Monday, September 21, 2009

Death Panels and all that

Like Mike Doonesbury this morning, I had thought all the Death Panel furor was behind us. But if Gary Trudeau thinks it's still a current topic, and Newsweek gives it featured coverage (The Case for Killing Granny, Rethinking end-of-life care, Sept. 21, pages 36-40 and page 8), it may be useful to review it one more time for those gullible enough to believe that we old-timers are about to be shut out of the system and left to die. That's deliberate nonsense. The facts are:
Living wills (or advance medical directives) have been around for years. My own was first notarized in June 1997, and I update it as "still valid" and sign it every year or two to show that my mind hasn't changed. I make sure my own doctor and any hospital I go to has a copy.
The reason doctors and hospitals advise people to do this is so that the your personal desires are on record even if you are later found unconscious, or are unable to communicate, or have relatives telling the medical attendants to do this or do that regardless of your own stated wishes.
You may state that you want everything done to keep you alive, or want Hospice care, or want to let nature takes course, or any degree of treatment in between. It's up to you. But unless your desires are recorded while you are still conscious and of sound mind, the doctor or hospital will have nothing to go on.
My own advance directive says, in part, "If I am disabled by [for example] stroke, dementia, or cancer, I do not wish my life prolonged artificially. If there is no reasonable chance of recovery or fully conscious existence, then let my dying process take its natural course without tube or IV feeding, radical surgery, extended use of a respirator or other resuscitation measures. Relief of pain and/or routine nursing care are OK. I do not want my medical care to threaten bankruptcy of my family and heirs.
"In particular, I do not want attorneys, judges, doctors, or ethics committees quibbling about my intent or wish. What I want is to go to my Maker when my time comes, with what measure of human dignity is possible."

The difference between a "Death Panel" and a Living Will is who makes the decision - a nameless bureaucrat, or you yourself?

As a doctor, I have seen people kept alive for a few extra days while they are dying of incurable, painful cancer or other disease, and their medical costs keep building up to loss of home and all the family's funds, only to prolong the pain or keep the heart beating, but with no useful outcome. But without instructions to the contrary, doctors do what they can to keep a person alive.
President Obama's Health Plan encourages doctors to counsel patients on how to make their wishes known. It's still a matter between only you and your doctor.

Wednesday, September 9, 2009

The President's Medical Plan Speech

I listened carefully to the President's address this evening, both as a retired doctor and as a senior citizen now living on a moderate fixed income. In general, it was well received; even the Republicans stood and applauded at several points.
He laid out the main actions and the reasons. Skeptics on both sides will say "not enough detail", but he emphasized the results he was seeking: against the law for insurance companies to refuse coverage of pre-existing conditions, against the law to drop insurance or raise the premium when a client's treatment is too expensive; everyone can keep their present policy if they like it, and their present doctor too. There will always be details to work out, and I expect modifications will be necessary after the plan has been in operation a few months or years.
Most people's first reaction will probably be "How can the nation pay for all the extra care when the 45 million uninsured get coverage?" But the fact is, these 45 million are already here, already getting care, in the Emergency Room—the only place required to take care of them—but an ER visit is ten times the cost of a doctor's office visit.
You don't believe that cost ratio? Google the comparative prices. What I found was $170 for the average first office call, and from $1,000 to $2,000 for an average ER visit, tests, and treatment included in both. Sometimes the severity of the case demands ER care, but moving the headaches, colds, and minor injuries into the doctor's office can save billions per year.
Opponents like to quote the figure one trillion dollars over the next ten years as the increased cost of the President's plan, but that's 100 billion per year. Savings from over-testing, over treating, and over use of the ER could easily cover that.
My first reaction to Congressman Boustainy's rebuttal was that I thought the President covered all those points, but then I realized Mr. Boustainy would have had to write his speech before he heard the President, who had finished only about five minutes earlier. The only differences I can see are the Republican wish to make insurance purchasable across state lines (which I like) and their desire to "Press the reset button and start over" which would send us back to square one.
The biggest savings in present medical care I see are (1) tort reform with resultant easing of over-testing and over-treatment, and (2) lifting the ban on competitive bidding on pharmaceutical contracts. Downsizing the "donut hole" is useless if drug prices get upsized the next day.
Overall an excellent speech, and substantive. More later.

