MCN | Medical Consultants Network

The Power of a Second Look

Home / MCNTalk / Tag: The Practice of Medicine

Viewing items tagged:

The Practice of Medicine

Managed Care…Is It Coming Back?

As the largest U.S. health insurance companies struggle to cut costs, many are reverting to similar models of managed care. A recent Wall Street Journal article, “Remember Managed Care? It’s Quietly Coming Back,” explains how some health insurers are developing plans with more restricted choices of doctors and hospitals, and weighing new requirements for referrals before patients can see specialists. Insurers argue that the new managed care plans will be very different from the 1990’s version and will help reduce medical expenses.

While both sides of the managed care debate provide valid points, it is also important remember why this kind of plan was implemented within American health care in the first place. The fact is, the U.S. spends substantially more on health per capita than many other developed countries but we don’t have superior health system performance.

In a report by PBS Frontline, “The High Price of Health: A report on the managed care revolution and it’s impact on doctors, nurses and patients,” provides an in-depth look into the pros and cons of managed care and makes the case that whether people are for managed care or not,  creating a model that both cuts cost and provides quality health care is most important. In the report Mark Roberts, a professor of political economy at the Harvard School of Public Health states:

“So the challenge of managed care today is not whether we should be for it or against it. The alternative – totally unmanaged care – comes with a price tag neither the public sector, nor the private sector can afford. Global economic competition and the impending retirement of the baby boom generation means that neither corporations nor tax payers can go back to the old fee-for-service, use-whatever-you-want system. The task is to make sure that we get more of the good kind of managed care and less of the bad. Plans that offer value-for-money and good customer service need to be the ones that succeed in the marketplace.” Read more…

 

Medical Identity Theft: The Fastest-Growing Type of Identity Theft In the World

Identity theft takes many guises.  It can happen to anyone at anytime and is a nightmare to fix if it’s not discovered early. In the medical realm, it has become the fastest-growing type of identity theft in the world and can ruin a person’s name, finances, career, and reputation. The article, “Medical ID theft: Double Danger for Doctors,” by American Medical News illustrates how MD identity theft creates double the amount of risk for doctors.

The articles states that there are two kinds of medical identity theft: one that involves a patient’s identity being exploited; and the other that involves a physicians professional identity being stolen and used. Both create huge consequences for doctors as their profession is compromised and they can be held responsible for the theft of a patient’s identity.

The article focuses on Los Angeles based-internist, Dr. Anne Peters, MD, who became the victim of an international crime ring who had stolen and used her medical credentials to scam Medicare out of hundreds of thousands of dollars. The article states:

“When Dr. Peters sought advice on how to resolve the situation, she not only came up empty-handed, but she soon started feeling like a criminal herself. She was visited by federal agents, she received notices from the Internal Revenue Service regarding back taxes on $750,000 she never earned, and she was even detained once at the airport for more than an hour when she returned from a trip abroad. Meanwhile, Medicare stopped sending her payments for legitimate claims.”

Six years after struggling to clear her name,  Dr. Peters became an advocate for medical identity theft awareness and helps shed light on the fast-growing crime among her colleagues and among federal agents, who have developed programs to help physicians in similar situations. The article provides a clear look into medical identity theft red flags, risks, and how to prevent it from happening in the future.  Read More…

The Premie Challenge

By Brian L. Grant MD

Rafi, now age 3, was born premature at 28 weeks unable to maintain body temperature, breath or feed unassisted. He spent a month in the Neonatal Intensive Care Unit and is alive now because of a multidisciplinary team, medicine and technology.

The photo of the boy holding the flustered chick is my three-year-old grandson Rafi. He is perfect in every way. But his life is a triumph of medicine and technology. Rafi was born at 28 weeks of age, after an unexpected premature labor. His mother was rushed to deliver at the University of Washington. When born, he looked similar to the photo below. The delivery of such a small baby was easy. But what followed was not. A large team took over in the Neonatal Intensive Care Unit (NICU) and for the next four weeks, Rafi was watched and cared for. He was unable to maintain body temperature, feed or fully breathe unassisted – so others helped. After a month in that unit, he spent another month in a less intensive unit in Seattle before discharge at what would have been about 36 week’s gestation.

Absent the care he received, he would have died at birth. He had no apparent abnormalities beyond prematurity, and being kept alive while being allowed to mature took care of the issue. His situation is hardly unique, as the article, “In Premies, Better Care Also Means Hard Choice,” from the New York Times describes. The article focuses on the decision(s) to resuscitate premies.

