20 September 2013
This blog is derived from this blog written by Leslie Kernisan. She makes many points that I can agree with and I list them first followed by points I have.
Points of agreement: (Read the blog for Dr. Kernisan's explanations.)
#1. If the 35-hour work week will mean more thorough and better care, then make this happen.
#2. If the newly minted PCPs would truly take care of the Medicare beneficiaries, this could be a great purpose.
The following are a listing of Dr. Kernisan's tasks she performs regularly:
#3. Following up on 6+ chronic conditions and 12+ medications, in an integrated whole-person fashion.
#4. Following-up on the work of multiple specialists, many of whom hadn’t explained their thinking to the patient and family.
#5. Resolving the conflicts inherent in attempting to follow clinical practice guidelines in patients with multiple conditions. (See this JAMA article to understand how well intentioned practice guidelines could cause serious problems for elderly patients.)
#6. Adjusting care plans as a function of goals and what seems feasible for the patient. It is pointless to recommend chronic disease management per best practices if it doesn’t seem feasible to the patient and family.
#7. Explaining why certain commonly requested interventions – antibiotics, diagnostic tests, specialty consults – might not be helpful.
#8. Helping patients and families prioritize and identify a few key health issues to work on at any given moment.
#9. Helping patients and families evaluate the likely benefits and burdens of possible medical approaches.
#10. Helping patients and families cope with the uncertainties of the future.
#11. Weighing in on family conflicts.
Now I have left out one factor that I feel doctors should not become involved in and I am admitted tired to hearing them.
A point of disagreement and points not covered which need to be considered
#1. Addressing end of life planning. I have seen doctors, hospitals, and family side-step this so often that I place no value in these discussions. My own family has shown their own opposition about my wishes for end of life. With rationing on the horizon, doctors and hospitals are turning a deaf ear. I realize that medical supplies and other factors are not infinite, but still rationing is the buzz-word at the CMS and in the Congressional arena. Read this blog - http://bobsdiabetes.blogspot.com/2011/08/cms-threatening-more-euthanasia.html And this blog - http://bobsdiabetes.blogspot.com/2013/05/medicare-enforcing-healthcare-rationing.html
#2. The physician shortage will be here and is in many areas of the country. It will take more than a decade to correct for this as it is, even if the 35 hour-work-week becomes a reality.
#3. Let us stop squabbling about who may be able to help during the shortage. Many doctors are urging their state medical boards to prevent NPs, PAs, and Pharmacists from practicing unsupervised. Most medical professional organizations are also filling the printed pages, the internet, and air with their opposition to these professions. Even if allowed to practice, there will still be a shortage as many of them have gone the specialist route in search of better wages. I feel fortunate that I have at present two NPs that I see on a regular basis. Even though my state allows them to practice independently, they still work under the supervision of MDs. My blog - http://bobsdiabetes.blogspot.com/2012/11/are-doctors-lobbying-themselves-out.html
#4. Many state medical boards have even limited PCPs and Family Physicians and what they can practice, at the request of specialists and their whining. Licensing boards are also limiting what some para-professionals can and can not do. Because some doctors have seen the need for education in the diseases of cancer, diabetes, MS, and others, they have taken patients knowledgeable in these diseases and spent time and occasionally money to train them as peer mentors or peer-to-peer workers to assist them in educating their fellow patients. A few state medical boards are now trying to even stop this from happening. This blog - http://diabetestopics.blogspot.com/2013/09/are-doctors-threat-to-their-own.html
#5. PCPs are even trying to prevent organizations hired by the hospitals to enter patient's homes after a hospitalization and assist patients in need. Many of these patients seldom see a PCP, don't have one, or cannot get an appointment to see one soon enough after being discharged from the hospital to prevent rehospitalization. This blog - http://diabetestopics.blogspot.com/2013/09/pcps-are-putting-themselves-in-bad-light.html
#6. With the tsunami of new patients coming January 1, 2014, many doctors and specialists are cleaning house of undesirable patients that might prevent them from receiving the incentives from CMS that they feel they are entitled to receive. This blog - http://bobsdiabetes.blogspot.com/2013/09/changing-doctors-now-may-not-be-best.html
#7. With the CMS program for assisting obese patients now underway, most hospitals have established the weight-loss clinics into the bariatric clinic to charge a fee to do an evaluation. This evaluation is to determine if the bariatric clinic can convince these patients to go the bariatric surgery route, thus gaining the surgeons and hospital more money. If not, these patients are deemed unfit to accomplish weight loss and not accepted into the program. This blog - http://bobsdiabetes.blogspot.com/2013/05/medicares-obesity-program-has-problems.html
#8. Even the doctors now have DSM5 for medication for every conceivable mental health issue and are to forget counseling from a positive perspective to enable their patients to take charge of a mental health problem and overcome it. Medications are now the only answer. This blog - http://diabetestopics.blogspot.com/2013/09/the-dehumanizing-of-patients.html
#9. I have no idea if this is just my corner of the world, or is more widespread, but when a patient questions a procedure, operation, or medication, we are told we more than likely have cancer and need to see the oncologist. Four doctors have thrown this in my face in the last five months even after I have been given a clean bill of health by a VA oncologist after two different days of tests and procedures. Then when I tell them this, they just say that the VA is not the most reliable. Only one doctor has thanked me for going through the tests and eliminating the concern about my elevated white cell count. No blog – yet.
