Health Care Reform

It will probably take months to figure out whether the health care reform bill has overall positive or negative effects. I am certainly hoping for the positive.
Share your thoughts!

Things that seem positive to me are the provisions for better preventive and primary care, the provision of insurance to additional millions of people, the subsidy of health insurance for small businesses, insurance companies' inability to exclude for prior medical conditions, and the elimination of a lifetime cap on insurance expenditures.

However, time will tell whether insurers will find a way to make these changes justify increases in premium. In addition, the supposed savings depend on Medicare not fixing the physician payment problem. This will push physicians out of Medicare and into other programs.

Organic Chicken and Illness: Silly Checkout Comment

A Costco checkout clerk yesterday felt obligated to let me know that if I ate organic chicken, I should be very careful about how I handled it to prevent bacterial infections such as E. coli.

While I appreciated his concern for me and other Costco shoppers, this man is spreading misinformation. People are no more likely to catch E. coli from organic chicken than from any other form of chicken. Organic chicken simply means that the food the chicken is fed is grown without pesticides. Even whether chickens are treated with antibiotics or not has nothing to do with whether we catch bacterial infections from them. Catching bacterial infections such as E. coli or Salmonella from chicken has only to do with how the chicken is handled from the point at which it is slaughtered until you eat it.

For more information, see http://www.organicconsumers.org/articles/article_19725.cfm

Managing my Ads

Comments welcome on which ads should be excluded from this blog, or ads that would be helpful. I would like to provide some links to various services which I think are helpful and if I think the services are good, they might as well be ads to support the time spent writing the blog.

Fun data

http://www.google.com/publicdata/home

Interesting graph showing the association between fertility rates and life expectancy. Just one of the interesting things you can access on Google public data.

ads and ethics

I have an uneasy feeling about ads on this blog....Of course, I'd love to generate some income from it. However, I also don't want to be influenced to put on content that will attract more ads, or to avoid content to prevent certain types of ads from being posted. For example, I'm not really that interested in having ads that push specific medical therapies...it creates a conflict of interest, making it less desirable for me to criticize certain things. I don't mind directly consulting for corporations and disclosing that to my patients so they can evaluate any conflicts of interest, but it's harder to control against the influence of corporate ads, as some of the editors of medical journals have found out the hard way.

Uninsurance

Recently a patient had an dermatology outpatient laser surgery procedure. The procedure was supposedly "preauthorized" by the PPO plan, and all the person's deductibles had already been met for the year, so it would seem that there would be no out of pocket costs besides the copays for the doctors and the facility. Wrong again!!! There was a "laser rental" charge that no one said anything about in advance, which turned out not to be covered by the insurance (why?).

Just another insurance ripoff....please comment if you've experienced anything similar.

Personal Health Records (PHRs)

I tell all my patients to establish a web-based, secure personal health record (PHR). And yes, I mean personal, which you subscribe to. Not one hosted by and paid for by your friendly health insurance company, which may be used to raise your insurance rates in the future. Not one hosted by your provider organization, which you can't control the release of, and which often doesn't show you your own doctors' notes. And not even one hosted by Google, which seems to be having some trouble figuring out to stop your data from being shared in some interesting ways. To be fair, some of this is just because it is such a big target (Chinese hackers requiring NSA help) but some of the problem comes from its own internal corporate decisions (Buzz? everyone in your contacts? hullo??) [Yes, I realize I'm dissing the host of this very blog and its ad service..but then again, if my criticisms draws ads or clicks, they make money so they can laugh all the way to the bank...]

So if you want a PHR under your personal control, with data not released to anyone unless you ask it to, this means that you need to pay for it, not anyone else. But the privacy and security that offers, and the access to your own data, is worth it.

Why do I recommend a PHR? Because it makes your records accessible to anyone while ensuring security and privacy of your records. If you get or have the potential to get care in multiple provider organizations (this includes anyone who ever travels), it means your provider can have access to your records if you so desire. This eliminates unnecessary duplication of services, prevents complications of these duplicate tests, and reduces the cost of your health care co-pays. In addition, your provider will make better diagnoses and choose more appropriate treatments having access to your medical history. Provider organizations are not required to keep your records for very long, and often they do not. If you do not request these records and keep them yourself, they may disappear and the information will be lost forever.

