23 August 2013

Obesity – A Disease or Condition

This doctor that has it right about obesity. I feel that the doctor's attitude is the correct one and until we understand this, we will be following the path to a greater explosion of obesity. Dr. Claire McCarthy is the doctor and her blog says a lot. It was not until I read her blog, that I became interested in the controversy surrounding the American Medical Association's decision to label obesity as a disease.

We all know that being overweight can lead to many diseases, from heart disease, diabetes, and cancer. And if this isn't enough, we face the social and emotional problems. Employers can be very hard on employees that are overweight, teenagers are especially cruel to classmates that are overweight, and children are almost as cruel.

While I understand why the AMA decision is to label obesity a disease is a heated controversy, I appreciate Dr. McCarthy bringing out some of the more difficult parts that had escaped me. Yes, the obesity declaration has brought lots of attention and the pharmaceutical companies are working hard to bring out the latest and greatest pill to treat the disease. Other resources are being sought to battle this new disease.

Whether anyone is taking obesity more seriously (other than those want to make a profit off of unsuspecting people) remains to be seen. As expected the scammers are already at work and developing more money making schemes to fleece people. Already there are new ads appearing on television for natural remedies to help weight loss. I just hope people from the FDA are aware of these new ads. I feel they are making claims that will produce no results.

Since I am retired, I have no worries about what an employer will need to do, and while I have talked to one person that says he is waiting for the doctor to prescribe a pill, he has no more worries. Another person has stated that she will be going to the health food store to see what is available to help lose weight. The sales people are waiting to ring the cash register for her.

Dr. McCarthy correctly states that calling obesity a disease puts the attention on the patient, because this is how we (doctors) think about diseases. I feel this is important enough to quote her when she says, “We will never solve obesity if we don’t make healthy food and safe, affordable exercise opportunities available to everyone. We will never solve obesity if we don’t deal with the grain subsidies that make unhealthy foods so widely available and cheap. We will never solve obesity if we don’t deal with the corporate and cultural factors that contribute to selling and buying super-sized sodas and fries.”

Dr. McCarthy is the first person that I have read that brings nutrition and what we eat into the discussion. Then she really caps of the discussion with the following, “Maybe it’s better not to call it a disease or a condition. Maybe we should just call it what it is: a thief. Because it is: it’s stealing the future of our children. It is increasing their risk of health problems, shortening lifespans and even taking away employment possibilities.

Maybe if we looked at it that way, we might get mad—and getting mad may be exactly what we need. Because more than anything, solving obesity is going to take a whole lot of effort and energy on the part of every single person, no matter what their weight. It’s going to take creativity, initiative, collaboration, tenacity and a whole lot of elbow grease.

Let’s stop worrying about what we call it—and start working together to fight it. Let’s not let our children’s future be stolen.”

22 August 2013

Hospitalists – What This Can Mean for You

Dr. Richard Gunderman is correct that in about 15 years ago, the hospitalist has evolved into being to care for hospitalized patients. Today there are over 30,000 hospitalists in the US. Dr. Gunderman follows this up with a statement that is supposed to be from a patient's point of view, which I have to disagree with very carefully. He says that hospitalists offer a number of advantages. Yes, they do from the hospital's point of view, but I think not from a patient's.

The reason is that they are employees of the hospital and answer to the hospital and the hospital's directives. Yes, in many hospitals they are on duty (in shifts) around the clock which is an advantage for the patient, but if an administrator wants certain tests done for certain types of patients, this may harm these patients when they don't need the tests. Because the hospitalists are familiar with the hospital's standard procedures, information systems, and personnel, you would think this would help. If the standard procedures are always to do more tests, then the patients may be the ones not benefiting.

Hospital medicine offers many benefits to the hospitals. This is where Dr. Gunderman nails it. Since hospitalists are generally hospital employees, they are easier to manage. They receive their paychecks from the hospital; they are more inclined to be responsive to the initiatives of the hospital leaders and easier to integrate with other members of the hospital's staff. The hospital has more control over the financial dimensions of this type of medical practice and can ensure that little or no potential revenue is lost because of the decisions hospitalists make. This is the downside for hospital patients.

When family physicians came in to see their patients, the hospitals had no control on the length of stay, or what procedures were ordered or not ordered. Now as healthcare under the ACA moves toward a model in which hospitals are paid not for the care they actually deliver, but for patient populations in the hospital, the incentives will shift to delivering less care over shorter periods of time. Again, the patients may suffer when they need to be in the hospital for longer periods, but are discharged too early.

