Check out this f-a-n-t-a-s-t-i-c piece in the new Consumer Reports on why consumers should care about medical overtreatment:
The chronically ill are not the only ones vulnerable to overly aggressive care. Consider the case of a middle-aged IBM executive from the New York City area who experienced chest pain. He went to a cardiologist, who ordered a full workup, including a CT scan of his chest. The scan found no heart problem, but at the edge of the film the radiologist noticed “something funny” in the neck area. A neck surgeon performed a biopsy and found nothing wrong. The cardiologist then performed an angiogram to look for abnormalities in the blood vessels. Complications from that procedure landed the executive in the hospital for a brief period. By the time it was over, his bills were more than $150,000 and he still had no diagnosis. Eventually the pain disappeared on its own.
Months later, when the executive’s chest pain returned, he told his medical history to Paul Grundy, M.D., an internist and director of health-care technology and strategic initiatives at IBM’s headquarters in Armonk, N.Y. Grundy asked him what he was doing at the time. “Oh, we started gardening again,” the man told him. It turned out that overzealous use of his string trimmer had strained a chest muscle, a condition that required no treatment other than an over-the-counter pain reliever. None of the high-priced specialists (some call them the “partialists”) had considered muscle strain, a common condition often mistaken for heart pain.
Few Americans are aware of the dangers of this type of unneeded testing and overreliance on specialists. Instead, many fear that their health problems will be neglected or inadequately treated. But for people with good private health insurance or Medicare, the perils of overtreatment are real.
This is a real challenge for consumers … how to get motivated and activated about overuse of medical services in a way that doesn’t feed into folks who just want to limit care — necessary or not — to save dollars. It’s a real risk, but the issue is real, too.
This is a sad situation, but it’s not common. It’s just one case. The bill is a little excessive, but better safer than sorry. My mother had the same symptoms and ended up being a serious situation.
So how do we get the patient back in the center move from being centered on the doctor to centered on the patient? The premise is that the problems of health care quality and cost are, to a very large extent, failures of the way we have organized and designed care in the United States. More specifically, the current failures in healthcare are failures of primary care—the inadequate system design of the primary care practice, the inadequate reimbursement of primary care, and the poor organization of other health care resources, such as hospitals and specialists around primary care. Note that primary care is not just the primary care provider or even the primary care practice itself. Primary care is an intensive relationship between the patient and her/his primary care practice. The patient is the critical part of primary care.
Although we tend to focus on the problems we face, there are reasons for a great deal of optimism—optimism due to the opportunities we have to improve and redesign care. Medical practice redesign is happening today. It is taking hold and has become a movement that is gaining momentum.
For the first time in history, we have both the knowledge and the capabilities to force substantial change. We are at a unique time in the history. In five or ten years, we might well look back with amazement at the pace of the changes that are currently taking place. The route is clear: We know what to do. We know how to make the system better. The crucial question is whether U.S. health care will have the courage to take on these difficult solutions. When one compares the U.S. health care system with those of other industrialized countries, one is led to the more specific conclusion that the two major problems in U.S. health care are the way we deliver primary care and the way primary care is financed.
My premise is that primary care is the only natural locus of control of health care quality and costs. It is the only entity that is charged with the longitudinal care of the patient. It is the only entity whose job it is to consider the whole patient—the health of the whole person, including mental and physical. While I would not argue that primary care should be all things to all people, it should be designed to achieve much higher performance than it achieves currently. Such a redesign of primary care is possible today. However, if primary care is not successful in its core tasks of prevention, wellness, and the care of common conditions including many chronic conditions, it will not be possible to control either quality or cost of care in the United States. Again, hospital care and Part-ecialty (specialty) care are crucial to health care, but their use is all too often the failure of upstream care. But and this is very important before we can fix the rest of the system we need to have a strong foundation in the healthcare system that can only be a strong robust accountable system of primary care and prevention.
