Tuesday, February 22, 2011

Why Consumer-Driven Health Care Will Fail

The creation of consumer-driven health plans (CDHPs), health insurance policies with high deductibles linked to a savings option and with more financial respnonsibility shouldered by patients and employees and less by employers, was completely inevitable. The American public likes to have everything, whether consumer electronics or other services, as cheap as possible. With escalating health care expenses rising far more rapidly than wages or inflation, it's not surprising employers needed a way to manage this increasingly costly business expense.

In the past, companies faced a similar dilemma.  It wasn't about medical costs, but managing increasingly expensive retirement and pension plan obligations. Years ago, companies moved from these defined benefit plans to defined contribution plans like 401(k)s. After all, much like health care, the reasoning by many was that employees were best able to manage retirement planning because they would have far more financial incentive, responsibility, and self-motivation to make the right choices to ensure a successful outcome.   

How did that assumption turn out anyway?

Disastrous according to a recent Wall Street Journal article titled Retiring Boomers Find 401(k) Plans Fall Short.

The median household headed by a person aged 60 to 62 with a 401(k) account has less than one-quarter of what is needed in that account to maintain its standard of living in retirement, according to data compiled by the Federal Reserve and analyzed by the Center for Retirement Research at Boston College for The Wall Street Journal. Even counting Social Security and any pensions or other savings, most 401(k) participants appear to have insufficient savings. Data from other sources also show big gaps between savings and what people need, and the financial crisis has made things worse.

In others words a lot of people don't have enough money to retire.   The options they have are simply "postponing retirement, moving to cheaper housing, buying less-expensive food, cutting back on travel, taking bigger risks with their investments and making other sacrifices they never imagined....In general, people facing problems today got too little advice, or bad advice."

Though employers were able to manage retirement expenses, employees paid a significant price.  This wasn't intuitively obvious in the 1980's when these plans became more commonplace.  Over the past decade, the less than rational behavior by employees hasn't gone unnoticed by those who study behavioral economics or those in the government.  As a result, more organizations and companies are nudging employees into the right behaviors with auto-enrollment into 401(k) plans and auto-allocation of these funds with protection from any future liability as noted in the Pension Protection Act of 2006.

The analogies to health care and specifically consumer-driven health plans should be clear.  Workers don't save adequately for retirement even when in their best interest.  It's very likely that workers won't save money adequately to fund future health expenses.  After all, if people can't fund retirement, something we undoubtedly all look forward to, which one of us is willing to saving for chemotherapy or open heart surgery, which no one wants?  According to the annual Kaiser Family Foundation Employer Benefits Survey, the average annual deductible for single coverage and family coverage is nearly $2000 and $4000 respectively for health insurance plans that are health savings accounts (HSA) eligible.   The deductibles are slightly lower in health insurance policies that are linked to health reimbursement arrangement (HRA).  About 13 percent of employees are covered under either plan.

Unlike those in retirement planning who can work longer, even if not desirable, employees who are ill may not have an option to work to pay for their medical expenses.  There continues to be evidence that people are curbing their health care due to the ability to pay.

Though experts debate on whether this is a good thing (patients are avoiding unnecessary and expensive therapies and opting for less pricey but equally as effective options) or a bad thing (patients are avoiding the preventive screening tests or therapies that overall can decrease future costs), the opportunities to ensure patients make the right choices should be clear from workers' less than optimal experience with 401(k)s.

If employers wish to help curb medical costs, then they will need to engage workers with programs like employee wellness, assisted decision making (either as second opinions or patient-friendly informed consent), and access to medical experts, equivalent to personal financial advisors, who may be able to help workers make the right choices for their health.  Within the business community, there is some acknowledgment that access to these tools will be necessary to not only manage costs but keep employees healthy and productive.

Done correctly, consumer-driven health care can be what everyone hoped they would be, nudging healthy behaviors and slowing health care costs with workers selecting only cost-effective therapies.  If implemented poorly and organizations simply shift health care costs and financial responsibilities to workers like retirement planning decades ago, the nation will need to accept more than ever that increasingly more people get the medical care based simply on their ability to pay and not on medical necessity.

As a practicing primary care doctor, I hope that day never comes.

Monday, February 14, 2011

What Doctors Wish Their Patients Knew - Critique of the March 2011 Consumer Reports article

First, I'm a big fan of Consumer Reports and even listed their Consumer Reports Best Buy Drugs website in my book, Stay Healthy, Live Longer, Spend Wisely - Making Intelligent Choices in America's Healthcare System, because of its accurate, unbiased, and money saving information in getting the right treatments for the best price.

So naturally when I saw this month's issues cover story - What Doctors Wish Their Patients Knew, I had to read it.  Overall, it was excellent and made a lot of sense.   Their conclusions were obvious to me, however, might not be as intuitive to the public (after all it is titled what doctors wish their patients knew!).

