Primary Care or Specialist?

I was driving home from the mall today and have no idea why, but I started thinking about the changes I’ve recently made to the way I manage my health care. My internist where I used to live was not comfortable managing some of my conditions so he referred me to specialists. So, when I moved to NC I automatically asked my new internist to refer me to the same set of specialists to continue the monitoring.

Was this the right thing to do?

Over time I have asked or my internist has volunteered to take over the monitoring of everything but my gynecological exam and allergies. Without realizing it specialists have disappeared from my appointment calendar. It happened gradually. Now as I think about it here are the factors I considered as decisions were made:

• Diagnoses  were made and conditions are stable
• All blood and other tests only need to be done yearly or every other year for monitoring purposes
• Some specialists required quarterly visits to “check in”. I didn’t feel they were obtaining valuable information and I didn’t have questions or see the value of continuing with that frequency of visits
• Specialist co-pays are twice my primary care co-pays and cost for my insurance company significantly more money
• My primary care feels he only needs to see me yearly unless I develop a problem
• I like the way my primary care doctors thinks things through and interacts with me. He is more than willing to monitor and order tests as needed
• I like having one person actively overseeing everything as I think it is more likely that I will receive better “whole person” care. By this I mean that new symptoms are more likely to be reviewed in light of all my health issues rather than from a specific condition point of view.

Had I had ongoing issues that needed a specialists knowledge I certainly would not have made the changes. Don’t get me wrong. Specialists have played an important role in my diagnosis and care over the years. I believe it is important to recognize there are times when they are no longer needed. It is good stewardship of healthcare resources and dollars to use them appropriately and for the right reasons. I will certainly go back to the specialists if need be and have them monitor my care if it is warranted, but for now I am very comfortable with my care choices.

What about you?

s it time to reassess how you receive your care and from whom you receive it? If you are not sure, talk to your primary care doctor.

Image from: healthylifecarenews.com

Research Shows What Many have Known for Years

I wasn’t one of those four patients, but when I was prescribed statins in the mid 1990′s and had muscle problems. I was told, “That type of muscle problem is not a side effect of statins.” My body and my instincts told me otherwise, so I refused to take the drugs. Until last year I was pressured by various doctors to take statins and then the pressure stopped. I didn’t why, but was relieved. Most likely it was because of the new research that was becoming available.

Many factors led to my decision not to take statins – among them were:

• My cholesterol has been high all of my life.
• My good to bad ratio and all other parameters measured show that I am at a low risk for heart problems even though my father’s family had heart failure.
• I eat a healthy diet
• I get a reasonable amount of exercise.

After thorough discussions with my doctors and a considerable amount of research on my part, I have felt comfortable with my decision. For me, I felt the risks were higher than the benefits, especially since the statins didn’t lower my overall level very much. Lifestyle and diet changes along with supplements work for many people.

Besides the well-known muscular side effect, statins can also cause liver damage, digestive problems, increased blood sugar, memory loss (I don’t need anything more contributing to that) and others potential problems. More information about these side effects can be found on the Mayo Clinic website.

Reassess Your Needs

Now that more has been learned about statin drugs I am very glad I listened to my body. I wish the FDA would put it on their questionable drug list. 20 million Americans take statins. Are you one of them? Whether you have recently started taking statins or have been on them for a long time, you may want to revisit why you are on statins and weigh your risks and benefits with your doctor.

Images from: drugsideeffects-info.com and neuropathyandhiv.blogspot.com

Needless Cancer Deaths

How long she had the cancer I don’t know. It was stage four IV when diagnosed and there was little the doctors could do as it had already spread to other parts of her body by then. When I realized my system was acting like hers, I ran not walked to the doctor and have been having colonoscopies every five years since I was 40. The “stuff” you drink is much lower in volume and less harsh on the system than it was back then, so if the preparation is keeping you from being tested I say, “Just do it!”

Colon Cancer Most Treatable Cancer

Colon Cancer Screening Guidelines

A breath of fresh air. Those of you who know me and my healthcare stories will know why this story thrills me so much. My husband had surgery yesterday morning at Novant Kernersville Medical Center. We got up very early and drove in the dark to a new shiny hospital for the first time. A few questions and thoughts rattled around in my brain, as much as my brain can rattle that early in the morning. Do they have the kinks of starting a new hospital worked out? Is the staff as experienced as they should be? Maybe he won’t get an infection like I did last year when I had surgery. Maybe no bad bugs to invade yet!

