April 18th, 2007 by Dr. Val Jones in Opinion
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Ask any American if they think
their current healthcare system is operating smoothly and efficiently, and
you’ll hear a resounding “NO!” Adjectives such as
“confusing, complicated, and disorganized” are often used to describe
our current state, and for good reason. The science of medicine has
advanced enormously over the past 50 years, but somehow this rapid growth in
knowledge has been plagued by chaos. With every new therapy, there’s a
new therapist – and the result is a fragmented assortment of tests, providers,
procedures, and administrative headaches. So what does a patient in this
system really need? She needs a coordinator of care – a compassionate
team leader who can help her navigate her way through the system.
She needs a central location for all her health information, and an easy way to
interact with her care coordinator so she can follow the path she has chosen
for optimum health. She needs a medical home.
Primary care physicians (especially family physicians, pediatricians, and
internal medicine specialists), are ideally suited for the role of medical team
leader in the lives of their patients. It is their job to follow the
health of their patients over time, and this enables them to make intelligent,
fully informed recommendations that are relevant to the individual. Their
aim is to provide compassionate guidance based on a full understanding of the
individual’s life context. The best patient care occurs when
evidence-based medicine is applied in a personalized, contextually relevant,
and sensitive manner by a physician who knows the patient well.
Revolution Health believes that establishing a medical home with a primary care
physician is the best way to reduce the difficulty of navigating the health
care system. We believe that our role is to empower both physician and
patient with the tools, information, and technology to strengthen and
facilitate their relationship. Revolution Health, in essence, provides
the virtual landscape for the real medical home that revolves around the
physician-patient relationship.
What’s the advantage of having a medical home? Jeff Gruen, MD, Chief
Medical Officer of Revolution Health:
1. Care is less
fragmented: how many times have you heard of friends with multiple medical
problems who are visiting several physicians, each of whom has little idea
of what the other is doing or prescribing, and none of which are focusing
on the big picture? When a single physician is also
helping to “quarterback” the care, there is less chance that
issues will fall between the cracks, and less chance that consumers will be
put through unnecessary and costly tests or procedures
2. Care is better:
studies have shown that excellent primary care can reduce unnecessary
hospitalizations and assure that preventive tests are performed on
time. One study for example showed that the more likely
it is that a person has a primary care family physician, the less likely
it is that they will have an avoidable trip to the hospital. This
makes intuitive sense: a physician who knows you is critical to have if
you were to get very sick and need alot of medical
attention.
3. Care is more holistic:
medical care is part art and part science and good care requires the
clinician to understand something about the whole person they are caring
for. Many complaints that are seen in primary care practices are
physical manifestations of underlying emotional, family or adjustment
issues. A good primary care clinician who knows the individual and
family is more likely to strike the right balance between appropriately investigating
physical causes for complaints, and addressing more subtle underlying
causes
So to physicians and patients alike, we say, “Welcome home to Revolution Health.”
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 1st, 2007 by Dr. Val Jones in Medblogger Shout Outs
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In a really engaging recent post, ER doc Edwin Leap (via GruntDoc) discusses why it seems that the general public is outraged at reports of the occasional specialist who makes $500,000 and yet do not flinch at the much larger salaries of football players, musicians, or media tycoons.
I posted a response to Dr. Leap’s blog post, explaining my take on why people are so angry. Let me know if you agree:
You are right that there is a lot of anger towards physicians – it is the collateral damage of the broken physician-patient relationship. When third parties (insurers) got between us, and reimbursement dwindled with drastic cuts in Medicare/Medicaid, physicians had to make up the difference in volume. When you see 30+ patients/day none of them feels as if they’ve had a valuable interaction with you. And the physician’s memory of each individual patient (and their psycho-social context) becomes dim.
When we lose the sacred, personal, physician patient relationship – we lose the best of what compassionate individualized medical care has to offer. This is why patients believe that a government sponsored system can give them the same level of care that they currently receive. I shudder at the idea of handing over medical decision making to a distant bureaucracy that only knows what’s right for a population, not for the individual. But if doctors continue to treat patients like a commodity, the patients are actually receiving nothing more than population-based care anyway. Quality care is personal, and the physician-patient relationship is a trusted bond that cannot be easily broken. We need to know our patients well so that we help them to make the best possible decisions for their personal situation. I believe that the IMP movement (see Gordon Moore’s work) – where PCPs use IT to drastically reduce overhead costs so they can afford to see fewer patients – is one of the best ways to improve healthcare quality.