In summary, primary care doctors matter and having a long-term relationship with one can save time and money.  Respect and being courteous still matter to both doctors and patients.  Thoughtful use of the internet might overcome the resistance doctors have to patients researching information.  Generic medications, which are inexpensive and very effective for many conditions, are excellent and should be used.

A more in depth analysis reveals the following.  Primary care doctors are vitally important.  As Dr. Kevin Grumbach, professor and chair of the department of family and community medicine at the University of California San Francisco noted, "a primary-care doctor should be your partner in your overall health, not just someone you go to for minor problems or a referral to specialty care."  Indeed, that is why I went into primary care.  I prevent problems.  I diagnose problems.  On the occasion I can't solve your problem, then I need the assistance of my specialty colleagues.

I'm not a gatekeeper.  I'm not simply a referral center or an obstacle in getting you the right care.  In fact, I'm the first logical place to always get care and be your partner in keeping you healthy and well.

A long-term relationship with a primary care doctor is also important according to three-quarters of the 660 primary care doctors surveyed.  Consumer Reports found some evidence that patients who frequently switch doctors have more health problems and spend more on care.  This seems to make sense.  Having someone you know and trust to get care over a long period of time can keep you healthy and save you money.  The challenge for many Americans is trying to keep the same doctor.  Employers often switch insurance carriers to save money.  Doctors drop out of health plans.  Patients change jobs and have a different health plan or no health insurance coverage.  In other words, a primary care doctor isn't simply a commodity, but rather a vitally important relationship.  Unfortunately the health care system and the general public don't view them that way.  Practicing primary care doctors are leaving the specialty and medical students are not interested in a primary care field even though it is has potential to be one of the best choices in the future.

Respect and being courteous are two traits still valued by doctors and patients.  The majority of doctors polled felt that being respectful and courteous would help get better care.  Patients equated respect and courteousness as professionalism.  Doctors who treated them respectfully, listened to them with understanding, and spent time with them scored high.  Though professionalism scores increased more when patients felt that their doctor seemed technically competent, I find it hard to believe that patients can honestly determine who is skilled clinically.  I think my car mechanic is skilled, but I really don't truly know as I'm not a mechanic.

I'm sure patients believe I'm technically competent as I explain everything I'm doing.  For a knee examination, patients will hear me say -  I'm palpating the meniscus both the medial and lateral aspects to check for arthritis or a meniscus tear.  I'm examining the medial and lateral collateral ligaments of your knee and making sure they are intact and not strained or torn.  I'm looking for fluid in the knee and mechanics of the knee with the range of motion.  I'm checking the health and integrity of the ACL and PCL.  Instead of wondering if I'm simply waving my hands like a magician, the description of the examination demonstrates my value as a doctor.  Patients, and some doctors, have forgotten the value of taking a detailed history and a good physical examination.  There was a time doctors didn't have the imaging tests of xray, CT, or MRI.  Once I explain what I'm doing, then they understand why these tests are often unnecessary, which of course saves money and time. If showing and verbalizing our examination and thought process is professionalism, then we need to do more of it.

Although the article suggested that 80 percent of doctors felt taking a friend or relative to an office visit would be helpful, I believe this expectation to be a little unrealistic.  Unless a family member or relative is particularly worried or if the visit is very important, say a consultation with a surgeon or an oncologist, it isn't necessary to have someone else tag along.  People are incredibly busy.  Taking time out of the day to accompany someone for an appointment isn't going to happen.  The reason for this suggestion is that doctors discover patients don't typically remember everything that occurred in the office.  This point really is about providing patients a strategy to recall important information (using the mneumonic D.A.T.E. can be helpful).  

Suggestions on how to thoughtfully research information on the internet was a plus.  Besides MedlinePlus and the Mayo Clinic, one should also consider Healthcare.gov, which has a preventive app, my health finder, that gives personalized specific age and gender information on what tests are needed and appropriate (it's under the Learn About Prevention tab).  Not surprisingly due to the ease of looking information on the internet, 61 percent of patients have researched their condition.  Sadly doctors were not as enthusiastic.  Half of doctors said that online research was not helpful at all.

Physician wariness to the plethora of online information is due to the lack of respect from some patients who demand certain treatments, medications, or interventions, without understanding the nuance of a diagnosis.  It isn't as simple, though it seems like it, as putting in a bunch of diagnoses and then just then hitting Google search (or worse I'm feeling lucky).  I don't mind patients emailing me links to articles or suggest diagnoses.  In fact, I learn a lot from patients.  I do however find it difficult to treat patients who are insistent on their way or the highway and in those cases will suggest they find another doctor.  It's about a trusting partnership not just about patients who are empowered with small pieces of information.