We were greeted by a very pleasant young lady. Every person we encountered made us feel as though we were the only people they were serving that day. All were equally pleasant and upbeat and attended to every detail of their responsibilities and to our questions - and we always have many questions.

As I think about it, the positive experience started before the day of surgery when we met his surgeon for the first time.

• He was very thorough explaining the procedure, how he was going to do it and the reasons why he was choosing one method over another.
• He took all the time needed – we never felt rushed for a second.
• His scheduler bent over backwards to schedule the surgery to meet our needs – very short notice and prior to a scheduled event.

Once the surgery was scheduled several people from the hospital called to ask their set of questions to be sure everything was in order prior to my husband’s arrival at the hospital.

Personalized Health Care

I don’t know if it is typical, but his whole surgical team arrived within minutes of each other in his room before the surgery! The surgeon, anesthesiologist, nurse anesthetist, the surgical assistant and the nurse assistant. Because my husband has chronic kidney disease due to past medical errors, GERD (acid reflux), high blood pressure and severe sleep apnea several having them all there at once allowed for a thorough discussion with all players involved. Best of all they heard our questions and cncerns and involved us in the decision-making process.

Had they each made separate stops several things could have gone wrong and I’m not sure the conclusions reached would have happened. He might have been in jeopardy during the surgery or had complications afterwards. Below is a list of actions the team took that were different from their normal routine because of my husband’s particular situation:

Decisions prior to our arrival at the hospital:

• A different antibiotic used because of his kidney problems
• Regular vs laparoscopic surgery because of the surgeons experience in knowing how to evaluate the best procedure to use

Decisions made during the pre-op “pow wow” with the team:

• General anesthesia with intubation vs spinal anesthesia because of GERD and sleep apnea.  I shared my concerns and observations about my husband’s issues with these conditions. The team discussed the options with us as they came their conclusions and reasons for them rather than leaving the room and having a hushed conversation in the hall. They asked my husband for his preference based on the information shared before making the final decision.

Decision in the operation room:

• The doctor routinely uses steri strips and a dressing to close up the incision. After going through his checklist and discovering my husband is allergic to the adhesive used in bandages, he changed to a different type of dressing.

I suggest that before you have surgery ask if your doctor and the hospital use the WHO surgical checklist.

Discharge Instructions BEFORE Surgery

In addition to all of the decisions made, the team spent a considerable amount of time going over everything we needed to know about the post-operative process and recovery at home. This is the first time I have ever seen this done before surgery when the patient can hear and understand the instructions. Hurray! In the past, instructions have always been done by a nurse, who we had never seen before. They were given just prior to discharge when we were still too groggy from the anesthesia to think much less understand, ask questions or remember. This time the instructions were not only given before the surgery, but were repeated before we left the hospital. Once again we weren’t rushed. We had plenty of time for questions and concerns.

Was our experience an anomaly or is it the culture and routine of this new community hospital. I certainly hope it’s the latter and that they share their methods with other hospitals.

My husband was so comfortable with the experience he didn’t seem to want to leave. The staff was so very patient. He still has his recovery ahead of him, but at this point we couldn’t be more please.

Yes, it was Personalized Health Care the way it should be.

Images from: sites.novanthealth.org and wellingtonicu.com

I have been very frustrated by the lack of information from our news media about what is inside Obamacare officiall called the Affordable Care Act (ACA) besides the insurance issues and the effort to provide coverage for as many people as possible. I have spent a considerable amount of time searching for information to help us understand what is in the bill and the costs associated with it- the good, the bad and the unknown. The image to the right echoes my questions very well.

So, first I will share some of what I learned from an interview I discovered in Medscape’s One on One series. In it Eli Adashi, Professor of Medical Science at Brown University, interviewed by Dr. John McDonough, Professor of the Practice of Public Health with the Harvard School of Public Health who is the author of Inside National Health Reform. He was also involved in the creation of the Affordable Care Act.

