June 11th, 2012 by Dr. Val Jones in Health Policy, Opinion
Tags: DocTalker Family Medicine, Physician Shortage, Primary Care, Squeezing Out The Doctor, The Economist
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I don’t read The Economist frequently enough to be sure that I dislike its entire staff of writers, but I have been repeatedly disappointed by its health coverage. In this latest article, “Squeezing Out The Doctor” the writers describe the increased healthcare needs of an aging western civilization, combined with a relative shortage of physicians to care for seniors. The conclusion? This is a “win” for patients.
Now, in case you find that conclusion as irrational as I did, let me summarize how they arrived there. The argument goes something like this: doctors have been unfairly controlling the practice of medicine for the past century, and now with the oncoming flood of patient need (and relative MD shortage), they won’t have time to do everything they have in the past. Physicians will therefore be forced to narrow their scope and outsource many of their current tasks to nurses and support staff. This is a win for patients because they will have shorter wait times for care and lower healthcare costs with the same care quality because most of what doctors do can be replicated by ancillary staff. At last we will be able to remove the self-important, over-educated, control freak physicians from the delivery of healthcare!
Oh, here’s another great idea: why don’t we improve our school systems by squeezing out the teachers? Who needs teachers when mature students could train others in the same subject matter? Most of what teachers do is just baby sitting, right? We could easily outsource that to daycare centers or teens with a little baby sitting experience. The few teachers we retain should be reserved for only the most difficult cases: severe learning disabilities. Just think of the cost savings in teacher salaries! Imagine the improved access to schools if we didn’t have to adhere to some arbitrary teacher to student ratio. What a win for students. The only possible downside is that teachers may lose some of their current social standing, but so what?
The oncoming physician shortage will not bring the glorious improvements in healthcare delivery touted by The Economist. More likely it will create a two-tiered system whereby the poor and underinsured will get a substandard level of care. If you think that only doctors balk at long hours for low pay, try pitching that deal to nurses. They are just as savvy as physicians about personal economics. Having them take over primary care under the current (or worsening conditions) will burn them out just as quickly and nurses will specialize or quit nursing in droves. There is no magical, “let’s just get someone else to do it for less” model in healthcare when we’re already scraping the bottom of the barrel in terms of ROI for providers of any stripe.
Physician scarcity can be ameliorated by setting doctors free to spend more of their time in patient care, and less of it on distractions (such as excessive documentation for coding and billing purposes). But the solution is not necessarily outsourcing that work to someone else. It’s killing it all together. Radical idea? My practice is doing that now and growing a thriving business to boot.
Primary care doesn’t have to be expensive. Most patients need less than a full hour of a physician’s time per year, an annual cost of about $350. In my practice, we bill for our time and we spend it however it makes best sense for the patient – via phone, email, office visit, or house call. It’s in our interest to see as many patients as possible, and therefore we are increasing access to services. Office wait times are non-existent because many issues can be handled via phone (patients are not required to come to the office for every and any request for the sake of billing).
What’s the catch? We don’t accept insurance. Patients can submit claims to their carrier for reimbursement for our out-of-network services, but we have opted out of public and private insurance plans so that we can spend our time with patients instead of coding, billing, and being beholden to third party documentation requirements and regulations. This system works marvelously for any patient open-minded enough to see that a high deductible health insurance plan (for catastrophic coverage only) saves them thousands per year in premiums, while their primary care “out of pocket” will cost a few hundred or less. The math works for all. Access is improved, costs decrease, quality is maintained.
Now that’s a true win for patients.
June 9th, 2012 by Dr. Val Jones in Health Policy, Opinion, True Stories
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A patient was having difficulty swallowing her pills, so her doctor suggested that she might try peanut butter to help the medicine go down. Unbeknownst to the doctor, the patient assumed that this meant that she should mix all her prescription meds into a jar of peanut butter and scoop out a spoonful each day to spread on her toast at breakfast time. This practice was discovered during a home visit by a nurse a few weeks later, who relayed the potential “compliance issue” to the patient’s physician.
Clearly peanut butter is a sub-optimal storage mechanism for prescription medications, and dosing will likely present a challenge in this scenario… However the real message for me is that home visits are critical to understand how (and what) our patients are doing. All the claims data in the world is a poor substitute for the information that can be gathered in a simple house call.
Health insurance companies have gotten this message. Last month I began working for an agency that helps private insurers risk-adjust their Medicare Advantage client pool. In short, private health insurance companies contract with the feds to cover richer benefits for Medicare members who wish to kick in a little extra in premium. The government subsidizes this premium for the members based on their illness severity score (the sicker the patient, the higher the rate paid to private insurers to cover them).