Our national focus on disease management programs is a good example of the failure of primary care and the failure of our efforts to improve care. If disease management programs are considered necessary today, it is because primary care is not doing its job. From a primary care perspective, the treatment of chronic conditions, such as diabetes, congestive heart failure, and asthma, is basic and straightforward. The care of these conditions is simply not that difficult. However, the quality failures in the treatment of these conditions are well documented. Disease management programs represent a Band-Aid® approach to problem solving. They acknowledge that there are problems in health care delivery, and instead of addressing those problems directly, these programs create additional, expensive, fragmented responses to the primary problems. For some reason, the health care industry has demonstrated an inability to develop a sharp focus on solving core problems. It seems much more willing to create complicated responses to our problems than we are to fix the core problems of our delivery system. Disease management is a perfect example. If primary care is not delivering high quality care for those with chronic conditions, we can either find a way to work around primary care or we can find a way to fix it.
There are far too many efforts focused on working around primary care and not yet enough efforts focused on fundamentally redesigning primary care so that it can deliver the appropriate performance. To spend our limited capital on programs that disable primary care is dangerous and expensive. At the same time, primary care has to take a very different role in terms of accepting accountability and responsibility for its performance. There is no doubt that the current model of primary care is not appropriately designed, an therefore, it is not capable of accomplishing the role that
we need it to accomplish; at the same time, the financing system does not support the efforts of primary care. We have continued to devalue the role that the primary care practice performs. This is clearly expressed in terms of reimbursement. The current financing system provides inadequate financing, as well as the wrong incentives, to primary care providers.
But there is a solution, and there are some exciting opportunities. What would it take for primary care to assume that role of the key coordinator and caregivers? It would take a redesign of the primary care system; it would take redesign of the finance system. But with that said in the Patient Centered Primary Care Collaborative we have the employers of over 50 million lives, and all the primary care players with a membership over 333,000 physicians from the AAFP, ACP, AAP, AOA and all the national healthcare benefit companies at the table and we are designing our primary care system around the following three key elements.
The first is doctor patient “Relationship.” We want to make sure that we provide our patients with fantastic relationship. Great relationship in health care does not just happen spontaneously; it is a product of system design. Our systems must foster the creation and maintenance of effective relationship. To a large degree, care is relationship; it is not only the things that we do, but it is the quality of our interactions. When relationship is disrupted, care suffers.
The second component is patient centered, the patient’s needs at the center or “Service” If you want to cut out the jargon.” The service we buy for our employees should be the best service that patients experience. We know that there is a substantial gap between the service our employees should get and the service that they do get. Examples of service defects include relatively poor access to physicians and the inconvenience of waiting—waiting for appointments, waiting in the medical practice, and waiting for test results, for example.
The third component is “Reliability.” How do we create medical practice systems that exude clinical reliability? Reliability, like its cousin, Patient safety is a characteristic of the underlying system design. These components of Patient Centered Primary Care (PCPC) —Relationship, Service, and Reliability—are critical to the care process, particularly within primary care. Yet our current medical practices have substantial deficits in each of these areas as has been well described by the Institute of Medicine and others. Getting these components right will be critical to the redesign of primary care if we desire that entity to produce the outcomes of higher quality, more cost effective care. In fact, for the first time in history, we have both the knowledge and the technology to make the achievement of these aims possible. Technology is obviously an important
enabler of the characteristics of Relationship, Service, and Reliability.
Example: A critical component of relationship is our ability both to know the patient and to communicate with the patient. Patients feel cared for; they feel the right relationship when people within their medical practice know them. That means that health care workers have to have instantaneous access to patient specific information such as medications, problem lists, social history such as the individual’s occupation or avocations, and more. Knowing a patient is the opposite of a patient feeling anonymous. Electronic systems are necessary for this. For example, when doctors are taking calls over the weekend and a patient calls in with a problem, they have instantaneous access to that individual’s records. The benefits of having such patient specific information readily at hand are obviously in terms of improving safety and quality of care. However, what the patient experiences is a much stronger bond to the practice because they feel known. Therefore, when we are designing medical practices, it is an imperative to consider how our information systems foster relationship by making the most applicable patient-specific information readily available at all times.
