Category Archives: Culture

Workplace clinics: All good

A Wall Street Journal piece (The Office Nurse Now Treats Diabetes, Not Headaches) notes the benefits of workplace clinics but also emphasizes the potential downside of loss of privacy or employer intrusion into the personal lives of employees. The ever-skeptical Deborah Peel is trotted out to lay out an Orwellian scenario.

Workplace clinics address the big, big issues of access and convenience, and do so in ways that align the interests of employers and employees. It’s a hassle to get an appointment at a doctor’s office. Even when you have an appointment it takes time to get there and waits can be long. It almost always means time off from work. Onsite clinics are set up to be convenient and to respect the value of employees’ time. The employers are the customers. They care about time away from work and access to care. They also generally are interested in evidence based medicine, consistency, and patient safety. All of those things benefit the employee.

It can be difficult for even well-educated, well-insured people to navigate the health care system, and partially as a result there are many people walking around with conditions that they are neglecting. This example from the article struck me as a good one:

John Martin, an accounts-payable specialist at Hanesbrands, visited the company clinic in January after leaving his Type 2 diabetes untreated for seven years. Tests confirmed that the 53-year-old’s blood sugar was high and that he also suffered from hypertension. Clinic nurse practitioners put Mr. Martin on medication for both conditions and arranged for free or discounted pills. A CHS health coach helped him lose 25 pounds in two months through dietary changes and an exercise program.

“This has made me change the way I live my life,” Mr. Martin said of the clinic.

This kind of intervention is a positive thing for all involved. I know I’d be more likely to want to work for a company offering this sort of support.

Welcome to summer –and sun protection

This is a blog about the business of health and health care policy so I don’t often delve into the realm of personal health tips. But since it’s the first day of summer and I’m a sun-sensitive bald redhead, I’ll make an exception.

It’s the time of year that newspapers write about sunscreen. A Washington Post article talks about the safety of sunscreens, contrasting “physical” sunscreens that block sunlight by reflecting it back,with chemical sunscreens that absorb the sun’s rays and keep them from damaging skin. The fear is that chemical sunscreens may be absorbed into the skin and cause trouble, e.g., by producing free radicals that cause damage to cells.

I share this concern about sunscreen safety, but my worries are also more practical and immediate. In particular, I’ve found that when I use sunscreen at the beach I often miss a spot –like the tops of my feet or some place on my back– and end up with a big, bad burn.

Twenty years ago I was working on a consulting project at an academic medical center in New York City. I was interviewing a dermatologist who took a look at me and couldn’t resist offering the advice that I should wear sun protective clothing, especially at the beach. Since then I’ve worn sun protective gear from Solumbra in the summer. I’m partial to their zip-front swim shirts, which I wear religiously. They’re comfortable in the water or on shore and I don’t worry about getting burned or needing to reapply sunscreen once I’ve gotten wet.

This year my wife asked me to try something a little more stylish than the plain, blue Solumbra swim shirt I favor. So I bought one from Coolibar, which looks better but is honestly not nearly as good.

If you’re sun sensitive like me, or just sun sensible, I hope you’ll take care of your skin by wearing sunscreen or protective clothing.

See you at the beach!

Of ACOs and the over-imaging of children

Today’s news feeds feature a big new study on pediatric CT radiation doses. Anyone who’s been paying attention will not be surprised by the results:

  • The use of CT scans in pediatrics rose dramatically from 199 to 2005 before leveling off
  • Some kids get huge doses of radiation –with the amount of exposure per scan varying dramatically
  • Thousands of people will eventually get cancer due to the CT scans they had as kids

Scans are popular because they provide lots of information for diagnosis, produce pretty pictures that patients can relate to, and because they are well-reimbursed. But the harms are real and the medical community as a whole has not done enough to get things under control. There are exceptions, though. The Image Gentlycampaign has called attention to this issue for years, and I have personally seen remarkable attention given to weighing the benefits and harms of CT at Boston Children’s Hospital. I’m sure they are not alone.

One of the fastest, most effective ways to address the problem of over-imaging in the broader pediatric community is through payment reform. In particular, when health systems have incentives to hold down costs and improve quality –as they do with Accountable Care Organizations (ACOs)– I suspect doctors will be much more careful about what they order. And when patients have to pay more out of pocket they may also initiate a discussion with their provider about whether the scan is needed.

Meanwhile, if your kid has had more CT scans than they need or if you yourself have had too many, you have a right to  be worked up about it.

Wanted: Entrepreneurial business models for doctors

My perception is that doctors in previous generations were more likely to devote their entire lives (professional and “personal” time) to the practice of medicine. Today’s doctors are more likely to consider lifestyle and not automatically put everything into doctoring. This is partly cultural –as younger professionals in general have put more emphasis on balance– but a large part is structural, because residents are working fewer hours by law and because more doctors are working for others, which encourages an employee mentality.

I don’t really have a problem with doctors who want to have a life outside medicine, but overall I prefer to be treated by someone who’s really dedicated and wants to devote most of their waking hours to it. By the way I feel the same about other professionals I work with.

So I’d like to see some of the structural issues addressed to encourage those who want to go all out to do so. Kaiser Health News has an article on the topic today (Doctors Transform How They Practice Medicine), which gets at my point at least indirectly. The article discusses how physicians are opening “medical homes” to provide more coordinated care or opening concierge-style practices that limit the number of patients and charge extra fees.

Those are both kind of interesting but also a bit ho hum. I’d rather see a broader array of offerings including those that include more remote services and incorporate specialty care. I hope and think they’ll come because despite the fact that many docs are rushing into hospital employment, I believe many would rather work for themselves if there were a viable way to make it happen.

