August 12th, 2007 by Dr. Val Jones in True Stories
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This week’s host of medical grand rounds invited individuals to submit blog posts that feature stories about “sudden change.” As I meditated on this theme – I realized that one of my patients played a key role in my sudden career change from academic medicine to joining a healthcare revolution.
As chief resident in PM&R, I spent a few days a month at an inner city clinic in the Bronx, helping to treat children with disabilities. The clinic was dingy, overcrowded, largely windowless, and had waiting lines out the door starting at 8am. Home health attendants generally accompanied the wheelchair-bound children to the clinic as many of them were orphans living in group home environments. The kids had conditions ranging from cerebral palsy, to spinal cord injury from gun shot wounds, to severe spina bifida. They sat together in a tangled waiting room cluttered with wheelchairs, walkers, crutches, and various prosthetics and orthotics. There were no toys or even a TV for their amusement. The air conditioning didn’t work well, and a lone clock ticked its way through the day with a bold black and white face.
The home health aides were eager to be called back to the examination rooms so that they could escape the oppressive conditions of the waiting room. I opened the door to the room and called the name of one young man (we’ll call him Sam) and an aide leapt to her feet, knocking over another patient’s ankle-foot orthosis in the process. She pushed Sam’s electric wheelchair through a series of obstacles to the exit door and back towards the examining room.
Sam was a teenager with cerebral palsy and moderate cognitive deficits. His spine was curved into an S shape from the years of being unable to control his muscles, and he displayed the usual prominent teeth with thick gums of a patient who’d been on long-term anti-seizure medications. He looked up at me with trepidation, perhaps fearing that he’d receive botox injections for his spastic leg muscles during the visit. His wheelchair was battered and worn, with old food crumbs adhering to the nooks and crannies.
“What brings Sam here today?” I asked the home health aide, knowing that Sam was non-verbal. She told me that the joystick of his electric wheelchair had been broken for 10 months (the chair only moved to the left – and would spin in circles if the joystick were engaged), and Sam was unable to get around without someone pushing him. Previous petitions for a joystick part were denied by Medicare because the wheelchair was “too new” to qualify for spare parts according to their rules. They had come back to the clinic once a month for 10 months to ask a physician to fill out more paperwork to demonstrate the medical necessity of the spare part. That paperwork had been mailed each month as per instructions (there was no electronic submission process), but there had been no response to the request. Phone calls resulted in long waits on automated loops, without the ability to speak to a real person. The missing part was valued at ~$40.
I examined Sam and found that he had a large ulcer on his sacrum. The home health aid explained that Sam had been spending most of his awake time in a loaner wheelchair without the customized cushioning that his body needs to keep the pressure off his thin skin. She said that she had tried to put the electric wheelchair cushion on the manual chair, but it kept slipping off and was unsafe. Sam’s skin had been in perfect condition until the joystick malfunction. I asked if he’d been having fevers. The aide responded that he had, but she just figured it was because of the summer heat.
Sam was transferred from the clinic to the hospital for IV antibiotics, wound debridement, and a plastic surgery flap to cover the gaping ulcer hole. His ulcer was infected and had given him blood poisoning (sepsis). While in the hospital he contracted pneumonia since he had difficulty clearing his secretions. He had to go to the ICU for a period of time due to respiratory failure. Sam’s home health aide didn’t visit him in the hospital, and since he was an orphan who was unable to speak, the hospital staff had to rely on his paper medical chart from the group home for his medical history. Unfortunately, his paper record was difficult to read (due to poor handwriting) and the hospital clerk never transferred his allergy profile into the hospital EMR. Sam was violently allergic to a certain antibiotic (which he was given for his pneumonia), and he developed Stevens-Johnson Syndrome and eventually died of a combination of anaphylaxis, sepsis, and respiratory failure.
When I heard about Sam’s tragic fate, it occurred to me that the entire system had let him down. Bureaucratic red tape had prevented him from getting his wheelchair part, poor care at his group home had resulted in a severe ulcer, unreliable transfer of information at the hospital resulted in a life-threatening allergic reaction, and a lack of continuity of care ensured his fate. Sam had no voice and no advocate. He died frightened and alone, a life valued at <$40 in a downward spiral of SNAFUs beginning with denial of a wheelchair part that would give him mobility and freedom in a world where he had little to look forward to.