Tuesday, August 25, 2009

The Reston, VA, Town Meeting

I have just watched the town meeting at Reston, VA, held by Congressman Jim Moran, with Gov. Howard Dean, MD (Vermont) fielding audience questions. All things considered, it went rather well, although there was a lot of orchestrated shouting in the beginning, until one of the political activists in the crowd was invited to submit his question and speak to it for five minutes only, or leave. He left, rather than speak under the rules of courtesy.
The subject was, of course, House Bill 3200, Health Reform. Mr. Moran spent most of the first hour explaining the bill's provisions and dispelling ten of the most widespread misconceptions making the rounds ("Grandma's going die", "The government will assign you a doctor", etc.), and then Dr. Dean, himself a physician as well as an ex-governor, explained the major points as well as what was left out of the bill and why.
I am pleased that the bill preserves personal choice of each person's choice of insurance carrier and choice of doctor, and is designed to have everyone medically insured. I would be more optimistic about the plan for handling the cost if the bill had not left out two of the biggest ways of lowering health care costs.
Tort reform will not be in this bill. Dr. Dean explained that including it would mean submitting it to the House Judiciary Committee which is strongly opposed to tort reform, and would not have allowed it to come out of committee for a vote on the floor. But by capping the non-medical, non-economic costs some lawyers seek, tort reform would reduce those tests and treatments of little benefit to the patient, done only to prevent a trial lawyer from accusing the doctor of negligence. Dean did predict that continuing progress toward nationally recognized standards of medical care will eventually solve the problem. (Adhering to standard of care is a strong defense against claim of negligence.)
Bidding down the price of medicine for Medicare and Medicaid will not be allowed, in exchange for a 50% reduction in the "donut hole" where seniors pay the full price of medicine out of pocket. This was an agreement between the President and the pharmaceutical companies. I think the President would have found bidding a much bigger way of cutting costs of medical care (Dr. Dean said the VA bidding system cuts the cost of their medicines to between one-fourth and one=half of what the other programs pay.)
But politics is recognizing what will pass Congress and what will not, and doing the possible. The final bill must pass the Senate, too. Mr. Obama may yet give all citizens a way of paying their medical bills without going bankrupt. I hope so.

Wednesday, August 12, 2009

Dealing With Our Fear of the Future

"How can we possibly pay for medical care for forty-five million more people who have no insurance?" The answer is, you are already paying for it, and at more than three times the amount it should cost.
These uninsured are not millions of newcomers to America. They are already here in the system, our fellow citizens with low-paying jobs or no jobs at all. Doctors who are willing to accept some non-paying patients already see them every day of the week.
Every time any of those forty-five million gets sick or injured but can't get in to see a doctor, they go to the hospital emergency room, the only place that by law must accept and examine them, and give them emergency care. Usually the ER doctor on duty has not seen that person before and must do a reasonably complete exam and lab tests to know what's going on. The charge for an emergency room visit, as many readers know all too well, averages over $1,000, compared with an average for an office visit or urgent care center of $150.*
Every time an uninsured patient, who can't pay for his care out of pocket, gets medical care at an Emergency Room, you, and all of us, are paying the cost of his care out of our present taxes or the increased rate a hospital must charge to make up for what they can't collect from the non-payer. These 45,000,000 are already in the system, and we are already paying their costs. It makes sense to get their colds and minor injuries out of the ER and into the doctor's office, at less than one-fifth the cost we are paying now. That alone would save about half the alleged trillion dollars of new insurance premiums.
In addition, instead of getting medical care after his condition has reached crisis proportions, the newly insured can get preventive care or early care, reducing chances of his needing hospitalization later on (where the cost of care is even higher than the ER.)
It's true that when the presently uninsured get insurance, they will use doctors more often, but the increased need for doctors will not be like all the newly insured are just getting off the boat and entering the country. They are already here. When doctors know that insurance will pay something for every patient, you will see more men and women entering medicine as a career.

*The reader can find many sources for cost information by Googling Consumer Health Ratings, Emergency Room, typical average cost.
I surveyed reports from Florida, Minnesota, and Vermont, plus an additional survey by G.M.P. Employers Retiree Trust.

Friday, July 31, 2009

Getting there is half the fun

Yeah, right. Your six-year-old wakes up this morning with a really sore throat, a cough and a fever. Or maybe she has an earache. Or perhaps you've found a lump in your breast. Your family doctor's telephone receptionist gives you the run-around, "Our next open appointment is in six weeks. If you're really concerned, go to the hospital emergency room . . .would you like their number?"

No, thanks, you already have their number. A doctor who has never seen you before, and likely will not be on call the next time either, will put an automatic thermometer in your kid's ear, glance down her throat, and give you a prescription for a cough syrup you've already tried at home. See your doctor in three days if there's no improvement. Your doctor's already-full schedule is not the ER doc's problem. You'll get a bill for several days worth of your wages, and are no better off than before you came in. The ER doc is reasonably sure your child will be better soon, but he fails to convince you.