As far as Emergency Medicine is concerned – we need to get the non-sick patients out of the ER and back to the PCPs. Easier said than done – but if the patients have a real relationship with their PCPs they’re less likely to substitute an ER doc inappropriately.
My 2 cents! 🙂
Patients are angry about physician salaries because they know instinctively that they are not getting the quality care that they are paying so much for… Moreover, the major cost causers (hospitals that cost shift unpaid bills to the uninsured and take large cuts for hospital administrator salaries, and for-profit insurance companies) don’t have a name and a face to the patient. So docs take a double dose of anger on the nose, further damaging the already strained relationship. We must go back to our roots – and support the personal doctor patient relationship that has been a pillar of American medicine. Revolution Health can be our meeting place… the new digital medical home, supporting the old physician-patient team decision-making approach!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 9th, 2007 by Dr. Val Jones in True Stories
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In my last post I described how VIPs don’t necessarily get better medical care. In this post I will describe a case study of a bully whose behavior wasted endless resources and time. This is a true story.
The son of a business tycoon experienced some diarrhea. He went to his local emergency room immediately, explaining to the staff who his father was, and that he required immediate treatment.
Because of his father’s influence, the man was indeed seen immediately. The physicians soon realized, however, that there was nothing emergent about this man’s complaints. After several blood tests and a stool sample were taken, he was administered some oral fluids and monitored for several hours, they chose to release him to recover from his gastroenteritis (stomach flu) at home.
The man complained bitterly and said that he wanted to be admitted to the hospital. The physicians, with respect, explained that he didn’t show any signs of dehydration, that he had no fever, his diarrhea was indeed fairly mild (he had only gone to the restroom once during the hours of his ED visit – and that was when he was asked to produce a stool sample). The man’s pulse was in the 70’s and he had no acute abdominal tenderness.
The man left in a huff, and called his father to reign down sulfur on the ED that wouldn’t admit him.
And his father did just that.
Soon every physician in the chain of command, from the attending who treated him in the ED right up to the hospital’s medical chief of staff had received an ear full. Idle threats of litigation were thrown about, and vague references to cutting key financial support to the hospital made its way to the ear of the hospital CEO.
The hospital CEO appeared in the ED in person, all red and huffing, quite convinced that the physicians were “unreasonable” and showed “poor judgment.” Arguments to the contrary were not acceptable, and the physicians were told that they would admit this man immediately.
The triumphant young man returned to the ED for his admission. Since the admitting diagnosis was supposedly dehydration, a nurse was asked to place an IV line. The man was speaking so animatedly on his cell phone, boasting to a friend about how the doctors wouldn’t admit him to the hospital so his dad had to make them see the light, that he moved his other arm just at the point when the nurse was inserting the IV needle. Of course, the poor woman missed his vein.
And so the man flew into a rage, calling her incompetent, cursing the hospital, and refusing to allow her to try again.
At this point, the ED physicians just wanted him out of the emergency room – so they admitted him to medicine’s service with the following pieces of information on his chart:
Admit for bowel rest. Patient complaining of diarrhea. Blood pressure 120/80, pulse 72, temperature 98.5, no abdominal tenderness, no white count, patient refusing IV hydration.
Now, this is code for: this admission is total BS. Any doctor reading these facts knows that the patient is perfectly fine and is being admitted for non-health related reasons. With normal vital signs, and no evidence of dehydration or infection, this hardly qualifies as a legitimate reason to take up space in a hospital bed. And when the patient is refusing the only treatment that might plausibly treat him, you know you’re in for trouble.
The man was discharged the next day, after undergoing (at his insistence) an abdominal CAT scan, a GI consult, an ultrasound of his gallbladder, and a blood culture. His total hospital fee was about $8,000.
Do you think he paid out of pocket for this? No. He submitted the claim for payment to his insurance company. Their medical director, of course, reviewed the hospital chart and realized that the man had no indication for admission, and refused medical care to boot, so he denied the claim.
So the son appealed to his father, who then rained down sulfur on the insurance company, threatening to pull his entire business (with its thousands of workers insured by them) from the company if they didn’t pay his son’s claim.
