An excerpt from 2060.
Willis murmured, “Not again.” He approached his mother, who was lying in bed with an uneaten tray of food on the bedside table. A stream of drool collected on her gown as she slumped to the right. “Mom.” Willis gently shook her, and she attempted to open …
When medical protocol meets family concerns
When I was in Sweden, I heard this phrase several times: “There is no such thing as bad weather, just bad preparation.” They said this when we asked them what they did with their children in dead of winter. The proud parents made it very clear that no matter what the weather, when it is time to go outside for recess at school, or to get out of the house …
Patients in Sweden received fewer post-op opioids. Why is that?
Family physicians and others have for years complained about ridiculous quality measures such as the meaningless use program, HEDIS, MACRA, etc. To its credit, the Agency for Health Care Research and Quality was willing to take a step back and ask, “What does high quality look like?”
Researchers led by Rebecca Etz, PhD were funded to go out and ask a variety of stakeholders their answers to this question. …
Medicine is too complex for computers to keep up with or understand
I had the distinct pleasure working with family physician colleagues in Sweden recently. It was a similar experience to a trip I made to Britain about five years ago that I also wrote about. I got to spend some time watching one of my colleagues care for her patients in her surgery (they use the same description of a clinic as the British).
I got to spend some time watching …
An American physician in Sweden. Here’s what he thought about its health care.
Some people think that the solution to better-supported primary care is in direct primary care/salaried physician payment models. I don’t think it is the best answer. I realize money is not the only motivator explaining why people perform work. Meaningful work matters too. But meaningful work that is not respected and paid for will not sustain or be the source of burnout and resignation, not only for physicians. I think …
Fee for service is not the root of all evil
I have had several dealings with the benefits managers/HR managers of large corporations and other large organizations over my career. I have one over-arching conclusion about what motivates these people: They will never be a source of disruptive innovation in health care.
I find them to be passive people. They are fundamentally people pleasers. They derive joy from helping their employees navigate their insurance plans, figure out deductibles and co-pays, explain …
Why managers will never be a source of disruptive innovation in health care
What I’m about to tell you is based on good insider information. But I also disclose that this is an amalgamation of a few reports of teledoc companies to me and their crony insurance companies, not a thorough analysis of the entire industry. I just assume there are other business models out there that look a little different, but I suspect the bottom line impact is about the same.
Most large …
The troubling questions surrounding telemedicine
Several years ago, a group of us concerned about health care costs and outcomes met with some local HR benefit managers. One was the head HR person of a city. In part of the conversation, she raved about a local chain of urgent care centers. She loved the fact that she could go to one after work to get her steroid shot for her colds. I had enough experience dealing …
What administrators don’t understand about urgent care centers
I don’t mean to pick on McDonald’s. Insert any other large retail business where customer satisfaction massively trumps every other consideration of the relationship between employee and customer.
Telemedicine companies have exploded the past few years. I suspect a lot of my readers have already seen this, but just in case not, a recent study in JAMA Internal Medicine measured the correlation between customers with a cold who called …
Physicians are trapped between patient satisfaction and unnecessary prescribing
I am a huge fan of Britain’s National Health Service (NHS), but probably not for the reasons many people might assume. It’s not because it’s “socialist” (a horribly inaccurate description), or that it’s nationalized, or anything like that. I’m a huge fan because somehow the people of Britain have developed the courage to talk about health care using very adult language. In the U.S., we can rarely progress beyond the …
The British are unafraid to talk about rationing. That’s something to admire.
On a recent flight, I sat next to a woman of about 30 who was originally from France but has lived in London for a number of years for work. After exchanging the usual pleasantries, she found out I am a family physician and it became clear she wanted to give me her opinion of the British health care system. I didn’t dissuade her.
For a little background, both the U.K. …
First, a history lesson. Back in the mid-2000 oughts, the AAFP launched a wholly owned subsidiary called TransforMed. It was originally started to help practices implement the “new model of care” from the Future of Family Medicine Report. Soon after it was launched, the joint principles of the patient-centered medical home (PCMH) were announced, so TransforMed pivoted to help practices implement the PCMH model of care.
In …
The tiny gains of patient-centered medical homes. Are they worth it?
A study from the National Bureau of Economic Research reports on the results of a large randomized controlled trial of a large employer with over 12,000 employees. Program eligibility and financial incentives were randomized at the individual level. Over 56 percent of eligible treatment group employees participated. The study found that in the first year, the employees who signed up were healthier and had lower medical costs, but, and …
Why workplace wellness programs don’t work
In a very unique study, researchers have tabulated how often family physicians provide patient care that is not covered with a CPT code. This is a little complex, for the non-physicians and even for many physicians to grasp, so I will provide a little more background first.
CPT stands for Current Procedural Terminology, which is the book written by the American Medical Association (AMA) since about 1965. This …
How the CPT system shortchanges primary care
There are some questions in health care that can’t be answered with a randomized controlled trial. We can’t randomize babies to inhale secondary tobacco smoke or not to test its health effects. We can’t randomize people to a different number of hours sitting the ER before receiving antibiotics after the decision is made that the patient has a bacterial infection requiring antibiotics. There are some questions where the best available …
Colonoscopy after a positive stool test: Does the time frame matter?
I have written about both issues before: freestanding ERs and retail clinics. Two recent studies continue to show how useless they both are in helping create a better more efficient health care system.
The freestanding ER study examined the number of these facilities and population characteristics where they locate. They identified 360 freestanding ERs, mostly in Texas, Ohio, and Colorado. This will come as no surprise; they were located in areas with better …
Freestanding ERs and retail clinics: Do they create a more efficient health care system?
Hospitalists, doctors who only see patients in the hospital, almost always in a shift work model, are the fastest growing “specialty” in medicine, from nothing about 15 years ago to about 50,000 today. There were some studies that I won’t review much here that showed some benefits from hospitalists compared to “usual care” in highly controlled environments, outcomes such as a 0.4 per day decrease in length of stay with …
Our national useless dialogue on the future of health care in the U.S. continues. Trumpcare has a long way to go before it potentially becomes law, so no one knows what it will finally look like. Obamacare is in a death spiral anyway. So the existing financing system will change no matter what.
But once again the two-party scream-at-each-other system is only talking about changes in health care financing. On one side, …
This is why the dialogue on the future of health care is useless
In our recent paper criticizing how industrial quality improvement has been misapplied to primary care, we didn’t just complain, we made suggestions for a better way forward.
This was under the assumption that regulators and payers will continue to insist on some kind of numeric reporting of outcomes by physicians or practices whether physicians like it or not, or whether it’s really useful and fair or …
Health bureaucrats talk out of both sides of their mouths
This post is based on a “friend of a friend” situation. Important details have been changed to protect anonymity, but not the basic realities I want to discuss.
A 49-year old man was diagnosed with a rare form of lung cancer about a year and a half ago. This sad situation is compounded by the fact that he was in a stable marriage with a wife and two children, ages 10 …
We must tell sad medical stories too
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