ACA “Title” Explanations

The bill contains ten sections / titles. Rather than give the titles, I will print the explanations Dr. McDonough provided of each. It gives a better sense of what each sections includes and the intentions of each.

“Title I is a revolution in terms of private health insurance in the United States. If it is implemented by 2014 as designed, health insurance in the United States will never be the same.”

“Title II is a revolution in terms of the structure of the US Medicaid program and the relationship between the federal government and the states.”

“Title III is some fundamental changes in our healthcare delivery system to improve the quality of care for all Americans and to make major significant changes in Medicare.”

“Title IV is all about prevention and wellness, and trying to create a structure where we try to help people and not just wait till they get sick.”

“Title V is all about the healthcare workforce.”

“Title VI is a little bit of a grab bag, fraud and abuse, transparency, elder justice, comparative and clinical effectiveness research.”

“Title VII creates a pathway for the US Food and Drug Administration to approve what are known as “biosimilars,” generic-like biopharmaceuticals.”

“Title VIII is a new national disability program called CLASS or Community Living Assistance Services and Supports.”

“Titles IX and X are the revenues to pay for about half the law.”

He adds these comments, “And if you look at the law along that kind of a structured way, believe it or not the law itself can actually become accessible and starts to make sense. You can actually begin to see what folks were trying to do, and why it came together and why it is the way it is.”

The explanations of each title sounds very good for the most part. But, what is embedded within each one of these titles as it unfolds over the years? As they say, “The devils in the details.” Nancy Pelosi said, ‘We have to pass the bill to see what is in it.” But, the dtails that have been kept very quiet in the public media. For me personally, Title III is both encouraging regarding quality improvement in the system and concerning regarding “making major significant changes in Medicare.” What do they mean?

Is the silence about ACA details all about politics?

Besides the media silence, the lack of publicity by both the Republicans and the Democrats about the details of the ACA as it has been unfolding makes me wonder:

• Are the Democrats not touting the good work being done, because of the millions of dollars being spent to make it happen? Money that is causing the deficit to soar.
• On the other hand, do the Republicans not want us to know about the good that is happening, because it will give them less fuel to use to get elected? Maybe they feel the “bad” parts greatly outweigh the good.

I fear it is all political. Our future and the quality of our health care and lives depend on what is embedded in the ACA. It’s time we learn the details of the implementation and the costs associated with them. It’s time to have the information we need to know whether or not so wecan help decide if the ACA is or isn’t repealed. I have already posted elements that I think are part of ACA. The posts are linked here: the use of surgical checklists, Patient-centered Medical Homes, Evidence-based Medicine and my first post about healthcare reform that I wrote after I attended a mini-course about it at the Institute for Healthcare Improvement in Orlando in December of 2010.

I have still to find information aboutthe money being spend since the bill was passed.

I will keep digging, but I’d like to learn from each of you as you discover things or learn of resources. Thank you in advance.

Images from: www.corporatewellnessmagazine.com and www.samhsa.gov

For years I have been looking for an MD who practices integrative medicine. Last week I learned of one who has recently opened a practice near me. I was ecstatic to learn that he specializes in the areas of my needs. I called to make an appointment and was thrilled to learn that the doctor accepts insurance from my insurance company, BUT then discovered that he doesn’t accept Medicare patients. Ouch! “Why?” I asked.

It’s a Business Decision

The explanation, “It was a business decision.” The person answering the phone continued to explain that in the face of the 27.4% fee cut (currently on hold until March 1, 2012 tied to the bill on taxes – the two-month patch) he couldn’t afford to accept Medicare patients as a new business. He had to sign an agreement which stated that if he treats Medicare patients they have to pay cash for “everything” and cannot submit any insurance for reimbursement. “Everything” includes appointments, lab tests, prescriptions, procedures, anything that he orders. I do not know if lack of reimbursement for these services is new or in existence before the Affordable Care Act.

The Story Behind Medicare Reimbursement Fees

When I did an Internet search to learn more, I couldn’t find much that helped me understand. I did discover the 2011 Annual Report of the Board of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.

Below are some excerpts that provides some incite. It’s a bit complex, but hang in there.