The medical director at the insurance company dug in his heels on principle, assuming that if he continued to deny the claim, the hospital would (eventually) agree to “eat the cost.”
In the end, the insurance company did not pay the claim. The CEO of the insurance company called the hospital CEO, explaining that it was really the doctor’s fault for admitting a man who didn’t meet admission requirements. The hospital CEO agreed to discipline the physician and eat the cost to maintain a good relationship with the insurance company that generally pays the hospital in a timely manner for a large number of patient services.
I ask you, my friends, does this seem fair? It’s because of these cases that doctors become (sadly) hard of hearing when it comes to patients who appear well, but may indeed have a serious condition.
In my next post, I will describe a true story of a baby whose life was saved because of her mother’s insistence.
P.S. There are many comments on this post, featured at Kevin MD.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 26th, 2007 by Dr. Val Jones in Expert Interviews
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I had the chance to speak with Jim Herndon recently about how the current healthcare climate is affecting orthopedic surgeons. He said that there are 3 things that worry orthopods:
- Decreasing Medicare reimbursement. In 1990, reimbursement for a total hip procedure was $2,200. In 2007, the reimbursement is $1,190. Medicare is planning to further cut reimbursement 30% in the next 4-5 years.
- Increasing malpractice insurance costs. Premiums are steadily increasing. In Boston, the average malpractice insurance is about $50,000/year. In Philadelphia, the cost is $150,000. And if you’re an orthopedic surgeon specializing in spinal surgery, malpractice insurance premiums can start at $250,000/year.
- Pay for performance. No one really knows how this will be applied specifically to surgeons (other than the obvious infection rates), but fears are mounting regarding how to show the best possible performance in one’s practice.
Let’s say that a typical surgeon in Philadelphia pays 33% in overhead (the hospital facilities, staff, etc.). Let’s say that he is also taxed 33% on his income. That means that he’d have to perform 382 hip replacements per year, just to pay his malpractice insurance. That’s almost 2 surgeries/day, 5 days a week, 11 months/year.
So what are surgeons doing? They are reducing overhead by setting up outpatient surgery centers (Dr. Herndon estimates that 60% of orthopedic surgery can be performed in an outpatient setting), they are increasing the volume of surgeries they perform, they are buying radiology facilities where they send their patients for XRays, MRIs etc. (Dr. Herndon explains that Stark Laws don’t prohibit this, so long as the physician takes on the risk of the facility – i.e. that he can potentially make or lose money), and they are financing physical therapy practices that supply therapy to their patients.
Orthopedic surgeons in private practice have become very business savvy in order to survive in this climate. But somehow I feel saddened by all this – the business of medicine is a grim reality that can create a wedge between the physician-patient relationship. A patient is left to wonder about the motivations behind tests and therapies – and perhaps even behind recommendations for the surgery itself.
I guess the second opinion has become more important than ever before?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 18th, 2007 by Dr. Val Jones in Medblogger Shout Outs
1 Comment »
An excellent blog post was forwarded to me for comment – an Internal Medicine physician reflects on his patients’ common underlying condition: isolationism.
Today I saw patients with the following problems:
- A person who had attempted suicide over the weekend
- A person who was possibly acutely suicidal and was abusing narcotics I was prescribing
- A person who is in an abusive relationship and has a severe eating disorder
- A terribly depressed woman in a dysfunctional marriage
- A pre-teen child whose father had suddenly died
My observation from today is that most of these people are isolated. They have difficult situations to face and the people who normally surround them are somewhat uncomfortable, not knowing what to say…
Western culture is obsessed with avoiding suffering. We entertain ourselves to avoid having to face the harsh realities of life. People die and suffer daily, and we are obsessed with the latest TV show, the latest political soapbox, or the latest self-help tool. We feel that the goal of society is to create happy and secure individuals. This is not true. The goal of society is to function as a unit in a healthy way – with the weak parts supported by the strong ones…
What I emphasized to the people I spoke with today was the need to find people who had gone through the same things. Those in the eye of the storm need to hear from people who have gotten to the other side that it is OK to feel the way they feel. Those who have gone through hard times have something huge to offer those who are going through them now – experience. You lose the pat answers when you have suffered yourself.
It is my hope that those who are struggling will find others online here at Revolution Health who can support them, and that those who have made it through to the other side will reach out to help others through our online community. Suffering is not meaningless if you harness it for good – your wounds can heal others.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