Sam’s story was the last straw in my long list of frustrations with the healthcare system. I began looking for a way to contribute to some large scale improvements – and felt that IT and enhanced information sharing would be the foundation of any true revolution in healthcare. And so when I learned about Revolution Health’s mission and vision, I eagerly joined the team. This is a 20 year project – creating the online medical home for America, with complete and secure interoperability between hospitals, health plans, healthcare professionals, and patients. But we’re committed to it, we’re building the foundation for it now, and we know that if successful – people like Sam will have a new chance at life. I can only hope that my “sudden change” will have long lasting effects on those who desperately need a change in healthcare.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 20th, 2007 by Dr. Val Jones in Health Policy
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Dinah at Shrink Rap had all her Medicare billing sheets returned to her this week. She had neglected to use the new forms with “red dropout ink.” These forms are not provided by Medicare, but must be purchased by the psychiatrist from a government or commercial printer. Good luck figuring out which parts of the form you’ll need, Dinah – seems as if there are many different versions (snapouts, continuation sheets, single sheets, part 1 and part 2) and they’ll cost you more than a few psychotherapy sessions will be reimbursed (not to mention the time you spend re-filling them out).
I suppose that if you do the math, it might be easier to just pay your patients to go elsewhere? The red tape (in this case “red ink”) never ceases to amaze me. Anyone else struggling with this problem?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 1st, 2007 by Dr. Val Jones in Health Policy, Opinion
6 Comments »
There were a series of amusing anecdotes presented at the
very beginning of Sicko. Various people
were denied coverage by health plans for things that didn’t have the right
coding or were submitted incorrectly.
One woman received a message that her ambulance transportation to the
hospital from the scene of a car accident (where she was knocked unconscious)
was not covered by her health insurance because she did not obtain pre-approval
for the ambulance ride. She asks, “When
could I have called for pre-approval?
It’s hard to get permission when you’re unconscious.”
Another person was declined coverage because he was too thin
(he was six feet tall and only 130 pounds), and one young woman was
denied because she was overweight (5’1” and 175 pounds).
While these denials are laughable, they are ridiculous
specifically because they are decisions that appear to be made by a computer –
or perhaps by applying inflexible rules to real life scenarios without the
benefit of human interpretation. [See my cartoon on the subject.]
And as we consider Mr. Moore’s proposed solution to the apparent
capriciousness of health insurance company coverage policies – we see that his
single-payer solution is really no different.
He is trading one impersonal decision maker for another. Big government is no more capable of
delivering personally relevant care than is the health insurance industry. The problem with both is that they take
decision-making away from the patient and those closest to their situation – the providers who have a
much better sense of what is needed and appropriate.
As a physician it really upsets me when a third party payer denies coverage of an important treatment to my patient. I understand that we have to have some broad, population-based rules for medical coverage as a means for cost containment – but a one-size-fits-all system will always fail some people. We physicians are regularly on the phone on their behalf, explaining to appeals associates why our patient needs X, Y, or Z… and then have to re-explain the medical necessity up the chain of command until a Medical Director is finally reached, who then has no incentive (other than basic human decency) to give in to the pleading physician’s request on behalf of her patient. We (and our staff) spend uncompensated hours upon hours doing this every week.
And Medicare creates rules to deny coverage to people too (and it probably doesn’t save on administrative costs over health insurance plans anyway, notes Charlie Baker at Harvard Pilgrim Healthcare, Inc.). So from a physician’s perspective it feels as if we’ve had our clinical judgment usurped by bureaucracy and for-profit health insurance companies. We have been reduced to claims advocates rather than clinicians. It is exhausting and infuriating – and I don’t see this improving any time soon (and neither does Paul Levy at Harvard).