In Rafi’s case, there was no discussion, just action. Perhaps had there been severe problems or anomalies there might have been, but it appeared to be a given by the system that he would be given all resources available. I can’t imagine the challenge his parents would have faced had they been asked to make a life or death decision at that trying time. And they and we are very appreciative of the incredible care Rafi received by a skilled multidisciplinary team. The actual cost is not known to me, but I assume it was well into the six figures – covered by his parent’s insurance without challenge. Such tertiary care resources are expensive. But Rafi shared the unit with babies from less fortunate backgrounds, who received the same level of attention. While payment for and cost of care is a big issue for all of us, the source or availability of payment played absolutely no role once a baby was admitted.

When I was a medical student on the late 70’s, one of my first clinical rotations was in a NICU. My first exposure to babies was of the two-pound variety, such that when I finally worked with full-term babies, I could not believe how big they were! The technology and skills to sustain these kids and avoid long-term problems continue to evolve and even then, I concluded that this is one area of medicine that truly has an impact – lives are saved that would have ended and many or most go on to lead normal lives. But challenges remain, especially in earlier gestation births. The ethical questions and values that the choices that were not available until recently are many. And each baby, family and set of resources creates a different set of opportunities as well as challenges. Read More…

Health Care and Cheesecake Factory: Can the former learn from the latter?

By Vanessa Radatus

Illustration by Harry Campbell for The New Yorker

This week, The New Yorker presents a fascinating article that delves into heart of what our health care system needs. Using The Cheesecake Factory as a model, American physician and journalist, Atul Gawande, provides refreshing insight as to how hospitals could learn a thing or two from this service savvy business. After all, who wouldn’t want a healthcare model that guarantees 100% satisfaction with quality and service, all at an affordable price?

Atul Gawande says it nicely: “In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.”

So, what can we learn from these flourishing businesses that continue to serve millions while managing efficiency, quality, and cost? For one, we must accept that whether we agree with recent health laws or not, our system needs a new model and fast.  With trillion-dollar healthcare costs only getting higher and a shortage of doctors to treat 30 million newly insured Americans, utilizing key business strategies from successful chains like The Cheesecake Factory may not be a bad idea.

In his article, “Restaurant Chains have Managed to Combine Quality Control, Cost Control and Innovation. Can Health Care?” Gawande takes a close look inside of The Cheesecake Factory’s  strategies to see how the business makes $1.2 billion in yearly revenue while maintaining affordable, high-quality products that always leave customers smiling. He explains that the success secrets behind the business is that instructions are precise, objectives are clear and oversight is tight. “The formula was Business 101: Use the right amount of goods and labor to deliver what customers want and no more. Anything more is waste, and waste is lost profit,” Awande stated.

If our hospitals aimed to reach the same amount of quality, efficiency and positive outcomes as these enterprises do, our healthcare system would not be in its current crisis. Awande proves a good point when he asked Dave Luz, Regional Manager of eight L.A. Cheesecake Factory’s, what he would do if he were manager of a neurology or cardiology unit in a hospital:

“This is pretty obvious. I’m sure you already do it. But I’d study what the best people are doing, figure out how to standardize it, and then bring it to everyone to execute.”

Unfortunately, this is not how medical care works. But new health-care chains are now hoping to do this on a mass scale, Awande says.

“They want to create Cheesecake Factories for health care. The question is whether the clinicians in the operating rooms, in the medical offices, in the intensive-care units—will go along with the plan. Fixing a nice piece of steak is hardly of the same complexity as diagnosing the cause of an elderly patient’s loss of consciousness. Doctors and patients have not had a positive experience with outsiders second-guessing decisions. How will they feel about managers trying to tell them what the “best practices” are?”

After a lengthy yet intriguing look into both the medical and food industry, Awande ends with this final thought for readers: ”

“The critical question is how soon that sort of quality and cost control will be available to patients everywhere across the country. We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change. Some will see danger in this. Many will see hope. And that’s probably the way it should be.”  Read More…

Atul Awande is a highly respected physician and journalist. His writings on the process and practice of healthcare are important. His book “The Checklist Manifesto” is a must read for anyone concerned about health care and hospital quality.

Medical Payment Collection Gone Wild

By Brian L. Grant, MD

Emergency rooms sit of the front lines of the health care payment crisis as they must provide care to all who come though many can’t afford to pay. Photo by Adam Gault / Digital Vision / Getty Images.

Emergency rooms  sit on the front lines of the health care payment crisis. On the one hand, they must provide care to all who come – by law, custom and ethics. On the other hand, the care is expensive and many can’t afford to pay. Many of the uninsured use ER’s as their care sources rather when they lack access to clinics and physicians. Creative companies have found ways to profit and help pay for the care provided. In this case, one such company crossed the line of decency and legality. Our fee for service health care system assumes that personal responsibility and solvency can be relied upon. Is society served by financial triage for essential or urgent medical needs?