Right now, PHRs are not yet what I hope they will be. Mainly because our federal government has not created a standard that it requires electronic medical record vendors to install which allows physicians and hospitals to share electronic records with their patients' personal health records. Even if the federal government just required physicians to share pdf files of their encounter notes with their patients over secure email, it would be a big improvement. Yes, I do look forward to the day when medications, allergies, diagnoses, are automatically uploaded to every patient's secure and private personal health record under that patient's own control and authorization, but I'm not holding my breath.

In the meantime, I've been recommending Peoplechart www.peoplechart.com to my patients. This farsighted company has been in business for 10 years, and their philosophy very much matches my own approach to patient-centered care. The company realizes that right now, most patients can't force their providers to provide standardized clinical data of any kind for a personal health record, but that people don't want to painstakingly enter all their clinical data into a spreadsheet either. So they also have come up with a way of indexing and using PDF files from providers who don't have EMRs or whose EMRs don't or won't provide comprehensive standardized clinical data feeds to a PHR (which is pretty much 100% of them right now). Peoplechart also does have the capacity to accept lab data and medication data in electronic form, and is building ways to accept other clinical data. (By the way, access this website through Internet Explorer as it's the only browser supported right now...support for Safari is not there yet so they only support the PC clientele right now). The good thing is that Peoplechart works only for you, and a human being answers the phone who helps you subscribe and figure out how to get records into the system. After you print out some authorization forms you send to them, they will collect your records for you and index them for you by date and source and author and what type of information is in them, and upload them to your personal health record). This record is completely under your own control and you decide whom to share your documents with and who is a member of your care community, which can then be changed at any time.

You might wonder what happens if your PHR company goes out of business. Make sure whichever one you choose guarantees that if that happens, you can get all your records on a CD, so that you can then upload them to whichever company is still out there in the marketplace. Of course, if you are a techie who's meticulous about keeping your own computerized records, you can download each of your documents to your own hard disk, CD, or other secure storage as Peoplechart collects from providers.

Another nice thing about Peoplechart is that it has some other good products such as a hypertension module which coordinates with the American College of Physicians' CardioSmart product, helping you and your physician keep track of trends in your blood pressure and your response to medications. Given how awful hypertension treatment and control continues to be in the U.S. according to the recent Institute of Medicine report, A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension, this is a very nice additional tool.

I do have a long wish list of ways I want Peoplechart to improve its PHR product, but at least it offers a physician like me a way to review your past medical records immediately when they are needed.

On a health policy note, the biggest improvements will come from requiring (and this is where the stimulus moneys now allocated to buying physicians EMR systems could really help) EMR vendors to provide physicians and hospitals with systems which will upload standardized clinical data fields (like diagnoses and medications) automatically to patients' electronic medical records, and requiring physicians to use these systems when patients request them, much like they are now required to provide paper copies of records when patients so desire.

If you have any sort of medical problem at all, signing up for a personal health record (PHR) is one of the best things you can do for yourself and your family.

Medicare: Much Better than Nothing

One of my pro bono patients is about to get Medicare. I am breathing a sigh of relief because this uninsured man with a history of heart problems including valve surgery, a rhythm disturbance known as atrial fibrillation, who often needs dangerous anti-clotting medicines such as coumadin, and who has some serious gastrointestinal problems as well, is finally going to have access to a primary care doctor, a cardiologist, a gastroenterologist etc.

I am so amazed by the beliefs some Americans (Tea Party, anyone?) appear to have that the uninsured have access to health care. What planet do these people live on? Here in the San Francisco Bay Peninsula area, we have a safety net hospital, Valley Medical Center, which is the only place which will see uninsured patients. When this man needed to be seen by a cardiologist immediately and needed a cardioversion procedure (where a device is used to deliver an electrical shock to try to convert the heart from an abnormal to a normal rhythm), Valley was so oversubscribed that it took several months to get the procedure done and several months to get an appointment with a cardiologist.