Healthcare is not free, as Dr. Leap points out, and unfortunately it’s also not personal. And that’s what I am lamenting – the depersonalization of medical care. My patients will not be able to make a full range of informed choices with my help – they will be given a very limited menu of options from their third party payer – who will argue that they are not limiting care because the patient can always pay out-of-pocket for anything their physician believes is necessary, but is not covered under their plan. And so where does that leave the patient on a modest income? Effectively, they are indeed limited to the options covered by their third-party payer. And this is so ironic, given the new push for personalized medicine (optimizing individual treatment via genetic testing, etc.) In the end it seems that we’re aiming for personalized medicine and an impersonal healthcare system. And maybe that’s part of what’s “sicko” about all of this.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 29th, 2007 by Dr. Val Jones in Health Policy, Humor
5 Comments »
Alright, I can’t help it – I just watched the new movie
Sicko, so I have to write about it. Labeled a propagandist
by some, self-contradictory by others, the value of Michael Moore’s
work is in its ability to get the public talking about a critically important
subject. And I must agree with the New York Times reviewer on this point – Sicko was the best
edited and most entertaining of Mr. Moore’s documentaries.
Why
Socialized Medicine Won’t Work in the US (In My Humble Opinion)
Sicko
was interesting for me because it compared the healthcare systems of the US, Canada,
France and Britain. Moore’s whole thrust is that socialized medicine is the
potential cure for America’s
healthcare crisis. I grew up in Canada,
spent summers in France,
trained in medicine in the US,
and my mom’s British – so I have a unique and very deep appreciation for the
cultural differences of these 4 countries. And here’s what I see: the way
a country cares for the sick is a reflection of their shared cultural
values. Each healthcare system has its own personality – like wine made
from grapes grown in the unique soil and climate of a specific region.
Even if you export the same vines to another place, the wine will never taste
the same. Let’s take a look at a few of these cultures (and yes I am
using somewhat stereotypical language to clarify the differences):
Americans
are fiercely individualistic. They are passionate, driven, and believe
that success is proportional to how hard you work. They believe in
survival of the fittest – if you’re not doing well, it’s probably your own
fault. Everything’s a competition, and capitalism spurs on a constant
parade of advertising, marketing, sales and consumerism, all orbiting the
almighty dollar and personal convenience. It’s critical to them that
anyone can attain the American dream – if they work hard enough. Fabulous
riches are within the grasp of any average Joe if he concocts a really good,
money-making business plan. Americans don’t have time for health prevention,
long vacations, taking care of others – no, they’re so busy working that only a
medical emergency will jar them out of their usual pursuits.
What
sort of healthcare system would grow out of this cultural milieu? A
hurried, high stakes, emergency intervention focused, technology driven
grab-all ruled by any stakeholder who can outsmart the competition.
Forget the poor, they’re not productive and don’t deserve equal care
really. But that financially successful “average Joe” will receive mind-blowing
technologically advanced care that costs hundreds of thousands of dollars and
can keep him alive long beyond any reasonable need to do so. Joe has a
shot at immortality, and somehow that makes all the work worthwhile. Yep,
that’s pretty much what the US
healthcare system is like.
Canadians
are good natured and tolerant. They put the needs of others first.
They will pull over in a snow storm to help you change a tire, and then they’ll
have a beer with you and talk about hockey at a local pub after towing your
vehicle out of the ditch. They will also wait patiently and without
complaint for hours on end in a line for tickets or groceries, or whatever the
line is for. There are so few people in Canada (compared to the land mass)
that nothing feels crowded or busy. Their socio-political views lean
strongly toward socialism –almost no one is really rich or very poor in Canada.
Everyone is treated with the same friendly respect, living comfortably, no real
crime or racial tensions. What sort of healthcare system would these
people invent?
A
socialized, government-run system that offers “free medical care” for all, with
insanely high taxes to cover it all. There are long lines, competent
doctors, and moderately satisfied patients.
The
French are argumentative and political. They tend to value
leisure above work, they don’t like rules imposed on themselves, and believe
that their government’s purpose is to serve their needs at all times.
They protest regularly, everything is unionized and everyone is focused
on personal rights and liberties. Employers are at the mercy of
government rules and employee whims. They work very little and expect
extensive social services, smoking cigarettes and drinking coffee, watching the
world walk by from neighborhood cafes. What sort of healthcare system
would these people want?
A
government-run, heavily social service oriented system that caters to a
leisurely lifestyle. Spa treatments, alternative medicines, herbalism all
thrive, but in order to keep people from overburdening the spas, copays for
many basic services run as high as 40% of the total bill.
So
the question is this: how would Americans respond to these other brands of
healthcare? If they were served up the Canadian system, they’d
scream at the tax rates, and become hysterical at the inability to trade up to
a platinum level of care for those who have “earned it.” They would not
accept the long lines for care and would immediately start a scheme for
off-shoring medicine to circumvent the lines.
