Government Health Care

Government health care? First, do no harm By: Daniel J. Popeo appeared in the Washington Examiner several months ago. It has some good points but many more bad ones.

American health care is littered with physician self interest and an overwhelming sense of patient entitlement. Physicians and advertisers convince patients that the “latest and greatest” treatment is the best. They work to sell more expensive therapies despite the proven usefulness of traditional, less expensive modalities. The complex relationship between physicians and industry substantially compromises health care integrity by causing a conflict of interest. The conflict may cause physicians to recommend expensive therapies.

As consumers you should always ask your doctor:
1) Will this let me live longer?
2) Will this help me live better?
3) Will this test change my therapy or diagnosis?

It’s your health care. Take responsibility.

Does Our Health Care Suck?

Today, I’ll share a personal experience. Several years ago I injured my shoulder. I “toughed out” the pain for about a week with motrin then finally asked a friend who was an older orthopedic surgeon. He asked several questions then placed his thumb on my shoulder and pushed gently. He asked, “Is that where it hurts?” I winced and said, “Exactly.” He told me what it probably was and offered two or three other less likely possibilities.

Then, the important part, he said there’s an operation for this but you probably don’t want it. He said no reputable surgeon would operate for several months. He noted that good surgeons would advise rest and gentle physiotherapy for 3 months then re-evaluate.

I felt better. I used the motrin for three more months rest the shoulder. After 4 months it still hurt and I had some limitations of movement due to pain. I broke down and saw an orthopedic surgeon rather than just a quick “curbside” discussion. He asked almost the same questions as my friend had. He pressed in the same place and offered the same diagnosis. He didn’t take and xray, CT scan or MRI. Then he sent me for physiotherapy and told me to come back in three months.

I was reminded of this recently when I read the story of journalist T.R. Reid’s shoulder injury. Reid’s experiment shows clearly what happens when doctors co-mingle interests in personal finance with theirs requirements for fiduciary responsibility for your health care. Many times it’s you, the patient, who suffers.

What does all this mean? Like we’ve said so many time, take and active role in your health care. Ask questions and demand answers.

It’s your health care. Take charge.

Caring

I teach physicians to communicate effectively. I’m not sure it works. Every now and then I am encouraged.

The two most common complaints I hear from my mother about physicians are:
1) He doesn’t listen. (Mom won’t see women physicians- no idea why.)
2) The front desk staff are idiots.

The most effective tool a physician has is her ears. The ability to take the time to listen, seriously listen, with genuine interest and compassion is rare. This is what I teach my students. That’s why the new book by Dr. Wendy Harpham caught my attention. She shares her experiences as a patient and physician.

Read Dr. Harpham’s book and change the way you think about your doctor. It’s your health care. You have the right to demand a standard of health care.

Disclaimer: I have no relationship financial or otherwise to Dr. Harpham, Amazon.com, Steve Majewski, or The American College of Physicians. It’s just a great book.

Stimulus or Health Care

Health Information Technology for Economic and Clinical Health Act, or HITECH, is a part of the American Recovery and Reinvestment Act (ARRA) of 2009. HITECH pours $19 BILLION into the economy but only for health care information technology. As you might expect this kind of money is an amount that gets attention even in Washington. It also makes potential vendors come creeping out of the woodwork. Many of the products have no track record of effectiveness yet the possibility of federal funding will compel many hospitals and practices to adopt an electronic record if it can be adopted for at a cost less than the federal grant.

The problem is that there is little evidence that the electronic health record actually improves care to a specific individual. Certainly there are theoretical advantages but so far no clear evidence of benefit. However, the aggregate data from such records may be more valuable than the individual benefit. Finally data regarding the effectiveness of diagnostic and therapeutic modalities may be accumulated. In this way worthless testing and treatment may eventually be eliminated.

Keep watching. Ask your physicians how she keeps and stores your records. It’s your information. Make sure it’s safe.

Chiropractic

Here at Safer Health Care we try to focus on positive interventions and encourage patients and physicians to question. We have specifically avoided the chiropractic- allopathic schism in health care.

Unfortunately the British Chiropractic Association (BCA) has forced us to ask some serious questions. Dr Simon Singh allegedly libelled the chiropractors according to a suit filed by the BCA against Singh.

The ruckus began when Singh noted that the BCA supports “bogus” therapies. Surely chiropractic as practiced by many chiropractors has some benefit in the care of musculoskeletal pain and injuries. Yet the BCA and many chiropractors (on both sides of the Atlantic) promote manipulations for organic illness such as lupus or asthma. Singh’s concern relates primarily to the complete lack of meaningful evidence for the use of chiropractic in these other illnesses.

We agree with Singh. All physicians- chiropractic, osteopathic, and allopathic must be willing to subject their treatments to the scrutiny of scientific rigor. Barring such scrutiny we become charlatans.

Patients should always ask about the science in their treatment. Make your physician explain in simple, lay terms what the therapy might legitimately be expected to do for you. It’s not science for the physician to simply describe his/her own experience- that’s not science.

It’s your health. Take charge and take care.

Back Pain

We’ve been away for a while but we’re back.

Readers recall that we’ve frequently written about conflicts of interest in the doctor-patient relationship. Conflicts arise anytime a physician’s judgment is altered by personal gain.

Our concerns have been validated again in a recent study published in the Archives of Internal Medicine (ARCH INTERN MED VOL 169 (NO. 10), MAY 25, 2009 ).