This really doesn't need to happen. You shouldn't have to use the expensive ER for an urgent, but non-emergency problem just because no doctor's office has any time open.

Doctors who allow the front desk to fill their appointment schedule chock-full ahead of time are not thinking things through. Common sense will tell any primary care doctor that many people's sickness appears without warning and they need help today, not next week or next month. And people merely needing a follow-up visit usually don't care if their next appointment is seven days or seventeen days from now, as long as they know they have one..

During my partnership days, my partners' habits drove me crazy. They all booked all their time in advance; one doc overbooked two extra people for each hour "because someone might not show up." Our large waiting room was usually full of irate patients, some of them waiting two hours after their appointment time. My partners were good doctors, but were clueless about office management, as long as the office looked busy. "The patients can always get in; they just have to wait a while if we're busy."

I decided I could run an office better by leaving the partnership and going solo, and I did.

Here is what works: The doctor sits down with his staff and they decide how much the average routine visit takes of the doctor's time. Not how long he'd like it to take, but how long it really does take, according to the people who work with him. Say, for example, that on average he can handle four visits per hour. More complex problemsa new patient, or a new pregnancy might take 30 minutes or an hour, and so would have one or more extra time slots assigned. In my own practice, I could usually handle repeat office visits in 15 minutes. Saving some time for hospital rounds, record-keeping, minor surgery, etc. each day, I usually had around six hours per day for patients' office visits.

I told my receptionist she could fill two 15-minute slots for each of those hours ahead of the day. A third one each hour could be filled from the phone calls from people who wanted to get in that day for something they thought urgent. The fourth slot each hour was saved for walk-ins. People rarely had to wait more than 10 minutes beyond their appointment time, unless I had emergency surgery or a baby delivery in progress.

Was it a problem to have an occcasional empty appointment slot? Not for me it wasn't. I used the time to return phone calls,sign or dictate letters, catch up on my medical journals, order supplies, or enjoy a cup of coffee at my desk. My patients were more relaxed, and so was I, not having to keep pace with an always over-full schedule. I found that it's not always necessary to bring someone in every month just for a blood pressure check or a blood sugar, once their condition stabilized.

Not every patient who only had a question required an appointment; sometimes the question could be handled by phone. My receptionist always brought the patient's record to my desk along with the call-back number, She only called me out of a patient's exam room if she judged the call truly urgent, or if another doctor was calling about a patient, but I tried to answer the less urgent calls as soon as possible.

This system of scheduling even gave me time to see occasional people who hadn't been able to get an appointment with their own doctor. Many had a problem that could be dealt with in a single visit, after which they could go back to the other doctor again.

So - Doctors, rethink your appointment scheduling. Packing your schedule full ahead of time causes tension, always trying to keep up, and it makes your waiting patients fidgety, even miserable if they are feeling pain or are otherwise ill. You'll also be more at ease if you get in the habit of starting on time, and limiting the length of your coffee break. (Read the newspaper at home.)

Receptionist, If the doctor is unavoidably behind schedule (and hey, it can happen) let the patients know. If the doc is way behind, offer to reschedule them. If he's avoidably behind very often, let him know.

Saturday, March 7, 2009

Improving Medical Office Efficiency

I recently talked with two acquaintances, about a week apart, who had complaints about their doctor's office. Neither of these families had ever been patients of mine, but people tend to bring up medical subjects when they learn that I write about medicine. Both had complaints about their doctor's office help.

"It was embarrassing," one told me. "The doctor told his office girl to make me an appointment with the urologist (kidney specialist), and she made one with a doctor who turned out to be a neurologist (brain specialist). The neurologist sent me to a urologist not far away, and didn't charge for his own office visit, but why wouldn't she have known the difference?"

The other patient had had at least six back surgeries over the years (laminectomy) and no surgeon would now touch his scarred back. His local doctor was trying to manage the pain on various pills and patches, some of which eased his chronic pain, but not the "lightning spasms" that struck when he moved wrong. Additionally, over the years, he had developed reactions to some of the medicines, and the doctor was trying a new one. Medical insurance refused to pay for it. The doctor's office clerk said she would try and straighten the matter out, and would call him back.

She never did, not even to let him know the problem. He finally called his pharmacist to see if he could afford to pay for it himself, and found to his horror that a month's supply was priced at $525.00, half his entire monthly income, Presumably, the clerk could have found that out, but if she did, she never let him know. Presumably, also, the doctor should have known the price of the new medicine, but salesmen rarely mention that. Most doctors subscribe to a service that publishes latest drug prices, however.

