that can not be observed except by an invitation from the Chair. If anything, the RUC’s goings-on have been secretive and opaque. Go into any health care professional audience and ask, as I have, for a show of hands of people who know what the RUC is. It has been virtually unknown except in wonkiest circles.

Dr. Levy also points out that, in Medicare’s budget-neutral environment, hard decisions have to be made, and that in 2006, $4 billion – a little more than  one percent of that year’s Medicare allocation – was transferred to primary care. The clear implication is that this came at the expense of specialists. But she conveniently ignores the vast majority of coding valuations that have increased specialty income while strangling primary care. (More comprehensive background on the RUC, including articles by the AMA that describe the RUC’s perspective in detail, may be found here.)

Dr. Levy’s article presumably responded to a growing chorus of recent voices that have detailed the RUC’s disastrous impact on American health care, beginning most recently last October with a Wall Street Journal expose by Anna Mathews and Tom McGinty, and an explanation in the New York Times by Princeton health care economist Uwe Reinhardt. With David Kibbe MD, I wrote about this topic on Kaiser Health News in January, calling on the American Academy of Family Physicians (AAFP) to abandon the RUC. Then Paul Fischer MD joined in with his Family Physician’s Manifesto. All this work built on the foundation of many health care professionals – John Goodson, MD; Robert Berenson, MD; Thomas Bodenheimer, MD; Roy Poses, MD to name a few – who have carefully documented the biases and excesses that have been wrought by the RUC’s shadowy process.Continue reading…

You’re Sick. I’m Not. Too Bad.

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By ELAINE SCHATTNER, MD

There’s a popular, partly true, some­times useful and very dan­gerous notion that we can control our health. Maybe even fend off cancer.

I like the idea that we can make smart choices, eat sen­sible amounts of whole foods and not the wrong foods, exercise, not smoke, maintain balance (whatever that means in 2010) and in doing so, be respon­sible for our health. Check, plus.

It’s an attractive concept, really, that we can determine our medical cir­cum­stances by informed deci­sions and a vital lifestyle. It appeals to the well — that we’re OK, on the other side, doing some­thing right.

There is order in the world. God exists. etc.

Very appealing. There’s utility in this outlook, besides. To the extent that we can influence our well-being and lessen the like­lihood of some dis­eases, of course we can!  and should adjust our lack-of-dieting, drinking, smoking, arms firing, boxing and whatever else dam­aging it is that we do to ourselves.

I’m all for people adjusting their behavior and knowing they’re accountable for the con­se­quences. And I’m not keen on a victim’s men­tality for those who are ill.

So far so good –

Last summer former Whole Foods CEO John Mackey offered an unsym­pa­thetic op-ed in The Wall Street Journal on the subject of health care reform. He pro­vides the “correct” i.e. unedited version in the CEO’s blog:

Continue reading…

Which Way Transparency Nirvana?

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By MICHAEL PAINTER, MD

First the good news—many are pushing the envelope on public reporting of health care information these days. For instance, last week the HHS/Health 2.0 Developer Challenge awarded honors to a new mobile app—using Hospital Compare data in new and innovative ways—try it. This application maps and provides some quality information as well as immediate ER waiting times for nearby hospitals. The idea of this app challenge, as you know, is to unleash moribund federal information, such as that sitting in the creaky Hospital Compare—to innovative types who will take it and create new—and, ideally, useful ways to present the information. That’s an exciting turn that makes altogether too much sense.

Then Wednesday, I had the good fortune to attend a very thoughtful AHRQ sponsored meeting on public reporting of care information for consumers.  The meeting included a good mix of consumers, employers, regional alliance leaders, health professionals, researchers and others.  Bill Roper provided the opening keynote.  The messages ranged from overt optimism about the important role of public reporting in the drive toward sustainable high value care—to the sober assessment that although public reporting has matured (some)—we may also be reaching limits.  As Steve Jencks commented—we’ve made progress—but let’s keep some perspective here—public reporting still needs some quick wins—it “isn’t quite covered in glory, just yet.”

Meredith Rosenthal, in her plenary presentation, observed that public reporting is essentially about to graduate from high school—sitting in the guidance counselor’s office trying to decide whether to go to college or trade school.  Bob Galvin, in the closing session, added—that while public reporting is indeed in the guidance counselor’s office—and it clearly has a bright future—it’s a pretty confused student.

The problem? There seems to be near unanimous sentiment—at least in this group—that public reporting of quality and cost information is critically important to drive sustainable health care quality and value. Continue reading…

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