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Video: Healthcare Reform: Putting Patients First

July 30th, 2009 by Dr. Val Jones in Announcements, Health Policy, Video
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Better Health bloggers from across the country participated in a historic discussion about healthcare reform at the National Press Club on July 17th, 2009. I managed to condense a 3 hour event into a 4 minute video… for those of you who were unable to make it, here’s my highlight reel… Thanks to Freddie Dorn at Picture This Video for helping to create it!

Creating Cost-Efficient Primary Care Medical Practices By Using 21st Century Technology

July 29th, 2009 by AlanDappenMD in Primary Care Wednesdays
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Few business models can top the inefficiencies, high costs, and overuse of manpower as primary health care.  Every minor infection,  cut, runny nose, goopy eye, hack, itch, rash, low back pain, stomach ache, urinary tract infection, tick bite, bee sting … ad infinitum must run the required gauntlet of the five-office-staff  “touch points” in order to be treated.  Let’s count them:

1. Scheduler,
2. Reception / intake window,
3. Nurse,
4. Check-out window, and
5. Billing specialist

Once you’ve seen your doctor and interfaced with all of the “touch-point” staff, next comes the game of musical chairs between the patient, doctor, and insurance company to see who’s going to pay the bill. This game often lasts months and includes pitched battles before a resolution is reached, typically when someone gives up resentfully from sheer exhaustion. All this hassle might be understandable for a surgery, hospitalization or very expensive procedure, but instead we play this game for the simplest booboo. For day-to-day care, this translates into the American people playing this game at least 5 million times a day.

Every practicing family physician/internist’s office employs roughly 4.5 full-time people per provider who slog through the piles of paperwork needed in a third-party driven model. On the insurance side, it can be an even higher body count, with staff lined up to review the claims, police transactions, audit doctors’ notes, data mine patients’ data, review negotiated rates to be paid to each physician, and cut the checks.  Instead of a model where the patient gets a direct service and pays an immediate and transparent price, we create the illusion that health care is “free” and then wonder why it costs so much money to see the doctor. Just look at the people we need to pay in order to receive our free care.

Automation has not reached health care as it has with nearly every other U.S. industry. Rather than streamlining healthcare through technology, we instead keep adding new layers bureaucracy, including administrators who find purpose by helping to improve the authorization process, or the reminder systems for patients not to miss their appointment, or the services which broker the whopping cost of care if  the patient gets stuck with the bill, or act as navigators of  “the system” for people who need to figure out who to see next in the process of care. To stay viable, twenty-first century medical care will have to address these inefficiencies because they create barriers to rapid and transparent care.

The ideal future family doctor’s office will be automated and render most office staff obsolete.  Patients will schedule an appointment online without the hassle of a receptionist. Doctors and nurse practitioners will answer incoming phones and emails from their patients thereby immediately addressing medical questions, thus reducing delays and getting 50% of people what they need without an office visits when one isn’t needed. Patients will log-in and get copies of their personal health records that are linked to the doctors’ electronic medical record so that they can have a copy of their labs, vaccines, and update their own personal information whenever they need it.  The bill for service will become transparent, immediate and mostly policed by the patient who has a personal stake in the price. No one cries “foul” faster than a person who sees a bill and wonders if he’s been ripped off.

By re-engineering the dynamics of the office visit, far fewer doctor’s office of the support staff are required.  Instead of the 4.5 full-time staff per provider, a practice set up like what we’ve done at DocTalker Family Medicine requires only one employee per provider. The DocTalker model, which is a cash-only practice, uses computer, telecommunications and internet technology to enable the clinician to perform functions previously done by the front and back office staff, such as the receptionist, scheduler, in-window, out-window, billing specialist, and office assistant.  Thus a person’s care is centralized through one person (the doctor) rather than many, leading to efficiency and reduction in overhead costs. If competition is encouraged, this process will only get better and less expensive.

Shouldn’t this be a consideration when overhauling cost efficiencies for healthcare reform?

Let us hope that it is.