One day not too far off, stories such as the one featured in the New York Times article “Medical Debt Collector to Settle Suit for $2.5 Million” will be looked at with the same shame we feel towards the discrimination practiced in our country based upon race and other factors in past decades. We would regard it as abhorrent to deny access to K-12 education for the poor. Why do we believe that different standards ought to apply to access to health care? Why should employers have the burden and responsibility of providing health care for their employees, rather than this be a basic part of the social contract as members of society?

Do we as citizens and particularly those of us who have chosen to enter the field of health care have obligations beyond caring for our patients – to address systemic shortcomings and abuses the adversely impact the public health? Or is medicine just a job, and our goals to maximize profit?
Read more here: “Medical Debt Collector to Settle Suit for $2.5 Million”

The Release of the D.S.M – 5

The coming months will see the release of the D.S.M – 5. This 5th edition of the diagnostic and statistical manual is getting lots of news. Originally a useful tool for mental health professionals, allowing us to agree on who may or may not warrant a particular diagnosis, the manual has been co-opted and hijacked by many others for a variety of less noble purposes. We have attached two of many articles appearing in recent months. More will certainly come.

The hazards and dangers of the D.S.M are many. A main theme includes the medicalization and pathologizing of normal life. Grieve a loved one: Bereavement disorder. A bit strange? Autistic Spectrum Disorder; Crave Food or Alcohol: Addiction disorder; Easily Distracted: Attention Deficit Disorder. The list goes on. To the degree labels help treat problems they can be useful. To the degree that they confer entitlements, exculpation of responsibility, mandated health benefits, employment accommodation, legal responsibility or lack of responsibility – the benefits are far less clear and capacity for mischief and abuse quite evident.

 The following cautionary statement appears in the preface of the D.S.M. – 4: (emphasis added)

 Cautionary Statement
The specified diagnostic criteria for each mental disorder are offered as guidelines for making diagnoses, because it has been demonstrated that the use of such criteria enhances agreement among clinicians and investigators. The proper use of these criteria requires specialized clinical training that provides both a body of knowledge and clinical skills.

These diagnostic criteria and the DSM-IV Classification of mental disorders reflect a consensus of current formulations of evolving knowledge in our field. They do not encompass, however, all the conditions for which people may be treated or that may be appropriate topics for research efforts.

The purpose of DSM-IV is to provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat people with various mental disorders. It is to be understood that inclusion here, for clinical and research purposes, of a diagnostic category such as Pathological Gambling or does not imply that the condition meets legal or other non-medical criteria for what constitutes mental disease, mental disorder, or mental disability. The clinical and scientific considerations involved in categorization of these conditions as mental disorders may not be wholly relevant to legal judgments, for example, that take into account such issues as individual responsibility, determination, and competency.

Hopefully this statement or similar variant will remain in the upcoming edition. We should add: “Insurance coverage, employment and school accommodation, and denial or impact of individual choice or responsibility.

Psychiatry is not the only specialty guilty of misrepresenting science for politics, social justice and economic self-interest. But I fear we may be about to outperform in this capacity to the degree we use diagnoses to define not true disease, but normal human experience and variations. And to the degree others coattail on these diagnoses for goals other than improving emotional and mental states.

Tracing the Path of Jewish Medical Pioneers

There’s an interesting article in The New York Times this week about an exhibit at Yeshiva University Museum in Manhattan, “Trail of the Magic Bullet: The Jewish Encounter With Modern Medicine, 1860-1960.” The exhibition offers a rare look at a topic few patients ever stop to consider: the emergence of European and American Jews as innovators in medicine, despite their status as outsiders frequently scorned by the medical establishment.

While some religions place ultimate responsibility for healing in divine hands, “Jews don’t see a conflict between faith and medicine,” said Alan M. Kraut, a professor of history at American University who helped put together the exhibition and has written extensively about immigration and health. Read more…

“You can’t enjoy a meal when you know your mother is hungry”

Sadly, the title quote could apply to any number of situations related to life in sub-Saharan Africa, but in this case is taken from a physician in this article in the New York Times Magazine, “America Is Stealing the World’s Doctors.”

The premise of the article: In a globalized economy, the countries that pay the most and offer the greatest chance for advancement tend to get the top talent. South America’s best soccer players generally migrate to Europe, where the salaries are high and the tournaments are glitzier than those in Brazil or Argentina. Many top high-tech workers from India and China move to the United States to work for American companies. And the United States, with its high salaries and technological innovation, is also the world’s most powerful magnet for doctors, attracting more every year than Britain, Canada and Australia — the next most popular destinations for migrating doctors — combined.