If
Americans were offered the French system, they’d be immediately annoyed by the
inconvenience of the office hours (months of vacation are taken at a time by
all members of society, including doctors), they’d never use the preventive
health measures (they don’t have time for that stuff), and although they’d be
glad to receive home health aides for no more excuse than – “I just had a
baby and I’d like a government worker to clean my house” – when they saw the
tax rates it would take to make this available to all, they’d find it
unacceptable, especially with such high copays and out of pocket expenses..
So
socialized medicine will never work in the United States – not because it’s a
fundamentally flawed system, but because the American culture will not tolerate
it. Healthcare solutions are not globally applicable – (though I’d say
that from an IT perspective, there is an information sharing system that is
needed equally badly by all countries). Instead, systemic changes should
be personalized to the culture. Looking to other countries for magical
fixes to healthcare woes is like expecting that all cancers will respond to the
same chemotherapy regimen. Medical care is most effective when it is
customized to the individual, and healthcare reform will be most effective when
it takes into account the unique cultural values held by a country’s people.
In my next post, I’ll explain why health insurance companies
and big government health plans (Michael Moore’s solution to US healthcare
woes) share a common flaw.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 11th, 2007 by Dr. Val Jones in Medblogger Shout Outs
2 Comments »
Welcome to the latest round up of the best of the healthcare
blogosphere. Today it is my pleasure to offer you your weekly dose of Grand
Rounds, optimized for your state of mind.
I believe that there are two basic types of blog readers, and so you’re
getting Grand Rounds 2 ways (with a dash of cartoons thrown in for extra “feel
good” measure):
- Just
the Facts: Distractible, hurried, currently in between seeing patients –
or perhaps your kids, cats, dogs, llamas are begging for attention… or
maybe you’re an ER nurse or surgeon who has no patience for long winded
stories? You’re category one and
should proceed directly to Grand Rounds IR (immediate release – below).
- All
the Details: Calm, peaceful, you enjoy good prose and a cup of chai
latte. You like reading all the
juicy details of a grand rounds line up and will spend hours picking
through the references – or maybe you’re an Internist or Psychologist who
knows that the best medicine is found in the details? You’re category two and should proceed
directly to Grand Rounds XR (extended release – next post).
Many thanks to Nick Genes, father of Grand Rounds (who acts
behind the scenes to ensure the success of each host), and please check out
next week’s Grand Rounds at Code Blog: Tales of a Nurse.
Grand Rounds IR (asterisk
= honorable mention for great writing)
Happy Posts
*Starbucks Caters to Diabetics
Woman Saved by Bush Pilot in Frozen Tundra
*CEO Says He’s Sorry
Prayer Can Reduce Arthritis Risk?
*Disaster Unpreparedness [Cartoon]
Med School Graduation Ceremony [Cartoon]
Nurse uses Star Trek Mentor to Set Course for Kindness
Galaxy
Shrink Rap Podcast: Prank Call with Dr. Phil McGraw &
More [Cartoon]
*Cape Cod Vacation Derailed by Flood, Stroke, Famine & Infection
The Evils of Hand Washing
Sad Posts
Triage in the ED [Cartoon]
*Sad Cases in ED
Elderly at Risk of Death From Tranquilizers [Cartoon]
Life as a Nurse Assistant in Vermont
Hot Topics
Infanticide
Hucksterism
Healthcare Outsourcing (podcast) [Cartoon]
Blog Censorship A
Blog Censorship B
Arrogant Docs [Cartoon]
Should Kim See Sicko?
Helpful Tips
To Fend off Bears
To Get the most out of Medicine, Web 2.0 style
To Get into Medical
School
To Avoid Kidney Damage from Contrast Agents
To Perform A Pyloromyotomy [Cartoon]
To Diet Successfully – Gluten Free [Cartoon]
Case Reports
Wii-itis
Rare pancreatic tumor
Uncategorized
Cost-benefit analysis of genetic testing
Commencement Speech for Harvard Medical
School Graduation
New Alzheimer’s Research [Cartoon]
New Genetic Research
Book Recommendation for Type 2 Diabetes
For the full text version complete with cheerful commentary, please go to Grand Rounds XR
(next post)
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