Until next week, I remain yours in primary care,

Alan Dappen, MD

Senate Healthcare Bill Amendment Allocates Your Tax Dollars To Quacks

July 28th, 2009 by Dr. Val Jones in Health Policy, Quackery Exposed
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With healthcare costs spiraling out of control, and major rationing efforts under consideration – can we really afford to allow purveyors of pseudoscience to use up scarce Medicare/Medicaid resources? It’s hard to imagine that Obama’s administration would approve of extending “health professional” status to people with an online degree and a belief in magic – but a new amendment would allow just that. What happened to our “restoring science to its rightful place” and why are we emphasizing comparative effectiveness research if we will use tax dollars to pay for things that are known to be ineffective?

I hope someone reads and removes this amendment pronto (h/t to David Gorski at Science Based Medicine):

Here’s the language that Sen. Harkin has slipped into the 615 page Senate version of the health care reform bill:

HEALTH PROFESSIONALS.—The term “health professionals” includes—

(A) dentists, dental hygienists, primary 25 care providers, specialty physicians, nurses, nurse practitioners, physician assistants, psychologists and other behavioral and mental health professionals, social workers, physical therapists, public health professionals, clinical pharmacists, allied health professionals, chiropractors, community health workers, school nurses, certified nurse midwives, podiatrists, licensed complementary and alternative medicine providers, and integrative health practitioners;

Background Reading:

What Do Chiropractors Believe?

Acupuncture Doesn’t Work

Should Naturopaths Be Allowed To Prescribe Medication?

Homeopathy ER

Physicians Are Biased About Healthcare Reform

July 28th, 2009 by Shadowfax in Better Health Network, Health Policy
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From the department of “Credit where it’s due,” in the comments of my post on the Lewin Group, Nurse K pointed out the following:

Come on Shadowfax, you’re blogging about this stuff and you stand to make A TON of money if it goes through…for awhile…until insurance companies decrease your compensation since you’re making more per patient. I know you mentioned this before in like a comment or something, but ER docs stand to benefit (temporarily) probably more than anyone else. HUGE bias on your part.

Much as I (really, really) hate to admit it, she’s absolutely right.  In fact, I’ll go one further: I first got interested in this part of medicine policy because I was mad that I was seeing all these uninsured patients and wasn’t getting paid a thing for my efforts.  I started keeping track of the number of uninsured I saw every day, just as a pet obsession.  It was a sobering number.  After that I started getting a little perspective, talking to patients and seeing their bigger picture, understanding why they were uninsured, learning the particular challenges they faced getting health care, etc.   For me, this cause became something beyond the personal a long time ago and became a moral imperative.

But K is right to note the potential for bias, and it’s fair for me to acknowledge it.  I hope that my integrity on this point is evident.  The fact that I argued in the New York Times for an increase in primary care compensation, with an attendant decrease in the compensation of specialists, including Emergency Medicine, should speak well for my ability to see beyond personal self-interest. (God knows it didn’t make me popular in EM circles!)

This is something which struck me yesterday, reading the med blogs reaction to Obama’s presser.  Quite a few docs mounted their high horse and with great indignation denounced this:

Doctors are forced to make decisions based on a fee payment schedule that’s out there. So they’re looking… if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, “I’d make a lot more money if I took this kids tonsils out.” Now that might be the right thing to do, but I’d rather have that doctor making those decisions based on whether you need your kids tonsils out…

Now it’s a clumsy clinical scenario written by someone who has no clue about medicine.  But it’s a damned fair point.   Bias comes writ large, as in the Walter Reed orthopod who pocket $850K and falsified his research to benefit Medtronic, and it comes writ small, as in the ER doc who sees a small lac and has to decide whether to use a band-aid or a stitch, knowing that the stitches will pay 10x more.  It comes with the cardiologist who has to decide whether to take a low-grade troponin leak to the cath lab.  It comes with the surgeon seeing a patient with unusual abdominal pain and a slightly enlarged appendix on CT (you can observe or just take out the appy; guess which pays more).

Whether there’s a “fix” for that in the current reforms is debatable.  It harms our standing, however, to deny the possible existence of bias and to claim a moral purity that, as a profession, is not justified.  I think and hope that most of us in these ambiguous situations are able to come to the right decision for the patient the vast majority of the time regardless of our economic interests.  The best way to remain credible is to acknowledge the mere potential for bias and move on and debate the salient point.  Making counter-factual arguments that biases do not exist or that we physicians are too awesomely altruistic to ever be influenced by them does nobody any good.