Just how extreme is the situation? In Zambia, there are slightly more than 600 doctors working in the public sector, which is where most Zambians get their health care. That is 1 doctor for every 23,000 people, compared with about 1 for every 416 in the United States.

There are some hints at plans to address the problem:

  • There are 13 sub-Saharan medical schools receiving support from a United States-financed $130 million program; 
  • The Global Fund to Fight AIDS, Tuberculosis and Malaria provided money to Zambia’s ministry of health (Zambia is featured prominently in the article) to recruit and retain doctors;
  • Western aid agencies, many financed by donors like Bill and Melinda Gates, have also hired local doctors at higher salaries.

But apparent solutions can create further problems; many of the doctors hired by aid agencies are doing research. They don’t see patients. Frustrated public health officials in Zambia and other developing countries call this the “internal brain drain.”

And there are other circumstances: a friend of mine was in the Peace Corps in Niger about a decade ago. a Nigerien friend of hers wanted to go to nursing school, so we agreed to spend the $300 to cover all his expenses in the program. But he decided to go to mechanics school instead to become a bush taxi driver. Why? He’d have a more secure income; in Niger nurses are hired by the government which clearly had no funds – and no history – of paying public workers (when I visited in 1999 the school systems were closed as the teachers had been on strike for months, not having been paid for at least the prior 6 months). In the scheme of things it was a minor situation to be sure, but nonetheless strikes an important chord: medical providers, like everyone else, are part of an economic system, though unlike many others their presence has immediate has life or death consequences for the community. There are no easy solutions, either in the article or in real life, though the answers probably lie somewhere in the simple phrase that is the title of Nobel Prize for Economics recipient Amartya Sen’s major work, Development as Freedom.

It’s a well written article and a situation worth contemplating. Read more…

The Web Is Awash in Reviews, but Not for Doctors—Here’s Why

Here’s an interesting piece from the New York Times, noting that it’s puzzling that there is no authoritative on-line collection of reviews for physicians, the highest-stakes choice of service provider that most people make. From the article, some suggestions as to why this is the case:

  • Getting in the faces of the previously untouchable professional class has inevitably led to legal threats.
  • “To advise people anonymously through an open site when this is an important decision for people’s lives, I don’t think it’s proper,” noted the A.M.A.’s president, Dr. Peter W. Carmel. “The evidence that’s given on many of these consumer sites is undocumented, unverified and anonymous. It may well have nothing to do with actual patient treatment.”
  • Given many physicians’ wariness, it’s understandable that patients may be reluctant to mix it up with them online. But patients may be steering clear for a far more ordinary reason: if they live in a small town or are only one or two degrees of social separation from physicians or their family members, they may not want to create any awkwardness.
  • Perhaps the biggest problem with the ratings is that they are incomplete. WellPoint tracks doctors’ communication skills, availability, office environment and trust, but it doesn’t yet provide information about medical outcomes. While it’s nice to know how long different obstetricians make you wait, it would also be helpful to know how many babies they end up delivering by C-section. 

Read more…

More Doctors “Fire” Vaccine Refusers

When this MCNTalk blogger was pregnant and interviewing a pediatrician, she told me that she couldn’t take our child on if we didn’t have our child vaccinated on the routine schedule. Though I didn’t necessarily disagree with her, this took me by surprise; I had thought we were doing the interviewing, after all. As it turns out, my pediatrician’s standard is not so unusual. Per this Wall Street Journal article, more and more pediatricians are choosing not to treat children whose parents don’t allow them to receive standard immunizations on a standard schedule.

Some interesting points:

  • In a study of Connecticut pediatricians published last year, some 30% of 133 doctors said they had asked a family to leave their practice for vaccine refusal, and a recent survey of 909 Midwestern pediatricians found that 21% reported discharging families for the same reason.
  • For Allan LaReau of Kalamazoo, Mich., and his 11 colleagues at Bronson Rambling Road Pediatrics, who chose in 2010 to stop working with vaccine-refusing families, a major factor was the concern that unimmunized children could pose a danger in the waiting room to infants or sick children who haven’t yet been fully vaccinated.
  • Pediatricians disagree about what their duty is to these families. “The bottom line is you should try to do whatever you can to maintain the family in the best care,” said Michael Brady, chair of the pediatrics department at Nationwide Children’s Hospital in Columbus, Ohio, and a member of the AAP’s immunization committee. “If they leave your practice, they’re probably going to gravitate toward another practice with unhealthy practices.”
  • Other physicians say they rarely have had luck persuading vaccine opponents to change their minds.

Read more…