Now it will be an advantage to the hospitals if hospitalists only admit patients who truly need to be hospitalized. Then they will be responsible to take steps to see that the length of hospital stays and costs associated with their stay in kept to a minimum. Because the hospitalists are hospital employees, these objectives will be easier to achieve.

A problem with hospital medicine under this system will be the large breaks in cohesion of care that will be introduced. Many feel that the information technology systems can overcome the lack of cohesion. The fact that an electronic medical records (state-of-the-art is questionable) is available to everyone involved in the patient's care, the health professionals supposedly will understand the patient and what is wrong. The interesting fact that everyone forgets is that an electronic record and true knowledge of the patient are not necessarily the same thing. Therefore, every time another person is added to the team, it makes sense that important information will not be conveyed.

Another shortcoming is that the hospitalist is focused on short-term care. When someone is admitted to the hospital with a heart attack, there are definite advantages in being cared for by an acute-care physician. These physicians are knowledgeable in follow-up and long-term care and they understand the patient's life outside the hospital. If patients are to survive for the long term, they need physicians who see beyond the hospital stay.

Trust is something often missing between a hospitalist and a patient. Trust relies on the human relationship that takes time and effort to build and not on electronic records. An hospitalist will be short-changed on this every time and the patient will always prefer physicians that have known them for years and have built this trust, not a doctor that they have just met. From the patient’s point of view, where the physician happens to be based is generally much less important than the quality of their relationship with the physician.

This is where small local hospitals will make a comeback and large, cold hospitals will begin to struggle for non-critical care patients will prefer dealing with their own physicians. The large hospitals will continue in some of the more difficult medical conditions, but many will struggle because they do not have physicians that have their patients' trust and a doctor-patient relationship built over the years. Be sure to read the blog by Dr. Gunderman.

21 August 2013

When, Oh When Will Hospitals Actually Care?

Probably Never! Some of doctors working for the hospitals may actually care, but the hospitals and administrators are only interested in growing the bottom line. So if patients are uncomfortable and not getting enough sleep – that is tough for them. Next, some will say I am castigating nurses unreasonably, but this is not the intent. It is just that they are positioned to carry out the wishes of administration and are positioned not to think for themselves. They operate following established protocols and this routine becomes a habit.

Yes, what I learned from Dr. Peter Ubel does require doctors down to think for themselves and learn cooperation. In exploring this with a nurse, she laughed at me and said impossible. When I asked if this was because they could not work and cooperate with others or they are just too pig-headed to cooperate, she knew I was testing her. She said, explain it to me.

I made sure she knew the ideas were from a doctor during his experiences while in the hospital. When she finished reading the blog, even she was surprised that these were not being considered and some put into practice. I made a comment about lack of cooperation and that I felt these were great ideas, but that I doubted that hospital administrators would allow this much efficiency. The cooperation would generate efficiencies and even some time savings, but it would be too easy for someone to fall through the cracks and administrators just could not allow this.

The nurse said that could be solved by having a room listing and check off boxes for each nurse, aide, and others needing to do something for each patient. She even said that the phlebotomist could check in early in the evening with her schedule for those on the different floors and everyone could see what could be coordinated to reduce the frequency of interruptions and work it around to coordinate them.

I asked about doctors that insist on having blood drawn and midnight and 4:00 A.M.  Will they create problems if it happens to be five to ten minutes late? She admitted that some doctors do demand that accuracy, but that can generally be accommodated. She said she would need to discuss this with the head nurse and this is where the most resistance could be encountered. She asked me to print out the blog and find an email address for Dr. Ubel to make it possible for her to get in contact with him as see if there was anything he could add and make it more convincing for the head nurse.

It is interesting what a doctor's blog can start. I admit I was baiting the nurse and thinking it would not even be possible to see this remotely attempted. I now know that it can work. Yes, there was resistance at the beginning until more realized that patients were happier and unnecessary interruptions were being eliminated. When two doctors realized the advantages, they quietly talked to other doctors and the word spread.

Some patients still require scheduled interruptions for medical reasons, but the percentage of change was about the same as Dr Ubel said Dr. Bartick achieved in her study. The nurse says that they occasionally do better, but it depends on the patient mix and why the patients are hospitalized.

I encourage everyone to read Dr. Ubel's blog here.

20 August 2013

Why Aren't Technology Vendors Held Accountable?

Because Congress gave them a golden egg and now that it has hatched into the golden goose, you can bet they will never be held accountable. They will continue to wait for the goose to lay more golden eggs so that they can continue with their proprietorial ways to get more dollars for their products and obtain the golden cow to continue to milk the healthcare system until it dries up. They have padded the coffers of Congress to influence the printing of laws that do not require them to have their systems validated for safety, efficacy, usability, interoperability, or to report adverse events or crashes.

