Category Archives: Patients

Are men comfortable with female physicians? Other factors to consider

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Nuzzel showed me that my friends have been sharing a new athenainsight: Are male patients comfortable with women doctors?  The post uses athenahealth billing data to demonstrate that male patients are less likely to return to female physicians than they are to male physicians, but for female patients the sex of their doctor doesn’t make a difference.

Athena’s conclusion is that men may be “less enthusiastic than women about seeing physicians of the opposite” sex. The article links to a Quora exchange, where all the respondents indicate that as patients they are equally comfortable with women as they are with men.

These findings are interesting, but I don’t think they tell the whole story.

When my long-time primary care physician retired I looked for a new doctor. I believe in the value of long-term relationships so wanted to pick someone I could be with for 15 years or more. I wanted someone affiliated with my preferred health system, with excellent clinical and at least decent communications skills, and around my age (late 40s).

My retiring physician recommended a female colleague in a practice close to where I live, who fit the bill. He had been involved in her training and had worked with her.

Like the Quora respondents, I was comfortable with being examined by a female physician. As I’ve written, I’m also comfortable being examined by a physician who is a friend.

But, although it was further down my list of criteria, I did have the sex of the physician somewhere on my list of factors. Why? Because at least on average, men work more hours and retire at an older age, making them more likely to be available to patients when needed.  One survey showed that 44 percent of female physicians worked part time, compared with 22 percent of men. Another showed 25 percent of women compared to 12 percent of men.

My personal experience reinforces those statistics. The recommended primary care doctor works part-time. Other  female physicians my family sees have taken time off to care for sick family members and attend to other family issues. One retired in her 40s to take care of sick parents. Working less or taking time off doesn’t make them bad doctors or bad people –quite the contrary, it may even keep them fresh or help them stay connected with patient needs– but it does have an impact on availability and longevity of the relationship.

In the end I chose the female primary care physician my retiring doctor recommended, and I plan to stay with her. But I’m also adjusting my expectations about primary care. For one thing I’m focused more on the relationship with the overall practice, rather than just with my personal doctor.

The practice seems to do a reasonable job of working together as a team, and I hope this will serve its patients as well or better in the long term than the more traditional and familiar one-on-one doctor/patient relationship. If it doesn’t turn out that way then my likely next step is to switch to a concierge practice rather than seek out a male physician.

Image courtesy of stockimages at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

Smoking and the ACA

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The Affordable Care Act (ACA) has created a wonderful laboratory for studying the impact of changes in healthcare policy. One of the more interesting papers on the topic appears in the latest Health Affairs (Evidence suggests that the ACA’s tobacco surcharges reduce insurance take-up and did not increase smoking cessation). (You’ll need a subscription to read the full article.)

Health plans can’t charge higher prices to people who are sicker, but they can tack on surcharges of up to 50 percent for tobacco users. States can limit or ban the surcharges, and some do. Not surprisingly, people subjected to high surcharges are a lot less likely to purchase insurance, especially because the way the surcharges work has a very significant impact on their out of pocket costs.

Beyond the headlines, there were several additional findings:

  • When smokers faced no, moderate or high surcharges rates of smoking cessation were unaffected
  • Low surcharges significantly reduced the degree of smoking cessation
  • Young smokers were much more likely than older smokers to be deterred from health insurance coverage by the imposition of surcharges
  • Surcharges were typically higher than the extra medical costs incurred by smokers

These findings have some interesting implications:

  • If the goal of the surcharge policy is to get people to quit smoking, then it doesn’t seem to be working very well. The least effective approach of all is to impose low surcharges. The authors speculate that the low surcharge smokers may feel they are being fairly charged and therefore don’t have an incentive to change. This is like the parents who are more likely to pick up their kids late from day care when a small fine is imposed
  • Surcharges knock younger people out of coverage disproportionately, which may destabilize the risk pools since younger people are generally more profitable than older people
  • The rising penalties for not purchasing insurance may not have much effect on smokers who face surcharges. Many low or moderate income smokers will be exempt from the penalties because the premiums –with surcharges– are deemed unaffordable
  • Patients with mental health problems are being discriminated against because they have much higher smoking rates than the general population. (I have been making similar arguments since 2007)

The authors mention in passing that high surcharges may encourage people to quit in order to obtain affordable coverage. They also note that the smoking surcharge isn’t always apparent on the exchanges, so smokers may not understand that they are paying more or how much.

I’d like to see the law tweaked to make the financial consequences of smoking more apparent to smokers. Surcharges could be displayed more explicitly, and the bar for being exempt from the insurance coverage requirement could be raised. Exceptions could be made for those with a mental health diagnosis.

These changes won’t necessarily be easy to achieve. Congress so far shows no signs of being willing to improve the law –though that may change if the Democrats retake Congress. Another issue is that tobacco use is generally self-reported for exchange customers, so we don’t know how many people are classifying themselves as non-users when in fact they are not.