Communication is another aspect of relationship. In today’s primary care system, the only way most individuals can communicate with their physician is by scheduling an appointment. It is terribly difficult for patients to get a physician to the telephone to discuss their health concerns or even to answer questions. The current system relies nearly exclusively on the very constrained interactions within a medical visit as the means of communicating with each other. We know how this feels both from a patient and a provider perspective. If we are to improve our communications, we must, therefore, move beyond the visit-based method of care to include other opportunities to interact. The use of much more telephone care, as well as electronic care via email becomes an imperative in a new system design. Patients need the ability to ask their doctor questions in a convenient manner at their own discretion. They need to be able to access their doctor for coaching and counsel when necessary. And we need their doctor to provide them with assistance and appropriate follow-up among other things. Much of this work can occur outside the visit, but it requires open communication systems between patients and their practice. In fact, in Denmark we have found that the proactive use of telephone and electronic care has allowed the Danes to reduce follow-up visits with patients by 50-70 percent while maintaining the quality of care and improving our relationships with patients at the same time. Note the significance of that figure—a 50-70 percent reduction in follow-up visits simply by moving to the use of non-visit care mechanisms. A last example pertains to clinical reliability.
Our primary care physicians have to be capable of tracking our patients so that individuals stop falling through the cracks. Diabetics frequently go without the appropriate follow-up or effective preventive measures, because existing practices have no way of specifically tracking these individuals and noting when they are delinquent for care. This ability to proactively manage our patients is critical—the function is called a registry, and they are possible today. Registries, generally electronic, provide us with the ability to place patients within specific groupings for tracking purposes. The appropriate care parameters for those different groups can be defined, and the care of individuals within those groups can be continuously monitored against those standards. Therefore, if a diabetic is due for an important test like and A1C, the practice knows it. If an at-risk patient’s numbers are not at a target level, the PCPC practice is aware and can pull the patient into the care process. Such proactive care can only be accomplished by reconstructing the practice around such registries and redesigning the work processes with these capabilities in mind. Such functions are necessary to deliver on the promise of highly reliable care. Contrast such a system with the near purely reactive system that we currently have.
I once got dizzy from getting up too suddenly and fell and hit my nose. I went to the emergency room to get treatment for my painful nose. Instead, they spent tons of money doing CAT scans and other tests to make sure I didn’t have a brain tumor. I knew the problem was just low blood pressure from getting up too suddenly. And so it was. They never did do anything for my nose.
A sad story, but this may be the situation more for corporate executives (where money is not a problem) than for the poor or middle class – where underdiagnosis and undertreatment of silent conditions such as diabetes and high blood pressure is a real problem (some would say epidemic). In general, it is important for the physician to ask the patient how serious they think the problem is, and by knowing the patient (which the physician ideally should), then determine the best course of work-up, and most importantly follow-up. (With a reliable patient who will come back, a non-acute problem can be evaluated in stages rather than an all-at-once/every-test-available approach.) I’d also guess that none of the physicians asked the IBM executive how aggressive he wanted to immediate testing to be – they just saw a high-end executive and decided that an everything evaluation was what was expected.
Ho hum! So what’s new? Oh ya, this was in a consumer magazine.
By the way, I don’t think it is wise trashing the “partialists” for doing their job. The best thing to do is for everyone to realize that a well-trained and dedicated primary care doc is beneficial for everyone, even if it is not the equivalent of letting your Maserati scream your net worth to the world. A specialist used the wrong weay is not better than a good primary care doc.
Nothing new under the sun… just like the concept of a medical home. Sounds like an old country doc, if you ask me.