August 12th, 2009 by Gwenn Schurgin O'Keeffe, M.D. in Better Health Network
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During a recent emergency room shift, I treated a 12 year old boy for a swimmer’s ear. During the visit, I learned he was from the South and was in the area visiting relatives before starting school in a couple weeks. It turns out he’s been battling this pain for a couple weeks and his mom is convinced it’s because of all the swimming he’s done this summer. Instead of rushing him to his own pediatrician at home, she has been “riding it out” to see if the pain resolved on it’s own.
This was true music to my ears! Most parents rush their kids to the doctor at the first sign of ear pain, even though the current recommendations are to not use antibiotics in this age group unless the pain persists or worsens past the first few days. So, if his exam were abnormal, my decision making process would be much simpler.
What wasn’t music to my ears was learning I was the second physician to see the boy that week. The grandmother took him to see her physician when she had a scheduled appointment a couple days earlier, “just for a curbside” and learned that he did in fact have “an ear infection”. No medications were given or appointment facilitated with a pediatrician or other physician. This was truly just a curbside. The family was left with no alternative but to use the ER.
The ER often ends up being our only option when visiting an area out of town, isn’t it? If staying at a hotel, many do have a cool option that provides a physician call service so a physician will come to you, as I learned a couple year’s back in Disneyland. And, some cities do have free-standing urgent-care centers that can help with these sorts of non-911 situations. But, by and large, the ER is it in most areas and for most people.
What a backwards situation! The majority of sick people have situations that do not need the ER yet find themselves having to because there are simply no other options. Think about how much time and money would have been spared for this family and the system had that first physician just seen the child as an office visit and written the same prescriptions I wrote 2 days later during the ER visit. Think about the healthcare savings to the system and personal savings to families if we had the same theoretical options to the hundreds of thousands of annual after-hours urgent care visits our system sees each year but is current seeing in the wrong setting!
In the big picture, seeing a basic sick visit after hours in the ER is like trying to crack a nut with a sledgehammer. It makes about as much sense, too. The truth is we just have no place for the after hours regular sick people, which, by the way, are the majority of people who get sick after hours, especially if their doctor is in another state!
It’s really not a shock ER wait times are so long…ERs are over loaded with patient’s just like this boy. Until we find a better system, better take along your iPod and a good book should you find yourself heading to the ER. You’ll be in very good company waiting to be seen so may as well come prepared for the wait.
*This blog post was originally published at Dr. Gwenn Is In*
August 12th, 2009 by AlanDappenMD in Primary Care Wednesdays
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The year is 1989. I drive cautiously along the rutted, pot-holed, brush-overgrown trail in my four drive “Suzy Trooper,’ threading through Tsavo, Kenya’s largest National Park, to one of its most remote and premier rock climbing areas, Kitcwha Tembo. Next to me sits my friend and climbing partner Iain Allan, a crusty and adventurous Kenyan who prefers the bush to civilization.
To this day, I remember exactly the moment he makes his pronouncement. Maybe it’s the lighting, or the elephant that has just blocked our road passage moments ago, or the fact that vigilance is critical to not being left stranded and risk becoming part of the food chain. On the other hand, Iain is always colorful. “ Alan,“ he said, reminiscing about his more than twenty years of guiding foreigners on adventure safaris through Kenya. “Don’t get me wrong. Americans are great people. They are friendly, generous, and love to laugh. But in a nutshell there’s one thing that sets Americans apart from other nationalities. Americans don’t like surprises. If just one thing happens, even a flat tire while on safari that wasn’t predicted, it ruins the rest of their day. They can’t take a surprise. If you can predict every flat tire, they might be able to adjust with a few hours warning.”
The “pronouncement” has clung to me ever since: Americans don’t like surprises. Since then I am reminded of the pronouncement frequently. Traveling in an airport offers some of the best examples. Cancelled flights are met with enraged customers screaming and accusing ticket agents as if they hold the power of “no surprises.” I’ve seen plenty of patients leave a trail of brow-beaten staff but smile warmly once the doctor walks in the room. Most days I can feel the truth of the pronouncement as our national debate takes on tones of “Please don’t let anything bad happen to us. Please protect me, take care of me, feed me, keep me comfortable, reduce my stress, and no matter what: please no more surprises … ever!”
The no surprises stereotype might sum up the way the rest of the world sees us, but we’re blind to this. I cannot stop thinking about “the pronouncement” as it applies to health care reform. To expect fixing health care without accidents and surprises is unrealistic. Americans might be able to adjust to all the upcoming flat tires if they are given adequate warning and have an understanding of what’s really at stake.
Here are three economic conundrums to the health care debate, and whose solutions will be rife with surprises:
- The U.S. spends 17% of our GDP on health care. No where else in the world even comes close to this, with 90% of other nations spending less than 10% of their GDP on healthcare. How much money is enough? How much of the economy can be allocated to healthcare and still have a functioning economy that covers housing, food, vacation, education, energy, retirement, and the security of basic needs.
- The amount of money spent in the U.S. on healthcare doubles every ten years and has been doing so for six consecutive decades. If we don’t understand what drives these inflators, how are we to address solutions that curb the staggering unaffordable care heading our way?