Why not just put everyone on Medicare? It would cost the taxpayers less in the long run, since when gentlemen like this one cannot afford care and cannot get appointments, they end up in emergency rooms, which is much more expensive, and happened to this man twice in the last several months.

feedback about our health: the ODL

Today I received a newsletter from AHIP, the friendly association of health plans. I learned again about the phrase "observations of daily living", or ODL's. This phrase is bandied about in some projects funded by the Robert Wood Johnson Foundation, studying whether automatically recorded data about our daily lives can help us manage our health. A variety of devices out there are designed to provide real time feedback about our diets, our exercise habits, sleep, sex, smoking, etc.

(I imagine that next - you heard it here - the neurotic and narcissists among us will be replaying our interpersonal interactions in real time for our mental health professionals...my prize is going to go to the person who gets our dreams and waking fantasies to be automatically recorded...)

Fantasies and cynicism aside, these data are extremely helpful to all of us in managing our habits. They can be useful for our physicians in determining what we need help with. However, of course they will also be used to inform our insurers for about our risk status. Be cautious, then, whose tool you use and where the data are going. Make sure the information from these devices goes to a record under your control, not your insurer's. If you are uploading data to your provider organization, is your provider organization authorized to release that data to insurers? These observations bring medical privacy concerns to a new level.

So check out the Zeo a device marketed to consumers that analyzes your sleep. Or Body Media Fit. Several others are listed at Wired.com

heart failure: do it my weigh....

Whenever people are discharged from the hospital after having had a flare or "exacerbation" of heart failure, they are asked to weigh themselves daily. When they go to rehab or nursing care facilities, the staff are asked to weigh the person daily. Unfortunately, a lot of the time, this doesn't get done, which as a doctor, I find completely mysterious. I was frustrated by this as a resident in training, and I am still frustrated by it today. Again today, I visited a woman out of the hospital for 3 weeks, who has atrial fibrillation (which makes the heart beat irregularly), who is being treated for congestive heart failure, and this one very simple way of tracking how things are going was simply not done during this entire time by the staff in the residential care facility where she is staying temporarily. despite being clearly written on her discharge instructions. Her ankles were getting more swollen, which the staff though was just due to her spending more time upright in a chair. The only way of knowing would be to have those daily weights....

One doesn't need a medical scale or to be 100% precise, but one does need an idea of whether the weight is trending up rapidly or not showing that fluid is accumulating....

Please, caregivers for people with heart failure...do this simple thing!!

The Workout Desk

Exertophobic (is that a word?) desk potatoes - hold the sour cream and take note! Now you can work out while you're sitting at your desk, and not virtually, either.

http://www.ivanhoe.com/science/story/2010/03/689a.html

PSA Inventor Supports Less Screening

In a fascinating op-ed today in the New York times, the inventor of the PSA test calls attention to its misuse and pleads for more reasoned application of this test. He notes how many men are being rendered impotent and incontinent for a very minimal risk reduction, if any.

http://www.nytimes.com/2010/03/10/opinion/10Ablin.html?th&emc=th

Until physicians can be assured that they will not be sued for malpractice for not performing screening, however, this is unlikely to yield much change in the current practice. There was a case in Virginia several years ago in which a family physician was sued for not doing PSA screening, despite the fact that he followed professional society guidelines which suggest having a discussion with patients about whether screening is necessary. His patient, based on this discussion, decided not to have PSA screening, and was later found to have prostate cancer, and sued the physician. At the trial, another physician testified that the "standard of practice" in Virginia was to perform PSA screening without such a discussion with the patient, and the physician lost the malpractice suit.

So, until we have seen our first successful lawsuit against a physician for performing PSA screening (which seems unlikely because any damages could not be attributed directly to screening alone), I wonder whether the situation will change much.

Should the doctor in your family be involved in your care?

I am constantly hearing from many sources that doctors shouldn't treat their own family members and friends when asked to do so. Can anyone provide data or evidence for this? I see "ethical" guidelines about this from state licensure boards, and medical societies. My malpractice insurer says it increases risk too. My two cents: I am aware of absolutely no evidence for these "ethical" guidelines. I'd like to see a single study of this question worth anything or any date, from a malpractice insurer or otherwise, showing that worse outcomes occur when trusted family member physicians, whom a patient wishes to be involved, are involved in a patient's care.