By healthcare business consultant David E. Williams, president of Health Business Group.

Uber the ambulance chaser

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Uber and to a lesser degree Lyft have decimated the taxi industry with a disruptive model that lowers costs, improves service, and identifies the few bad apples among drivers and passengers. Now both companies are venturing into a niche market that’s in need of serious reform: medical transportation.

Some patients need help to get to their medical appointments and Medicaid and Medicare step in as needed to pay for transportation. However, too often a patient is transported in an expensive limo or even an ambulance when a regular car would have been fine. The government recognizes the problem and has taken some steps to clean up the business, but it’s tough going.

I’m not exactly sure how Uber and Lyft will tackle the intricacies of the business, but they are diving in:

  • Boston Children’s John Brownstein has helped form Circulation, which will use the Uber network to provide rides to medical visits to seniors and those with disabilities. Medicaid will provide coverage
  • In New York, Lyft has been working with the National Medtrans Network on a pilot program

These services will be valuable in their own right because they are likely to reduce costs and improve service. But the downstream value to the healthcare system is even greater: if patients can get to and from appointments more reliably it may well reduce overall medical costs and improve outcomes.

Finally, it’s helpful for patients to have their medical appointments bracketed by state-of-the-art service experiences, since it will encourage patients and maybe medical offices to strive for the same service levels in their medical care. Kind of like how Disney pulls up all customer service in the Orlando area.

Image courtesy of vectorolie at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

 

Most young men don’t know about emergency contraception. Is that ok?

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About 40 percent of adolescent boys and young men know about emergency contraception, aka the “morning after pill” or Plan B according to a Journal of Adolescent Health study. Women who take the pill within a few days of unprotected sex or a condom break can avoid an unwanted pregnancy because emergency contraception prevents ovulation.

So how should we think about the 40 percent number?

The authors are pleased that the number is as high as it is, and take it as proof that educational campaigns are working. They’d also like to see the number go higher so that boys and men take responsibility for contraceptive planning. In an ideal world that’s undoubtedly true, but I wonder whether it would be better if men were less aware of emergency contraception rather than more.

After all, the possibility of pregnancy is not the only reason to avoid unprotected sex. Prevention of sexually transmitted diseases is right up there as well. If boys and men know that emergency contraception is an option, they may be less careful about protection and more likely to pressure their partners into having unprotected sex in the first place.

I’m not actually advocating for purposefully keeping people in the dark, but I’d focus the awareness message heavily on girls and women.

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

Mass Health Quality Partners releases patient experience results

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Massachusetts Health Quality Partners is a national leader in reporting on patient experience in primary care. Its latest data release at healthcarecompass.org provides valuable information for patients looking for a physician and for practices seeking to understand how they perform in absolute terms and in comparison with others.

You may be familiar with the adage, “What gets measured gets done,” so it really is important what we decide to measure and to publicize. Some patient experience topics, like communication, have been measured and reported for some time. The average score is now 93.5 out of 100 –which is great, but it also means that it’s hard to improve from there and that communication may not be a great way to choose between practices.

By contrast, some of the newer categories demonstrate opportunities for –and evidence of– improvement. This is just the second year asking about behavioral health screening –an important topic since so many behavioral issues first present in primary care. Scores on that measure have risen from 53.1 to 56.5 from 2014 to 2015, while some practices have shown improvements of up to 20 points.

Self-management, a new topic this year, comes in with a score of 54.0 for adult practices and 43.6 for pediatrics. Look for that one to rise in the coming years as well. Statewide results are summarized on the MHQP website.

Most of the scores are reported as Harvey balls, with four levels of differentiation. It’s easy to compare practices against one another on specific measures, but on the other hand it’s difficult to figure out how any given practice rates overall. That’s partly because unlike commercial rating sites, MHQP is a collaborative that needs to keep the providers on board.

A shorthand way to make comparisons is with the “willingness to recommend” score that’s reported as a percentage. I asked MHQP spokesman Joe Ternullo about this measure and how to use it:

How can patients use this measure to chose a physician?

People often ask others for a recommendation when choosing a new doctor. To learn more about this, MHQP asked patients:   “Would you recommend this provider to your family and friends?”  MHQP suggests that patients look at all available information before choosing a new doctor. This is because no single rating by itself can give a clear picture about a healthcare provider’s quality of care.

Can a consumer use that measure to make a decision when the information is presented at a practice level?

Yes. A consumer should use the ratings at healthcarecompassma.org to see how his/her primary care practice fares, or to look for practices in their region that have scored particularly well.  In either case, focus on two things. First, look at the percentage of patients who said they would recommend the doctor. Don’t focus too much on minor differences, such as between practices with scores from, say, 86 to 89. Second, look at its scores for individual aspects of performance, such as communicating with patients, coordinating care, and getting timely appointments.  These measures are a guide to help patients assess certain aspects of patient care. No single measure reveals everything about the quality of care at a provider’s office.  Different practices may excel in different areas. But a low score can point out certain aspects of care that a doctor’s office needs to improve.