But who knows how sick these members are? Health insurance claims data (diagnosis codes collected over the course of a patient’s lifetime) don’t correlate well with actual illness and current conditions, nor are these codes easy to get one’s hands on in the first place. Multiple previous carriers, incomplete medical records, various specialist physicians with paper charts or EMRs (that don’t talk to one another) all contribute to the poor data quality. So, as expensive a proposition as this is, private insurers are paying independent physicians to make house calls to tease out what’s actually going on with patients.
This process has been eye-opening for me in ways I hadn’t anticipated. First of all, I have a much better sense of how older Americans are actually living their lives by visiting them in their homes. I’ve gotten to know about the importance of family, the value of good caregivers, and the surprising lack of correlation between wealth and happiness. Second, I’ve gotten a sense of primary care quality in rural settings, and how communication break downs occur between patients and physicians. And third, I’ve developed an even deeper appreciation for the complexity of keeping people out of the hospital. Even the most well-intended advice can be “operationalized” in strange and wonderful, peanut-buttery ways.
I thought it might be helpful if I shared my experiences with you via my blog (patient privacy respected always, of course), so that we can explore the intersection between real life scenarios (discovered during house calls) and potential health policy. So stay tuned for more… 😆
January 6th, 2012 by Steve Novella, M.D. in Opinion, True Stories
Tags: Alternative Medicine, Anecdote, CAM, Cancer, Cancer Cure, Claims, Diet, Dr. Ian Gawler, Evidence Based Medicine, Meditation, Science, Treatment
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Dr. Ian Gawler, a veterinarian, suffered from osteogenic sarcoma (a form of bone cancer) of the right leg when he was 24 in 1975. Treatment of the cancer required amputation of the right leg. After completing treatment he was found to have lumps in his groin. His oncologist at the time was confident this was local spread from the original cancer, which is highly aggressive. Gawler later developed lung and other lesions as well, and was given 6 months to live due to his metastatic disease.
Gawler decided to embark on an alternative treatment regimen, involving coffee enemas, a vegetarian diet, and meditation. Eventually he was completely cured of his terminal metastatic cancer. He has since become Australia’s most famous cancer survivor, promoting his alternative approach to cancer treatment, has published five books, and now runs the Gawler Foundation.
At least, that is the story he believes. There is one major problem with this medical tale, however – while the original cancer was confirmed by biopsy, the subsequent lesions were not. His oncologist at the time, Dr. John Doyle, assumed the new lesions were metastatic disease and never performed a biopsy. It was highly probable Read more »
*This blog post was originally published at Science-Based Medicine*
January 5th, 2012 by DavidHarlow in Health Policy, Opinion
Tags: ACP, Avastin, CMS, FDA, Guidelines, Health Reform, Mammography, Medical Ethics, NPR, Physicians, Policy, PSA, Reform, Shared Resources, Tragedy of the Common
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There are at least two conversations going on in the health care marketplace today, each focused on one of two key questions. One is: How can we achieve the Triple Aim? The other is: Why do they get to do that? (It’s not fair! I want more!)
Until we stop asking the second question, we can’t answer the first question. Why? Because all too often the answer to the second question is the equivalent of: It’s OK, Timmy, I’ll buy you TWO lollipops; pick whichever ones you want.
It’s the tragedy of the commons, transposed to the health care marketplace.
Recent cases in point:
- Avastin
- Tufts Medical Center – Blue Cross Blue Shield of Massachusetts grudge match
- Mammography and PSA guidelines
1. Avastin. Late last year, Read more »
*This blog post was originally published at HealthBlawg :: David Harlow's Health Care Law Blog*
January 4th, 2012 by KerriSparling in Opinion, True Stories
Tags: Blood Sugar, Bolus, Dexcom, Diabetes, Glucose Monitors, Highs, Hydration, Injection, Insulin Pump, Ketones, symptoms, Thirsty, Type 1
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High blood sugars come in three different tiers for me: No Big Deal (NBD), Tricky Little Sucker (TLS), and What The Eff (WTE).
No Big Deal (NBD) highs are the ones I see when I first hear the Dexcom BEEEEEEEP!ing. They are the 180 – 240 mg/dL highs, where I’m cruising out of range, but not so far outside that it takes hours to correct. The NBD highs are usually mild in their symptoms (kind of thirsty, sort of tired, maybe wouldn’t have noticed if the Dex hadn’t hollered) are thankfully short in their duration, so long as I’m on the ball about keeping tabs on my blood sugars.
Tricky Little Sucker (TLS) highs are obnoxious pieces of garbage that hang on for hours. These highs are the ones where you hit anything over 200 mg/dL and just ride there for hours. HOURS. Like you can undecorate the Christmas tree and pack up all the holiday nonsense back into the attic and STILL find yourself rolling outside the threshold. They’re the ones that Read more »
*This blog post was originally published at Six Until Me.*