#10. More doctors will need to enter the realm of contract medicine to fulfill patients' needs, as doctors are more and more becoming employees of hospitals. Because hospitals are driven by the bottom line, little will change under the ACA and patients will continue to be treated only when they have a disease, illness, or injury requiring a doctor's care or that of a specialist. Heaven help the patient with hypertension or diabetes if the hospitalist decides to “tune-up” these patients when they are hospitalized for an unrelated disease or illness. This blog - http://diabetestopics.blogspot.com/2013/09/another-reason-to-be-careful-of.html
#11. More and more doctors believe and rely on faulty studies. They become very defensive when a patient becomes a “micro-expert” and knows the difference. This is especially true for some diseases and illnesses. This blog - http://bobsdiabetes.blogspot.com/2013/06/ada-relies-on-faulty-studies-not-good.html
#12. Some patients are even excited about the prospect of being able to see a doctor less often and become able to write their own prescriptions. There would be some restrictions some patients will not be able to meet. This blog - http://diabetestopics.blogspot.com/2013/07/some-patients-may-not-need-doctors-as.html
#13. Dr. Kernisan has covered “patient engagement” in her blog - http://thehealthcareblog.com/blog/2013/09/12/patient-engagement-on-metrics-and-meaning/ I am concerned about a problem I encounter all too frequently, the doctor version of patient engagement. The doctor asks the questions using his/her technical language and the patient is often unable to answer because they do not understand the question. I lose out because I do ask what a term means in lay language and the doctor often fumbles my question and out the door goes patient engagement. One part of patient engagement remains out in the cold because most doctors will avoid allowing patients to access their medical records. Hopefully, meaningful use will be denied for these doctors. Even one of the physician clinics had signs up in every exam room about access to EHRs and to ask the receptionist for a form and password. When asked, the receptionist says that it is not available yet. My translation – to let the inspector see this to pass meaningful use.
19 September 2013
The demand for primary care doctors is here now and will for many years to come. With the demand for these doctors increasing in many rural or less doctor dense areas, recruiters cannot fill the needs. Merritt Hawkins, a national health care consulting and recruitment firm, speaks to some of the issues, but not all. This firm along with two other staffing companies spans the lower 48 states and includes rural and major metropolitan areas.
As we become more aware of the needs for doctors in the rural areas and many underserved areas of medicine, all three recruiting firms have found that hospitals and medical groups are continuing to seek primary care physicians, nurses, and assistants. However, this is the first year that the request for geriatricians out paced the demand of previous years. This is also the first time that this specialty has entered into the firms' top 20 of the most recruited.
Travis Singleton, senior vice president at Merritt Hawkins, stated that, “It is interesting that our youngest doctors are treating our oldest patients, but I think that some of it is just reclassification, it was happening already.” Other specialties, such as radiology and anesthesiology, despite being among the most competitive and desired positions a decade ago, did not make the top-20 list for 2013.
Dr. Atul Grover, an internist and chief public policy officer at the Association of American Medical Colleges, says, “I think people are starting to look at the market and get nervous, because of Medicare payment changes that impact doctor's pay and the growing emphasis on preventive medicine.”
I think the “growing emphasis on preventive medicine” has many doctors making changes because they are afraid of preventive medicine and know little about it, after having practiced only treating people already ill or in need of treatment for a disease or chronic illness.
I have been made aware of two towns about an hour and one-half distant of recently loosing two primary care doctors because their agreement with the towns had been fulfilled. Both headed for hospitals in larger cities where they will become hospitalists and at a much higher wage and less hours.
Many doctors are taking different jobs to satisfy a work-life balance and not the hectic almost 24/7 hours and paperwork of meeting the needs of their current jobs. According to the three staffing firms, hospitalists ranked third on the top 20 list.
Even with the health care law's attempt to curb the high cost of emergency care, Merritt Hawkins reports an increased demand for emergency department (ED) doctors. With patients finding fewer primary care doctors available to meet their needs, patients will continue to turn to the ED as a last resort or for convenience.
This points out the increasing need for doctors to be trained that will serve in vulnerable communities and the need for incentives for them to continue to practice in these communities. However, the doctors that left these communities for large cities continue to lobby to prevent NPs, PAs, and Pharmacists who have remained in these communities from being able to practice unsupervised.
Therefore, it will be necessary for patients in these underserved areas to lobby their state legislatures in opposition to the state medical boards. Also these same patients in some communities to will need to lobby for restrictions on telemedicine to be lifted. The next decade will be interesting as the powers that exist now may see their popularity disappear and be replaced by the very groups they are muzzling now. And, I feel that the patients may play a large part in this.