And as a follow-on, how do practices use that information with their own providers?

Medical care is complex, and patient experience is only one measure of quality. For example, it is important to know how well as doctor helps patients manage conditions like arthritis, diabetes, high blood pressure or high cholesterol. But patient experiences can affect those clinical measures. Many practices have used the MHQP statewide patient experience survey results to improve how they interact with their patients.

The MHQP patient experience survey is a valuable community resource that we are fortunate to have in Massachusetts. The survey is supported by leading health plans and provider organizations.

By healthcare business consultant David E. Williams, president of Health Business Group.

Evidence based defensive medicine

 

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Defensive medicine –when physicians provide or recommend unnecessary treatment or testing in order to reduce their chance of being sued– has always bothered me. It harms the patient, drives up costs, and can be self-serving by generating more income for the provider. I’m also skeptical about whether “defensive” medicine really reduces the chances of being sued.

So I was very interested in a Today’s Hospitalist article (Does defensive medicine work after all?) that reports the results of an intriguing study of hospital admissions in Florida. The study, conducted by a Harvard Medical School professor, revealed that physicians who were responsible for the most expensive hospitalizations also had the lowest likelihood of being sued (0.3% vs. 1.5%).

There are plenty of limitations –correlation isn’t causation, it’s based on hospital admissions only, maybe the doctors in the high and low spending groups aren’t comparable, etc. — and yet it does give one pause. Maybe doctors who order more tests and treat patients more intensively really do get sued less. Could it be that patients and families are less likely to sue if they feel that everything has been done for them?

The findings have serious implications, especially as we leave the era of fee for service medicine and enter the age of accountable care and capitation. Will it be possible to get physicians to be less defensive in the name of cost savings? Is it fair to do so? What role should the patient and family have? Do we in fact need some kind of liability reform?

Dr. Anupam Jena, lead author notes that malpractice is bother under and over-stated. Malpractice costs are routinely reported at only 3-5 percent of total costs, yet physicians also say malpractice is a major concern. My own suspicion is that there’s only a limited correlation between real malpractice and what physicians actually get sued for.

Image courtesy of stockimages at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

 

Free market for surgery: interview with Allevion CEO Arnon Krongrad, MD

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Surgery can be expensive, scary, dangerous and even deadly. Yet it’s hard for patients and even for referring physicians to navigate the system. So I was intrigued when I was contacted by Dr. Arnon Krongrad , CEO of Allevion, Inc., a healthcare logistics company that markets surgery packages. The company’s Surgeo online marketplace let’s patients shop for the surgeon of their choice.

I explored the topic in depth with Dr. Krongrad in this email interview.

What are the limitations of referrals to surgeons by primary doctors?

Conventional surgeon referrals by other doctors, such as primary physicians, rely upon limited knowledge about a limited number of surgeons. For example, primary physicians tend to know a relatively small handful of surgeons for specific procedures, such as vision correction. The simple reality is that in today’s environment, when primary doctors are pressured to churn patients, type into EMRs, and speak ICD-10, they have little time to sort through choices of surgeons. They will reflexively refer to the familiar, which may or may not be optimal. Primary physicians, like the rest of us, might welcome systematic, easy access to knowledge about choice of surgeons.

It looks like your surgeons are selected based on the opinions of their peers. Are there more objective, quantitative ways to rate surgeons?

Surgeo’s purpose is to simplify access to quality care. In surgery, quality comes from the surgeon. The question, then, is how to qualify surgeons. This is an urgent question as our increasingly consumerist ecosystem demands transparency regarding cost and quality. It is a question with obvious and easy answer but a conceptual framework will help us to manage and make progress.

First of all, no, there are no objective, quantitative ways to rate surgeons. We should be clear. We are not talking here about waiting room times or adequacy of parking. We are talking here about clinical quality: blood loss, rectal perforation, positive margins, and the like. A system that has not produced an objective, quantitative way to transparently, uniformly, and broadly present cost – a much more cleanly quantifiable dimension of care – has only just begun to think about objective, quantitative ways to present surgeon quality.

As we think about surgeon quality, we should recognize that surgeons do not operate in a vacuum. Most critically, they operate on patients, who are varied, and produce outcomes that are varied. Let us use prostate cancer surgery as an example. The factors other than surgeon skill that affect various outcomes vary. For example, cure is affected by cancer grade and preservation of erections is affected by diabetes. So which outcome – cure, erections – are we looking at when we ask about surgeon quality? Once we decide, have we collected patient data in a way that would permit us to explain variation in outcomes between surgeon A and surgeon B? No, we’re just not there yet.