Here's a call to action for all my former academic colleagues at Johns Hopkins, UCSF, etc. How about some evidence-based patient-centered care? Why not do a study of whether people treated by family members, or whose family member physicians are involved in their care, have better or worse outcomes? As a profession, why do we assert something we have absolutely no evidence for besides our own prejudices? For those of you who do have a good clinician in your family whom you trust, wouldn't you consult them when you're ill?

In our practice, we assert in our tag line that "everyone needs a doctor in the family" (www.myadvicedr.com). We believe that on average, people benefit from having someone they trust, who is accessible, involved in helping them choose providers, compare treatments, and help them make sure that planned procedures or treatment are really the best thing for them.
It is my aim to be just like the doctor in the family whom you trust would be. So I definitely believe that trusted doctors in the family are a big help.

I'm willing to be proven wrong, but show me the data!! I would assert that we should not make blanket assertions without evidence as we are doing now in our state boards, medical societies, and malpractice insurance companies. How about some effectiveness research?

And meanwhile, I will continue advise my patients and others: If you have a trusted physician in your family, by all means continue to call them up and ask their opinion about everything you can. Until I see the evidence, I'm going with my gut. And if you can show me some evidence, I'll promptly post it the next time I blog.

Is it a good idea to see family members right after surgery?

I and a friend visited someone who had surgery today. Her closest relative (listed by the patient as her agent for health care decisions) had driven an hour to visit her in the recovery room as she woke up. When the family member arrived, she spoke with the surgeon. The surgeon said the patient was still asleep in the recovery room, and that the relative should go home and come back tomorrow because the patient needed to rest anyway.

When we arrived, we found the relative and her husband in the lobby, seeming anxious. The relative shared with me that she didn't know what to do because she was unable to visit the next day as she had taken today off work and was unable to take another day. She was very concerned that everything had been planned incorrectly because she had taken off today, but the patient had been in surgery all day today, and now no one would be visiting tomorrow. I reassured her that I would visit tomorrow and that other friends would as well. However, I was concerned that the surgeon had sent her away, as I believed from my conversations with the patient earlier in the day that she had very much wanted to see both her relative and me that night when she woke up. The relative then spoke to the patient's elderly mother on the telephone. The mother was also very upset that no one would be there when the patient needed it. The mother spoke to me, and I told the patient's mother to try to get some rest and not to worry. I told the relative to wait and that I would go back to see what was going on.

I went back to recovery and discovered that the patient had just gotten up. I asked the recovery room nurse if I might visit with her briefly, and he agreed. I smiled at her and she smiled back. She said she was in no pain, and had patient-controlled analgesia (a pain medication pump allowing her to give herself as much pain medication as she needed within limits). I then asked the patient if she wanted to see her relative, and our other friend, who was out in the lobby. She said she would very much like to visit with her relative and with her other friend and me for a little while.

I went to get the relative and brought her back to recovery for a few minutes. We then waited until the patient was moved to her regular room, when we, and the other friend, were able to visit with her for a half hour. We called the patient's mother and had the patient speak with her to reassure her that all was well. A friend called and we answered the phone for her and relayed good wishes (the phone was placed in an unreachable location to the patient, who was bed-bound due to a urinary catheter). We told jokes, and the patient laughed and felt happy to have friends and family around.

I was so glad that I prevented the important bad outcome of the patient waking up to no friends and family, as well as the relative and her husband going home distraught not even to have been able to speak with her, the patient's mother worrying all night without speaking to her daughter, while making possible the warmth, friendship and humor that the relative's and friend's visit provided.

Surgeons, please do not project your own exhaustion after the surgery onto the patient and/or the family who have come specifically to see and support the patient! If there are no medical issues which are preventing the patient from waking up after surgery, do not send family members home before the patient wakes up from recovery because you are tired, even if it is late!! Please encourage family members to stay and be with their loved one for at least a few minutes when they come out of recovery and get into their rooms. It makes a world of difference to all concerned.