Such things happen when new help is hired and isn't taught what the job involves, beyond how to fill the doctor's appointment book and send out the bills. Often there is frequent turnover of staff, either because of low pay, poorly qualified help, or poor instruction.

I learned, early on, to pay my staff a little more than the going pay rate, and to make an office instruction book covering phone etiquette, appointments, unhappy patients, inability to pay, emergencies, unavoidable delays, prescription refills, salespeople, etc. and updated it as needed. Knowing the price of my patients' medicines was my responsibility, and I tried to keep up to date and practical. I learned to try the more familiar, less expensive medicines first before going on to the "latest new drug" unless there was some specific reason to go directly to the latter.

The way our patients perceive us depends a lot on the people we employ. If you don't enjoy training new help every few months, Doctor, pay attention to them - the nurse, the technician, the clerk, the janitor, everybody, so they will stay with you. Competence and caring count, both yours and theirs.

Your office staff is one of your biggest assets. Treat them right. Don't leave it all to an office manager.

Monday, February 9, 2009

Mr. President, Medical Computer Systems Aren't that Simple

"When everybody has computers, communication will be efficient, and medical costs will come down." This is what medical experts say.

Yah. Just about everybody in medicine already has a computer. It just can't communicate with all the other computer systems. Remember the 9/11 Commission report about New York's twin towers? Firemen's radios weren't on the same wavelength as the police, and City Hall had still a different system. Communication was chaos.

Recently a friend told me that because the U of Washington medical center in Seattle designed it's own computer system, our local Kootenai Medical Center can't communicate with it directly, but had to send his MRI report by a disc delivered by the postal service. His treatment was delayed by three weeks.

Doctor groups, insurance carriers, and government offices are in the same situation. Each listened to a different salesman, whose product was always "the best", and they spent hundreds of thousands of dollars buying, installing, training in the use of, and maintaining, their system, only to find out that the hospital or the next office down the road had a different system. They aren't about to pay out that amount of money all over again. "Let the other guy match up with me" is the common attitude.

Never mind that there are hackers out there in cyberspace that can break into any system. Only last month the news was full of someone who had accessed the social security numbers of millions.

Never mind that there are now double the number of clerks in every doctor's office, to transcribe the dictation for the records, and each clerk has to be paid. Never mind that the average patient's medical record has ballooned to ten times the number of pages it used to be before the computer age - computers can print it all out in a few seconds, but how long does it take to read through all those pages to find the information you are looking for?

Never mind that computers can crash, or records disappear into cyberspace, if there is no hard copy backup.

And never mind that doctors and nurses still make medication errors even with everything computerized. The data is only as reliable as the typist and the reader.

Computers are a necessary advance in medical information transfer, but so far they are not money savers. And mis-information can still spread—even more easily spread—by computer.

Friday, January 30, 2009

"Now, Dear, we don't really know that yet."

My friend, herself a retired RN, has two stories to tell. The first happened when she was in her third pregnancy, with a past history of rapid labors, and she arrived at the hospital's emergency entrance "with a continuous contraction."

"I need to go to the delivery room," she told the nurse.

"Well, first we need to get your name, address, and name of your insurance." The nurse was proceeding by rote.

"I need to be in the delivery room!" gasped her patient.

"Everyone is in a meeting just now," soothed the nurse. "Now, your name?"

"HERE COMES THE BABY!" That finally focused the nurse's attention.

Fast forward fifty years: My nurse-friend has been referred to a gastroenterologist by her family doctor. A nurse practitioner is taking her history.

"I have upper abdominal pain. My GP found GI bleeding and a low hemoglobin."

The nurse smiled patiently. "Now, dear, we don't know that."

My friend had her family doctor's lab reports, but as often happens, the specialist only accepted reports from his own lab, "to eliminate error."

Before he would treat her, he required a gastroscopy (passing a scope down the throat and into the stomach to take a direct look.) "We're pretty busy," the patient was told, we can schedule you for six weeks from now." No medicine was supplied for the interim.

My friend returned to her family doc who gave a prescription for Prevacid. Taking that for six weeks healed her pain, and the gastroscope showed a stomach that by that time was almost normal.

Were she my patient, I would have just given her the prescription at her first visit and called in the specialist only if she wasn't improving after a week. Tests for blood in the stool, anemia and for Helicobacter (a common cause of duodenal ulcer and bleeding) can be done in the office. A scope should be done to rule out cancer, but the cancer will still be there when the specialist gets around to doing it.

My question to the specialist and his nurse would be, "Why don't you know that? Why didn't you confirm or disprove the family doctor's data at first visit, at least look at his lab reports, and save your patient time, worry, and money?" Sometimes it seems like no one listens to anyone else.