“Because knowledge of the potential long-range effects of the productivity adjustments, delivery and payment innovations, and certain other aspects of the Affordable Care Act is so limited, an independent panel of expert actuaries and economists was asked to review the assumptions and methods used by the Trustees to make projections of the financial status of the trust funds. In its interim report, the panel recommended the continued use of this supplemental analysis, similar to the illustrative alternative projection that accompanied the 2010 Trustees Report, for the purpose of illustrating the higher Medicare costs that would result if the reduction in physician payment rates and the productivity adjustments to most other provider payment updates are not fully implemented as required under current law.”

How Medicare Fees are Determined & the Impact of Delaying Needed Changes

Don’t give up. Keep reading. This paragraph explains a lot.

Regarding physician payments the report says, “Medicare payments for physicians‘ services are based on a fee schedule, which reflects the relative level of time and effort required for each service and also its relative complexity. These relative factors per service are translated into dollar payment amounts through a conversion factor, which is updated each calendar year based on the Sustainable Growth Rate (SGR) mechanism specified in law. The SGR system compares the accumulated amount of actual physician-related spending to a specified target level. If actual cumulative spending exceeds the cumulative target spending level, then one or more future physician payment updates per service will be reduced so that future actual expenditures will be lower and ultimately reach the target amount allowed under the law. Similarly, if the actual spending is below the target level, then future physician updates will be increased. The update adjustments are subject to limits on both the increase and the decrease. The intent of the SGR system, which was enacted as part of the Balanced Budget Act of 1997, is to limit growth in spending on physician services to a sustainable rate, roughly in line with the rate of overall economic growth.”

How do you like that formula? I certainly don’t understand it.

“Reflecting the accumulated impact of the 2007 through 2011 payment reduction overrides, and the requirement that future payment updates must be determined as if these overrides had not occurred, for 2012 the scheduled payment update is estimated to be −29.4 percent. Physician payments per service are projected to further decline under current law by an additional 0.3 percent in 2013.”

Will Decreased Payments Force Improvements?

It goes on to say, “It is reasonable to expect that healthcare providers, while being unable to match economy-wide productivity gains, will make every effort to improve efficiency, eliminate wasteful costs, and take other steps to maintain their viability despite the slower Medicare price updates. These price changes could reflect fees as low as 57% of what private health insurance pays and possibly even lower.” The report also states, if I understood it correctly, that for 2012 and 2013 doctors seeing Medicaid patients will receive 77% of what private insurance pays and then the fee would drop back to the 22% they currently receive.

We’ve been hearing in the news that many MDs are retiring or no longer accepting Medicare. They have incentive to see Medicaid patients for the next two years, but when their pay is returned to 22% of private insurance payments what will happen? Why is it structured this way?

We’ve been told that our care will improve with the impending changes, but if the number of doctors who care for Medicare patients continues to decrease as the number of patients (baby boomers truning 65) increase we will have a hard time receiving any care much less quality care. So, the question for seniors is, “Will healthcare improve or will it become unobtainable?

Images from: collinge.org and exceluser.com

I have been on Medicare all of three months. Up to the time of enrollment I wondered if my access to and/or quality of care would be effected with the change. In the last two weeks I have encountered two changes that I feel have or will have a impact on my care. One change that effects Medicare patients, the other effects everyone. I decided to search for the reasons behind the changes and try to discover other changes that I might be encountering. I have searched the Internet with every set of words I can think of to try to learn about the healthcare changes, but haven’t been very successful. I also wonder if the changes are part of the Affordable Care Act . I learned from people involved in the creation of the bill that there were 1000 one-line statements embedded in the Act that needed to be defined for implementation as of December 2010. I’d like to know more about those line items.

That said, I am starting a new category, “Healthcare Changes” and will report on changes as they happen to me or I learn about them. The insurance aspects of the Reform Act have received all of the press and, yes, it impacts our pocketbooks, but it is the “little” changes in our care that aren’t being talked about that will impact the availability and the quality of our care going forward positively and / or negatively.

I would appreciate your input as you, too, experience both positive and perceived negative changes in the way doctors can do things, things you have gained access to or no longer have access to, etc. Knowledge is power and sharing helps us all. Thank you in advance.