Family members need to be assertive!! You can ask your relative what they want when they wake up in recovery and then get transferred to their rooms. You will find out if they want you to see them or if are they the type of person who abhors being seen without their (take your pick) face on/dentures/glasses/wig/toupee/clothes. Most of the time, you will find that despite having scanty and ugly hospital gowns, urinary catheters, no teeth, etc. they want to see your lovely faces! And once they let you know this, do not let anyone, even the surgeon, talk you out of it, unless there are medical issues that are preventing your relative from waking up.

Surprised that doctors overlook heart disease prevention ?

We doctors get a little tired of reading about how our profession overlooks preventive care, when the simple reason is that we are not being paid to do it. Medscape reported today again, that at the American College of Preventive Medicine, a chart review study of over 3000 hypertensive Medicare recipients showed that doctors were missing a large number of opportunities for addressing cardiovascular risk factors, including high blood pressure, high LDL cholesterol levels, and uncontrolled diabetes. This was already found many years ago by McGlynn and colleagues at RAND who found that on average at any visit, about 50% of things recommended in guidelines for ambulatory care were not being done. Now as then, should this be a surprise when the amount of physician time that is paid for by Medicare and most health plans to do all these things is so minimal?

To put this in perspective, this is like doing a study to show the missed opportunity that supermarkets have to make sure people eat fruits and vegetables every day. If you aren't buying and paying for something, why would anyone expect that you will come out with it? It is not the supermarket's responsibility to do this beyond putting out the offerings. The health plans, and by inference the employers, government bodies, and insurers who set them up, which pay for doctors' time on the basis of various diagnostic and procedural maneuvers, and do NOT pay for appropriate quality of preventive care, are to blame for these "missed opportunities".

Most doctors are seeing Medicare follow-up patients in 10-15 minutes and of course they must concentrate on the most pressing issues, leaving little time for prevention. This reflects what their employers or their state and federal governments choosing health plans on behalf of the public, are willing to buy. Office visits by primary care practitioners are not paid enough by most third party payers for practices to be able to schedule the time really needed to address acute problems and prevention. To go through preventive care carefully for those with risk factors and chronic illnesses, together with the understanding of patients' values, lifestyles, and personalities required to select appropriate interventions may require 2 hours of time, rather than the 10-15 minutes physicians are now being paid for. That is just for evaluation of needed prevention, without even trying to discuss with our patients about how to intervene how to improve their motivation to change their lifestyle, etc. Why then would anyone be surprised at the result of these studies?

What does this mean for the average person?

If you are working or self-employed, and under 65, and have enough cash in the bank to buy your own doctor care, then it might be a good idea to save on insurance premiums by getting a high deductible plan that covers as little in the way of office visits as possible. You could then use what you save to buy your own care and consultation for prevention and managing any chronic illnesses you have. You'll get more out of a gym membership, using a personal trainer, enrolling in a weight loss program, and paying fee-for-service for one very thorough preventive care evaluation from a primary care doctor or personal medical consultant or advisor, than you will by using the short doctor visits paid for by health insurance plans. If you can afford it, you could use the extra money to enroll in a concierge internal medicine practice, which usually will provide you with excellent primary care and prevention. However, it may be more economical simply to pay as you go for primary and specialty care when you need it, since the concierge practices cover only primary care.

If you must rely on employer-provided health insurance, or if you are over 65 and a Medicare recipient without savings, you can make sure to go to your primary care doctor as frequently as your insurance plan will allow until all your concerns are addressed. Plan a separate 10-15 minute visit about each of your multiple problems. If possible, you can create a different agenda for each visit and address each of your risk factors for cardiovascular disease, such as obesity, high cholesterol, high blood pressure, diabetes, and inactivity at a different visit. Take advantage of the maximum visits for care that your plan allows for these conditions. Remember, if you get ill because you wouldn't spend money on prevention and management of your chronic illnesses and risks, you will be pay much more in co-pays and deductibles than you would have spent on preventing a heart attack, stroke or other preventable illness in the first place. If you try to cram everything in one visit to avoid another copay, you'll end up being penny-wise and pound-foolish.