Study finds overuse of imaging in back-pain care more for nonclinical reasons than because the diagnostic tool was required. Overuse for imaging of uncomplicated lower-back pain was associated with incentives based on patient satisfaction, the type of doctor and the size of the practice. Medicaid patients treated in practices that relied more heavily on government revenue (typically those patients with less-desirable reimbursement for physicians) received less-rapid and less-advanced imaging for lower-back pain. Small and solo practices, and family and general practitioners also ordered fewer advanced imaging tests for their patients, according to a report by researchers at the Center for Studying Health System Change.

The interesting part for those of us who study this from a policy perspective is that the patients who had apparent “underuse” probably had proper management. The physicians’ incentives for overuse probably led to excessive use of imaging in the other groups.

When your doctor wants to do a test you should always ask:
1) Can you (the doctor) interpret the results?
2) Will the results change my therapy or offer new options?
3) Will the results or changed therapy let me live longer?
4) Will the results or changed therapy help me live better?

It’s your health. Take charge and take it seriously.

HIPAA

HIPAA stands for Health Insurance Portability and Accountability Act. HIPAA provides for broad protections for the privacy of your medical records. Each health care provider must observe the protections defined by HIPAA. It’s not just law it’s the right thing to do. Additionally, each health care provider must have in place a written agreement that contractually binds each of its business affiliates to the provisions of HIPAA.

That usually works. Some of our readers get their prescriptions through third-party prescription renewal services. One such service is Express Scripts. I mention Express Scripts specifically because it seems to neglect basic requirements for confidentiality. For over two years Express Scripts has been sending me refill requests and “courtesy notices” in which the prescription needs of its customers are disclosed. That would be fine if these were actually my patients. They are not. Despite the fact that I have notified Express Scripts on multiple occasions they continue to violate the privacy rights of patients by sending refill requests to me.

So? You ask. Well it’s fine if you’re refilling your antacid. But what if Express Scripts sends me the refill request for your anti-AIDS drugs or your viagra- and by the way you live next door to me? What if its your testosterone inhibitor to control your pedophilia? What if its a medication that you actually need refilled in a timely fashion- I don’t, by the way, refill these drugs. In fact after two years I simply discard the mailings unread into our secure shredder. I have found that notifying Express Scripts of these errors does not stop the mailings (Express Scripts now faxes the forms so I pay for the paper that I later shred).

So? You ask again. It’s your health care information. You should carefully screen who “touches” or controls your information. And, if you use Express Scripts you definitely need to make sure they’re not sharing your private information.

Its you health care. Take it seriously and take charge.

Autism

The relationship between autism and vaccines has been at issue since 1998. Now there appears to credible evidence that the entire study was faked.

Regardless of the relationship with autism the reduction in vaccination rates has led to a direct increase in the incidence of measles in the UK and subsequent measles deaths. Unfortunately, Andrew Wakefield’s scientific fraud is not an isolated incident. Dr. Scott Reuben, also fabricated data related to perioperative pain relief. While we might see the adverse effects of Wakefield’s malfeasance now the effects of Reuben’s remains incalculable. That’s because Reuben’s work forms the basis of an enormous body of subsequent research.

The average patient could not possibly have understood these occurrences. In fact few of us in clinical medicine understood these occurrences. So what should you do? First, always be skeptical of “breakthroughs.” Next, always ask your doctor to explain new information. You should also use reputable print and electronic media for information. Do not rely on nut-job blogs and conspiratory-theory pundits. Last, watch for confirmation from other reputable scientists.

The medical literature may have more physicians seeking name recognition at the expense of scientific integrity. Use good judgement and be safe.

Conscience?

What happens if your doctor feels that you are morally bankrupt? We under federal rules she may not be required to refer you for proper care. In this case the rules are specifically about reproductive care.

So what should you do?
1) If you even contemplate that you might need reproductive services- contraceptives, emergency contraceptives, abortion services or information then ask at the very first visit. More important, ask before the start of the doctor’s history. Don’t even let her start (the reason in a minute).

2) If you and your doctor are incongruent on the provision of these services leave imediately. Don’t think about it, just leave.

3) Here’s the reason you do this first. Because you cannot be charged for services the doctor does not render,. Therefore you cannot be charged for a history and physical if the doctor does not complete one. Othert charges may be appropriate but the $350 history and compete physical will not be.

4) Once you leave, phone your insurance carrier and tell the service rep the story. Make sure you get everyone’s name with whom you speak.

It’s your health. Take charge and take care.

Nursing Shortage

One of the questions you should ask (read, must ask) when you check out a hospital is “What is the nurse-to-patient ratio?” Hospitals across the country are suffering under nurse shortages. Actually, that’s not quite true. Patients suffer from nursing shortages. Hospitals, especially administrators whose compensation is tied to year-end profit love nursing shortages. The reason? Simple, a full bed brings in revenue. If there are fewer nurses to care for the patients then the bed brings in the same revenue at a lower cost.

What does this mean for you- you want a hospital with the highest nurse to patient ratio. You should also check to see what percentage of nurses are “agency” nurses or “travelers.” These “rented” nurses are often very good and they allow a hospital to have flexible staffing at a lower overhead and less long-term employment committment. But if rental nurse percentage is too high then it may be a sign that the hosital is underpaying and therefore only attracting inferior nurses to permanent positions. Inferior nurses equal inferior nursing care. Don’t forget your nurse is the first person who will assess you if you become acutely worse while in the hospital.

So, what should you do?
1) Ask what percentage of nurses, by shift, are hospital employees as opposed to “contract” or “rental.” Ask specifically about the ward to which you will be admitted.

2) Ask if the CEO or other administrative staff is paid a bonus based on hospital profits. This means that administrators have a financial incentive to keep nursing costs down.

3) Ask how long the average nurse has been at the hospital. Be careful to have them exclude nursing administrators.

It’s your health. Take charge and take care.