Image from: mttoolsonline.com

The media coverage of the Affordable Care Act, more commonly called “Obamacare” focuses mainly on the “way we pay for healthcare”.  Avik Roy writes the Apothecary blog for Forbes.com. In one  of his latest posts he provided eye-opening information about the doubling of charges to insurers after major hospitals mergers. Among these merged systems are Harvard-affiliated hospitals Massachusetts General and Brigham and Women’s to form Partners HealthCare.
He suggested that because these hospitals are so prestigious, insurers were afraid to push back on the fee increases or not cover patients in their facilities for fear of media and political reprisals. Besides, what insurer would dare refuse to pay for patient treatment at some of the most prestigious hospitals in the country? They could stand to lose a lot of business by doing so. As Avik put it, “Today, Partners dominates what was once one of the most competitive healthcare markets in the world, with a hospital and physician network big enough to overwhelm competitors and intimidate insurers.”

Several other hospital and physician systems have merged with the same decrease in competition and increase in charges. Pharmaceutical company practices including successful lobbying efforts that prevent price negotiations and effect patent laws contribute greatly to the high cost of care.  I have often wondered about other medical system practices and how much they contribute to costs. I have already written about insurance claim costs.

The good news is that the Department of Justice is investigating Partners HealthCare for “anticompetitive behavior”. The Federal Trade Commission (FTC) is investigating a similar system in Toledo Ohio. Check out Avik’s full article for the more details and links to these investigations. For a more thorough analysis of hospital mergers by the FTC click here. To get an idea of the number of mergers taking place one year ago check out this USA Today article.

If anyone has other information regarding other business practices that contribute to high healthcare costs I’d like to hear about them. I think that until we get to the root cause of the high cost of health care and eliminate that which leads to high costs we will not solve our problems. Changing the insurance system as the Affordable Care Act is doing and adding more people to a system that is riddled with high cost processes, overcharges and the like will only make the cost of care higher and the problems worse. Let me know what you think.

Critical Needs for Successful Diagnosis and Treament

Dear Doctor I wish you:

-Would consider less expensive options before ordering the expensive ones.

-Wouldn’t be afraid of a dementia or Alzheimer diagnosis. Listen to and believe my observations about my elderly parent, and of those working with him/her at the adult daycare center.

-Would consider that I am more than a number on a test. If my result is slightly higher than the norm and it hasn’t gone up or down in twenty years, it may be normal for me. Maybe medication is not needed.

-Wouldn’t tell me it’s all in my head when my symptoms don’t fit neatly in a diagnosis or you can’t find out what is wrong. Help me understand why a diagnosis can’t be reached. Work with me the best you can or recommend another who might be able to help.

-Wouldn’t gloss over tests just outside the normal range, especially if they are linked to my condition, a problem my condition can progress to or related to my family history. Please consider repeating them in reasonable timeframe to confirm the result.

-If you are a specialist, please consider my problem holistically rather than just through the lens of your specialty. Let me know if a treatment you are recommending could cause problems in another part of my body in the future.

Dear Patient I wish you:

• Would tell me about your lifestyle – eating habits, exercise, stress level – Be honest.
• Would help me understand your goals for your health and your care.
• Would let me know limitations you have as it might impact what I recommend or the effectiveness of your treatment plan.
• Would write down symptoms when they occur (not obsessively) – chances are you won’t remember them. Miscommunication or lack of communication is dangerous.
• Would wait to do your Internet research until after you have seen me. I need you to describe your symptoms as they have occurred without being colored by what you read. Once I have evaluated you, then feel free to do your research. Be very careful about the Internet resources you use.
• Wouldn’t come to me having pre-diagnosed yourself from information you’ve found on the Internet.

Summing Up

Doctors are asking for the elements they want people to include in their story besides their symptoms and as they interact with them.

Patients are asking doctors to think deeper and more holistically during evaluation and diagnosis. Family caregivers often tell me of struggles they have in both the hospital and office settings in getting clinicians to value their input and take it into consideration when making decisions. I’ve heard several stories of serious complications that I’d term medical mistakes because family information was discounted or completely ignored.

Doctors are looking for details, patients for more respect and better processing of the information they do provide.  I wonder if the doctor would be freer to think holistically if patients provided more meaningful information about themselves in the right way and asked good questions to help the doctor think things through in a way that is personal to the patient.