- Whatever the amount of money is decided upon for healthcare in a year (and for arguments sake, let’s just say we’ll keep it at our current $2.4 trillion level for a year or two) what’s the best way to distribute this money, giving people the most options and coverage and personal choice?
I can see my friend Iain mulling these economic problems over, his face reflected by a campfire’s glow after a difficult but thrilling 5.10 climb and an unarmed descent through dense brush filled with creatures that only haunt most people’s dreams. Here sat a man who embraces danger knowing that life is nothing without surprises. How would he handle these kinds of conundrums with Americans?
“Well,” he’d say in his Scottish-Kenyan accent, “If you can predict every flat tire, they might be able to adjust within a short while. Americans are a great people… they only need to better prepare for the surprises in life.”
“That’s too bad,” I would reflect. “It feels like Americans aren’t even close to understanding the surprises that await them in the healthcare bush.”
The terrain ahead is dangerous and riddled with surprises in all directions. There are the insurance lions, lawyers ready to strike with any misstep. Let’s not forget the elephant politicians who can stomp you to death no matter the objection. Of course there are the innocent wallowing, but vicious hippos, the cape buffalo, the hyenas, the vultures… to all the animals there is a purpose and a reason, each feeding and jealously protecting their part of the $2.2 trillion per year corpulent health care body. Lastly there are all of us patients who must journey the bush, hoping that the guide we bring might be as competent as Iain.
“Iain,” I say, “What climb should we try tomorrow? Maybe we shouldn’t make it a surprise.”
Until next week, I remain yours in primary care,
Alan Dappen, MD
August 11th, 2009 by DrWes in Better Health Network, Opinion, True Stories
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It was a remarkable day in clinic yesterday.
Not because of the number of people I saw (12) or the clinical diversity seen, but rather how many people (4) asked me what I thought of the current health care reform bill before Congress.
The political spin being posed by Democrats is that people are staging town hall protests about their displeasure about the current health care reform efforts underway.
I don’t think so.
Rather, I think people are finally realizing that the health care reform proposal on the table is no longer about the “47 million” uninsured, but rather, “Hey, this health care reform thing, why, it’s about ME!”
-Wes
*This blog post was originally published at Dr. Wes*
August 10th, 2009 by EvanFalchukJD in Better Health Network, Health Policy
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If you were hoping for a thoughtful discussion on the reform of our health care system, I have bad, bad news.
It turns out that health insurers are “villians.” Public anger over the massive, mostly unread, reform bills is “manufactured,” and anxiety created by the expectation of unknown changes to people’s most valued benefits is the result of disinformation and “fishy” stories.
It’s like an employee benefits roll-out gone horribly awry.
The protests and disastrous town halls look to me just like the kinds of angry protests that happen all the time when employers make important changes to a benefit plan and the employees either don’t understand them or don’t agree.
Blaming the people who don’t follow what you’re doing and why is a big mistake. Sure, there is politics. But health care is a serious, emotional issue, and it should be no surprise that people react badly when they think something to do with it may be taken away.
Dreaming up ideas of how health care ought to work is relatively easy. But figuring out how to implement it is hard, and there are no short cuts. The people who actually run benefits plans – employers, benefits consultants, HR professionals – can tell you: there is no replacement for communication, engagement and respect for opposing views.
The strategy of demonizing those who aren’t on board is a mistake, and is as likely to set back the cause of reform as it is to further inflame an already volatile audience.
*This blog post was originally published at See First Blog*
August 6th, 2009 by GruntDoc in Better Health Network, Health Policy, Opinion
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The Happy Hospitalist, generally an excellent blogger, wrote yesterday about how salaried docs must be delivering better care than those greedy FFS docs, because the Cleveland Clinic does a terrific job with docs on a salary. I suspect their excellent outcomes have nothing to do with reimbursement model and a lot more to do with systems and a strong gatekeeper model.
He totally missed the elephant in the room in the Big Group Clinic model: who gets the money for doing the work.
He cites as an example a GI doc who left the Clinic for independent practice and quadrupled his income. Let’s say he’s working as hard as he did in the Clinic; is he billing more than the Clinic did? I doubt the Clinic wasn’t billing the usual amount for the work, so 3/4 of this docs’ billing went where?
I suspect it went into the overhead of the Clinic. This isn’t a knock on them, it works for their group, so fine. Other groups do essentially the same thing. It’s legal and morally defensible, and some docs don’t mind being salaried.
Salaried docs in a big Multispecialty Clinic have different incomes, but not as radically disparate as the non-clinic model. As a way to somewhat equalize RVRBS issues it works (I wouldn’t want to be in the room when salaries come up, though).
What salaries do not do is get docs to work harder, see more patients. Some docs are very dedicated, motivated people who would work for rent and grocery money. Others on a salary would do the minimum: if every patient is more work and more liability without more pay, well, why work more/harder? As an incentive to produce nothing beats getting paid for it.
(This isn’t an endorsement of excessive or un-necessary procedures; there are greedy jerks in all professions).
Also, a happy side effect of getting paid for what you do rather than for having a pulse is those who work hard resent those that don’t (but who would make the same on salary) a whole lot less. Way less inter-group stress.
Salaries aren’t all bad, but they’re not the Key to Great Healthcare.
Discolsure: I’ve worked ED’s both ways, and much prefer fee for service.
*This blog post was originally published at GruntDoc*