Finally, the best part of the issue was he Best Buy Drugs section which notes that many conditions, like high cholesterol, diabetes, heartburn, allergies, and depression have very good generic prescription medications that are inexpensive and very effective.  Consumer Reports uses evidence based research to back up the claims.  The vast majority of patients I care for do fine with generic medications.  That's what I buy.  You should do fine with generic medicationas as well.  They left out my favorite online pharmacy, Healthwarehouse.com which often has pricing better than Wal-mart and Costco for many medications.

What else do doctors wish patients knew?  Vaccines are safe and underutilized.  Body scans and life line screenings really aren't worth your money.  The fountain of youth really is eating less, moving more, and not smoking, and plenty of servings of fruits and vegetables.  Cancer screening tests are for everyone, not those with family histories as the majority of people who develop cancer are the first in their family.

But of course, that might take more than just a blog post, but an entire book.

Thursday, February 3, 2011

Why This Primary Care Doctor Loves his Electronic Health Record

A recent post in the Wall Street Journal Health Blog noted that a study found electronic medical records don't improve outpatient quality.  The authors of the Archives of Internal Medicine article, Electronic Health Records and Clinical Decision Support Systems, correctly points out that we should be skeptical and "doubt [the] argument that the use of EHRs is a "magic bullet" for health care quality improvement, as some advocates imply."

This should surprise no one.  Were we that naive to think that simply installing health information technology (HIT) in the medical field would generate significant improvement in outcomes?  Does simply installing computers in our classrooms improve educational test scores?

Of course not.

The excellent commentary after the article makes some plausible reasons why the clinical decision support (CDS) didn't seem to improve outcomes on 20 quality indicators.  First, it isn't clear that the CDS implemented across the various doctors' offices and emergency rooms actually addressed the indicators studied.  Second, the data studied is already dated (from the 2005 to 2007 National Ambulatory Medical Care Survey), a long time in technology terms (iPhone first debuted in 2007).  The authors of the original article also point out that there is some evidence that institution specific use of CDS actually improves quality.  Whether this can be scaled to the national level is the question.

In other words, it isn't just that perhaps CDS failed, but rather the robustness of the system was inadequate, that doctors failed to use them, or just as importantly patients were unswayed by the doctors reminded by the CDS to do the right thing. One of the 20 quality indicators studied was in fact the appropriate antibiotic use in viral upper respiratory infections.  As most people know already, there is not typically an appropriate antibiotic to use for a virus.  It's a virus.  It does, however, take good bedside manner to inform and educate an ill patient!

As someone who has had the benefit of a robust electronic health record since the spring of 2006, I know I'm incredibly lucky.  In an April 2009 New England Journal of Medicine article, only 4 percent of doctors nationally have a fully comprehensive EHR that I take for granted daily. Only 1.5 percent of hospitals have a comprehensive EHR, which I also have access to.  CDS is also an incredibly helpful tool and an excellent reminder to provide the right care every time.  It is a safety net.  Understandably some EHRs aren't that good, the CDS is clunky, and certainly the one I use is good, but not perfect.

The real issue isn't finding a perfect EHR, but rather how do we address the culture of the medical profession. There is something still heroic and mystical about a lone doctor, independent, smart, and getting the job done.  Indeed, to get into medical school, one has to be self-motivated, persistent, and determined.  Why on earth would we need a computer to help us?

Frankly, because it makes us better doctors.  CDS frees up time and mental energy.  I don't have to remember the latest guidelines on immunizations, repeating blood work, or treatment of illness like coronary artery disease, congestive heart failure, and hyperlipidemia.  Most of these diseases are well understood and often under a protocol, something known as precision medicine, a term used by Harvard Business School professor Clayton Christensen

Now I can focus on if the patient in front of me is an exception to the protocol as well as thoughtfully diagnose and treat their ailments which don't fit any protocol (cognitive medicine) because science hasn't evolved to that level of understanding.  I'm a big believer in the history and physical exam and how the use of HIT can make care more personal.  Having real-time access quickly and reliably to medical information and data 24/7 is important to make this happen.  Instead of hunting for lab work in a paper chart or trying to find a specialist's consultation, I can access the information I need rapidly and focus on the patient in front of me.

Sadly, however, many doctors don't feel the same way. Perhaps it is a generational thing. Perhaps it is because their EHR is inadequate.  It might also be, however, our training and tradition which limits us from improving.  If anything, the medical profession needs to emulate ourselves after the aviation industry where technology is used to support decision making and make pilots and flying even safer and better.  We are where our aviation colleagues were in 1935 as noted in Dr. Atul Gawande's New Yorker piece, the Checklist.  Because, really, CDS is essentially a checklist.

In the situation where a patient doesn't fit CDS, then we get to do what we do best and that is use all of our training to get a patient better.   HIT, EHR, and CDS are things the next generation of doctors must accept that will make the care we provide more personal than ever before.  In the end, that is what patients really want.

This is why I love my EHR so much.


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