18 September 2013
Now lawmakers become concerned about the ability of the system to protect personal health records and other private information. If our congressional people would have been concerned about this when they should have been concerned, maybe we would not need these concerns now. Unfortunately, we still would, as Congress is not far sighted enough, only to the next election and their reelection. That is what all the posturing is about.
Yes, cyber security needs to be a concern, but this will never be fully addressed, as Congress does not wish to offend the NSA because they will be the largest consumer of the information. The data hub, which is scheduled to go live October 1, will process names, dates of birth, Social Security numbers, health conditions, and several other pieces of personal information which at best will be very insecure.
Representative Patrick Meehan, a Pennsylvania Republican is on target when he questioned how CMS completed its security assessment nearly a month ahead of schedule after the agency had “for three years failed to meet a single deadline.” The hub, as it is called, will store little information, instead accessing information in other databases as needed. This means that once the hub is breached; all the other sources will be accessible. Data breaches at the hub would do “irreparable harm” to users, said Stephen Parente, director of the Medical Industry Leadership Institute at University of Minnesota. There hasn’t been enough security testing on the hub, which is a “massive IT project with literally no technical precedent,” he added.
Others are doing their best to downplay the security aspect and I feel are doing more harm than good. It is not a matter of if, but when the security breaches will happen. I say breaches and they will probably come in rapid succession once they start and the U.S. Department of Health and Human Services will probably do its best to cover this up and this is where the concern needs to be.
17 September 2013
Hospitals are beginning to put standards and safety measures in place to prevent hospital infections. With the Centers for Medicare and Medicaid Services (CMS) and now other insurance companies refusing to pay for hospital-acquired infections (HAIs), this has forced the issue and hospitals are taking notice. When hospitals have their bottom line at issue, they will take action, which is a good thing for patients,
Although hospitals have balked at safety standards for decades, being able to put a dollar value on associated costs could help providers and payers justify investing in prevention measures. Even with implementation of quality improvement initiatives, an estimated $9.8 billion is spent each year for treating HAIs. This was the finding of a study published online September 2 in JAMA Internal Medicine.
Quoting from the abstract, “With surgical site infections contributing the most to overall costs (33.7% of the total), followed by ventilator-associated pneumonia (31.6%), central line–associated bloodstream infections (18.9%), C difficile infections (15.4%), and catheter-associated urinary tract infections (<1 i=""> This is something that should not be ignored.1>
“"Not paying for hospital-acquired infections or errors are an important part of the movement toward paying for quality, not quantity, of care," Mitchell H. Katz, MD, director, Los Angeles County Department of Health Services in California, concurs in an accompanying editorial. This study, however, will enable hospital administrators to better prioritize their spending by allowing them to compare the costs of interventions with the savings accrued by avoiding infections.”
Patient safety should have always been a priority, but has not been as long as hospitals were able to be reimbursed for their lack of safety procedures.
16 September 2013
Apparently some doctors that are members of the Society of General Internal Medicine (SGIM) really do not care about their patients with diabetes, only the money that they can receive for helping patients develop the complications. Rather sad that doctors will work so hard to cause harm to a group of patients. Don't get me wrong, as some of the doctors that are members of the SGIM do not agree with their policy listed in Choosing wisely.
I will continue to vent about those that do support "Don't recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin.” This tells me that they don't feel that the progression to complications can be stopped and they do not want to continue trying to educate these patients. Just including this on the list of choosing wisely shows they don't care about these patients.
I have had an email from one of the doctors that has peer mentors expressing his concern for how limited this will make his work. I emailed him a copy of my blog that will appear on http://bobsdiabetes.blogspot.com/ on September 17 and he agreed that he sees this as true, but admitted he did not think insulin will be the only answer. He did think that insulin will be one of the solutions. He is concerned that test strips will disappear as a tool to assist in the management of diabetes for those on oral medications. He is also concerned about his fellow doctors and why they voted for this item.
I did email him back saying that these doctors will be considered doing harm by me. His comment back was that I was on insulin and why would I be concerned. I said because they are still people with diabetes and deserve advocacy even if they don't realize the problems coming at them. He does agree with the ideas that most type 2 patients on oral medications do need more than one test strip per day and people on insulin do need more than three tests strips per day.
He commented that he will not prescribe any of the sulfonylureas for people on Medicare or Medicaid that are limited to one test strip per day. He will not be responsible for causing hypoglycemia when the patient cannot test often enough to correct the episode. He does ask patients to notify him immediately after if they have hypoglycemia and correct it. He has his peer mentors reinforce this in the education and works with these patients using email to discover why they had an episode of hypoglycemia. He needs to use a telephone for three patients because they do not have internet service.
I did ask him if it may be a case that most doctors that are members of SGIM did feel that diabetes was progressive and this may have caused them to vote this way. He admitted that most of them probably do think this, but have caused this by their attitude and not doing any education. He felt that since he started using peer mentors for education, the patients of his are doing significantly better in managing their diabetes. He had been very uncertain about using shared medical appointments (SMAs), but the fact that he has peer mentors doing education while he sees patients individually in another room is working very well and he has had only one patient that walked out of a SMA. He concluded that he will carry on the good cause and work to prevent his patients from being denied test strips.