Heavy lobbying will not turn the tide as long as they have the golden goose to parade before the members of Congress. I could almost agree with Jordan Dolin, founder and vice chairman of Emmi Solutions if he would abandon the buzz words. If he would use the terms with real meanings that had known definitions it would make more sense. However, using terms like patient engagement is what the medical people use to hide what they are talking about and most patients are beginning to understand this and want no part of patient engagement.

Even he admits that the term patient engagement lacks a standard definition. Then the medical community muddies the water by alternating this term with meaningful use to keep patients off balance. Jordan also admits that what many health information technology types are doing is not going to fit within the definition of meaningful use that the Centers for Medicare and Medicaid Services (CMS) is looking for to satisfy the requirements.

Handing out a 100-page binder of information, call centers that remind patients of their appointments, waiting room entertainment systems, and printed hospital discharge instructions is being used to say that patient engagement is taking place. This is fallacious at best and is not engaging and assisting the patients in their care. To me as a patient, this should mean communications that is not one sided, but between a provider and patient, occasionally including an advocate or a patient's caregiver. This is communication that will encourage a patient to want to take better care of themselves and expend the time and effort to obtain better health. The term “patient engagement” should be relegated to the trashcan and replaced with the term communications.

Even one of the comments to Jordan's blog stated, “I know of providers who have a typed line on every piece of paper handed to patients that recommends smoking cessation. This enables them to successfully check a box on meaningful use e-templates (with 100% participation!). For all I know, it may help. But I wouldn’t hold my breath.” This is the asinine use of patient engagement and not of value, as I doubt these providers even knew which patients smoked and which did not.

Vendors should be willing to commit to their patient engagement promises, present proof showing improved outcomes and face some financial risk for failing to deliver. I won’t be holding my breath. And, I bet the boilerplate disclaimer “…[Vendor] makes no express or implied warranty for merchantability or fitness for any particular use…” remains a staple of all EHR contracts. Yes, the golden goose clause exempting them from penalties.

19 August 2013

Discussion on Future of Contract Medicine

Why is there the interest in Contract Medicine? There is a host of reasons, some are good reasons, and some are questionable. In the research I do, I am reading more articles about Concierge medicine. This seems to be the title used by most writers and then they mention other types of contract medicine as if they don't matter or are often the same fee structure without getting into the different fee structures.

This is not the anticipated growth that I had envisioned as I had expected California to be much higher, but New York, Florida, and Texas are projected to grow faster.

Why are people so willing to move to doctors in this type of practice? I had one person tell me that he will not wait months to see a doctor that has little time for him. He is now waiting six months just to obtain a physical that is required by his job. He indicated that unless he could get the physical in three months, he could be out of work. Therefore, he contacted seven different doctors and the quickest he could see any doctor was six months. This was even after he explained his need. He then contacted a doctor in “direct pay” and could get in for his physical in a week. He will be required to miss three days of work to drive to where the doctor is located, but he feels that his job is worth this and now his employer is contacting this doctor to get everyone's physicals completed.

It is a little disconcerting that there are only about 4000 doctors that are considered concierge doctors. I have not been able to determine if they are only concierge or whether this is a cover term that the article uses to cover the different classes of contract medicine.

Let me review the terms – boutique, concierge, retainer, and direct care (or direct primary care - DPC). All of these, by practice, are contract medicine or care. The contract is the result of a fee the patient pays at the first of each billing cycle to have access to that doctor for the coming period and if you wish to keep the doctor under contract and available to you. This does not mean that you, as the patient, will physically see the doctor that cycle, but the fee still must be paid. The fee is for only you and does not include other family members. Family members may be part of a family fee structure or handled on an individual patient basis.

There are several terms for the fee paid and include, contract fee, retainer fee, subscription fee, access fee, medical care fee, and the list goes on. Much of this naming depends on how the doctor wishes to describe it, and I will not attempt to list all possible terms. Most practices request the fee to be paid monthly, but some do collect on a yearly, semiannual, or quarterly basis.

For those who can afford this type of care, having that extra time with the doctor and knowing your care will be coordinated can be a huge plus for your peace of mind - and your outcomes. The biggest plus will depend on whether you are receiving preventive care. This in and of itself can save money and often keep you from needing to have care in a hospital. Under the current medical system, doctors are not paid for the time they spend with a patient, nor are they paid to coordinate the care of that patient.