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By David E. Williams of the Health Business Group.

What to do about heroin and oxycontin

USA Today has a full page article on the rise of heroin addiction in the suburbs, but adds absolutely nothing to what’s already widely known. (See, for example, my post on the topic from early 2012.) Teens and adults start by abusing the painkiller oxycontin, which is available by prescription, then turn to shooting heroin once they figure out how pricey it is to acquire oxycontin on the street.

The article presents no real ideas on what to do about the problem. If anything the article implies that it would be better to make oxycontin more widely available in order to stem the use of heroin. That’s a nonsensical approach as far as I’m concerned.

There are alternative approaches that might be more promising.

One idea is to establish better guidelines on the prescribing of painkillers after surgery. Many patients –maybe you’ve been one of them– receive an overly generous supply of oxycontin or vicodin after a minor surgical or dental procedure. Sometimes the patient gets addicted from that initial supply, other times the extras end up in the family medicine cabinet where teens might find them and try them out. It’s not always obvious how to dispose of these medications, which contributes to them hanging around.

One hurdle to overcome is that follow-up visits are inconvenient and also not very profitable for doctors. Perhaps if there were quality measures associated with good practices that would change the equation and tighten the initial supply.

Another issue relates to so-called “drug seekers.” We’ve all heard about drug seeking patients who come to the emergency room to get drugs. There are IT systems coming online that can at least identify such drug seekers and alert doctors, but this only works if the systems are consulted, which may not happen when middle-class patients are involved. It’s easy to label patients as “drug seekers,” which makes them sound like bad people. Some are. But many others are patients who are somewhere down the path toward dependency. They’re not trying to become oxycontin addicts and certainly aren’t looking to move to heroin. Rather than turning people away it would be better to have a path to refer these patients into treatment and then to track their progress.

There are great opportunities for physicians, payers, employers, consumers and pain management experts to work together to develop a more comprehensive view of the problem, to develop a strategy to address it, create new quality and safety measures related to achieving the strategy, and align incentives so that physicians are rewarded for doing the right thing.

We won’t solve the problem of painkiller abuse in one shot. But it’s reasonable to start by tightening up on the relatively easy places, such as cutting down on the distribution of unneeded post-surgical pain meds and figuring out how to better direct “drug seekers.”

Talking to teens about prescription drug abuse

I agree with the main recommendations of the Drugfree.org/MetLife 2012 attitude tracking study of teens and parents regarding drug use:

  • Do more to communicate risks of medicine misuse and abuse
  • Safeguard medicines at home
  • Properly dispose of unused medicines
  • Avoid modeling bad behavior by misusing or abusing drugs

The report raises quite a few interesting points, but some of the survey results raise more questions than they answer, and there are other issues not addressed.

Prescription drug abuse is a serious problem. One area the report focuses on is the abuse of stimulants such as Adderall. Here’s their take:

“In fact, almost one-third of parents (29 percent) say they believe ADHD medication can improve a teen’s academic or testing performance, even if the teen does not have ADHD, and one in four teens (26 percent) believes prescription drugs can be used as a study aid.”

And regarding prescription drugs in general:

“Parents and teens share the same misconceptions regarding prescription drug misuse and abuse. One in six parents (16 percent) believes that using prescription drugs to get high is safer than using street drugs, and more than one in four teens (27 percent) shares the same belief.”

“One-third of teens (33 percent) say they believe ‘it’s okay to use prescription drugs that were not prescribed to them to deal with an injury, illness or physical pain.’”

“One in four teens (25 percent) says there is little or no risk in using prescription pain relievers without a prescription, and more than one in five teens (22 percent) says the same for Ritalin or Adderall. Additionally, one in five teens (20 percent) says pain relievers are not addictive.”

While the survey is surprised at how high these numbers are, I’m surprised they are so low. And some of what the surveyors characterize as misconceptions I regard as accurate or at the very least open to debate. For example:

  • All else being equal, why wouldn’t it be safer to get high from prescription drugs than street drugs? The ingredients and dosing are known, the purity is bound to be higher, there’s less physical risk of obtaining the product (if from parents’ medicine cabinet especially), almost no risk of arrest, and if something goes wrong the emergency department can have an easier time figuring out what you took. Can it really be that only 1 in 6 parents and 1 in 4 teens agrees with me on this?
  • It’s interesting that only about 1 in 4 parents and teens think ADHD drugs can improve academic testing and performance. I’ll bet there’s more support from college students who are big users of these substances. And do we really know that these meds aren’t effective in “normal” people, especially when cramming for a test? Part of the issue here could be that plenty of kids with ADHD or who are just a bit restless are put on drugs and get used to having them
  • Direct to consumer ads tell us to “ask your doctor if [Drug X] is right for you.” And when we do ask, many physicians say yes. This includes pain drugs. In fact I saw a DTC ad for the pain drug Lyrica today. Given that, is it such a stretch that some people could think it’s ok to take pain meds without a prescription? And instead of emphasizing that 20-25 percent of teens who are unworried about pain drugs, perhaps the report should have emphasized the 75 to 80 percent who do think there’s an issue.

I really do think prescription drug abuse and misuse is a serious problem. But the problem is not just naiveté on the part of parents and teens. It gets to the fact that unlike a generation ago, we are starting to use Rx drugs as performance enhancers, and the use of consumer advertising to promote prescription medications has predictably created a much stronger consumer mindset about the use of these substances.

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By David E. Williams of the Health Business Group.