*This blog post was originally published at Movin' Meat*

Emergiblog In DC: The Panel, the Politics and the Ce-Ment Pond

July 25th, 2009 by Emergiblog in Announcements, Better Health Network, Health Policy, Opinion
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This is Congressman Paul Ryan of Wisconsin, speaking at the Better Health “Putting Patients First” event  in D.C.

I should talk about how passionately he spoke about health care reform (he did), about why he does not believe government should be running health care (he doesn’t) or that he took the time to come and speak at 8 am even though he had been up until 2 am working on the health care bill (he did) or that he spoke right up until he – literally- had to run back to the House to vote (he did).

And I will talk about these things.

But first, let me state the obvious and get it out of the way so that I can go on to discuss the serious nature of the health care reform debate before us.

Whoa.

Seriously, is it just me or are politicians getting better looking?

There. Now I can move on to the meat of the matter.

(I had to say it because you all know I was thinking it!)

*****

This event marked my first time in Washington, and just being there is awe-inspiring. Seeing the White House from the car window took my breath away, literally. I felt like Ellie May Clampett marveling at the ce-ment pond.  The National Press Club is a museum in and of itself.  Mother Jones and I were hoping we’d catch a glimpse of Sanjay Gupta, but he must have been off doing neurosurgery or something.

*****

By now, you’ve probably read who was on the panel (Dr. Wes, DrRich, Dr.Rob, Dr.Kevin, me, and Better Health contributors Dr. Alan Dappen, Valerie Tinley, NP and “token” – his words, LOL – surgeon Dr. James Herndon).

I will tell you straight up that I learned much more than I contributed.

The panel shot from the hip and spoke from the heart. Some of us had notes, some of us illustrated our comments with anecdotes and one of us (*cough*) had no clue what was going to come out of her mouth until that moment.

I’ll give you a hint….it wasn’t Valerie…..

*****

For the record, those of us on the panel were not told what to say, how to say it or what to believe, nor were we chosen based on what we do believe.  Some discussed concepts that should be taken into account no matter what plan we end up with, others were definitely against a single payer plan run by the government (*raising hand*).

The inefficiencies of national health plans of other countries were illustrated/discussed.  This hit me later: we should look at what works in those plans, not just what is wrong with them.  We don’t have to emulate them, just learn from them, and that includes the good and the bad.  It also applies to any universal form of coverage, not just a government-run plan.

Wish I had said that at the time.

So much for thinking on my feet (or on my butt, as the case may be).

*****

There was some controversy about not having any patient bloggers on the panel.  There should have been. I hope that, as a nurse, I spoke for patients, but it was not the same as having someone there who navigates the system as a patient every single day.

The patient bloggers were in the audience, though, and if you go to Twitter you can find the live tweeting at “#patientsfirst”. There was a pretty healthy debate going on in the Twitterverse while the panel was up on the dais.

Here I am with Lisa Emrich (Brass and Ivory) and Kerri Morrone Sparling (Six Until Me). Duncan Cross was also there, but my pic was blurry!

*****

While health care reform has been a hot topic for awhile, it was especially acute this week as the President was actively promoting a government run health care system and there seemed to be a huge sense of urgency to get what is called “America’s Affordable Health Choices Act of 2009″ passed ASAP.

The bill is over 1000 pages long.

I just downloaded it.

And Congress has not read it.

Folks, our representatives are being asked to pass legislation they have not had a chance to read.

While I will admit to being a bit unsure of exactly what happens in the Beltway (Civics classes and Schoolhouse Rock’s “I’m Just a Bill” notwithstanding), that can’t possibly be business as usual.

Can it?

*****

I’ll say one thing: no matter what we believe, why we believe it or what our role is in the health care system, it is a conversation rife with strong opinions and passionate debate.

And, in the end, because we are all patients in one form or another at some point in our lives, the conversation is about us.

So, when you hear the phrase “putting patients first”, think of it as “putting me first”.

That may help you get a foothold in the morass of information that is the health care debate.

It worked for me.

*This blog post was originally published at Emergiblog*