Secondly, formulaic objectivity, laudable as it might be, is not the only way to go. The other way is subjectivity, the argument for which was previously laid out in this article. In brief, the principle relates to the instantaneous ability of subject experts to detect artistry when they see it. It argues that surgeons know quality surgery when they see it. As one very senior surgeon who has taught surgery all around the world said it: “I can tell within a minute of skin incision if a surgeon is good.”

There are data, most notably in bariatric surgery, to show that subject expert peer credentialing correlates with objectively measured outcomes, such as hospital readmission. In other words, we think we can do well by patients and payers by applying the collective, subjective wisdom of surgeons.

Do other factors affect surgeon qualification? Any surprises?

Yes. Surgeo’s surgeons are qualified using a published, multi-factorial surgeon credentialing process that includes but is not limited to peer input. The idea is to try to get as close as possible to surgeons who know what they are doing and who exemplify the high standards of service and mission.

The additional steps have yielded some surprises. For example, Surgeo recently rejected the application of a very well known, very high volume, well published surgical specialist whose peers think highly of him. We rejected the application upon discovering what his peers did not know: that he has a history of numerous high-dollar malpractice payouts, including one incomprehensible loss at jury trial. This example relates to the opening comments: doctors do not investigate surgeon qualifications as fully as they might if given motivation and time. Surgeon qualification takes time, effort, and more than one criterion.

What do surgeons think of your approach?

Doctors generally are under siege. They are all looking for simplicity, fairness, and respect for their abilities and integrity. Surgeo delivers those and surgeons love the surgeon driven, clinically rational product design and administrative approach. The model works because it satisfies patients and providers. It has also satisfied payers, as when we used it in a previous chapter to satisfy Blue Cross and develop surgery bundles for the network.

What has been the most surprising reaction of your surgeons?

Surgeons are often paralyzed by the freedom that Surgeo offers. They have no idea how much to charge for their services because nobody has ever asked them before. Surgeo does not negotiate prices with its downstream vendors. Surgeo does not set allowed amounts or ask for discounts. This is unfamiliar to most doctors. This seems bizarre. Have you ever met a lawyer who has no idea what his hourly rate is?

What’s the history of Surgeo? What is its future?

One day, two things happened: Congress said everyone was getting healthcare and a man with cancer told me he could not get healthcare: surgery for his newly diagnosed cancer.

I tried to help him and ran into inflexibility and apathy. The solution ultimately involving sending him from Oregon, my surgical team from Florida, and a surgical robot spot purchased on eBay for 1% of retail from Colorado to an operating room in Trinidad. The exercise delivered a flat-fee surgery package at a price he could afford and worked for all involved. We then developed the model domestically and sold surgery packages to individuals and large payers. You can see a presentation of that case here.

Surgeo is a public, interactive, online face of surgery packaging and pricing software engine that was designed in-house under the direction of Kimberly Langer, our Chief Product Officer. Kim was formerly with a large payer, where she designed large enterprise claims related software. She built Surgeo to scale in a way that can work with payer EDI streams for easier network integration and for presentation to members of service choices and out-of-pocket costs. Kim also built it to accommodate our customers who want privately labeled software by which to market their own surgery packages. We’re seeing demand for that from financial and provider organizations.

You cover a variety of surgeries. Are there any surgeries that have been more popular than expected?

Penile implant surgery. We did not even think about this when we first set out. It turns out that there are huge problems related to this procedure. First of all, authentic conversation about male sexuality and erectile function is in very short supply and men with diabetes, cancer, and other conditions associated with erectile dysfunction have very few places to turn for substantive learning. Secondly, the pharmaceuticals for erectile dysfunction have taken over the airwaves and displaced much of the conversation about other, very effective treatments. We were amazed, for example, that one national network of diabetes activists, whose constituents have up to 70% prevalence of erectile dysfunction, has not discussed erectile dysfunction in 10 years!

What makes the challenges even greater is that penile implant surgery is often not covered by payers. We hear regularly from patients who thought they had what they call “really good insurance” that penile implant surgery is not covered. The way things are going, with CMS having dropped covered for vacuum erection devices, it won’t surprise us if penile implant surgery is just uniformly dropped.

We are getting sad, pleading calls from men with diabetes, obesity, cancer, and others who would like to restore their erections, relationships, marriages, and mood. These men are finding a delivery system that is broadly opaque and unhelpful. In response, we built in response is a national penile implant surgery package network. It features peer credentialed surgeons, comprehensive flat-fee packages, finance navigation, and financial protection in the event of complications. It offers plenty of choice.

The risk protected, flat-fee penile implant surgery package network is a model for efficient delivery of non-covered services. It can help payers to help direct members who do need those services.

What do you mean by financial protection in the event of complications?

Surgeo packages protect surgical patients against financial surprises by bringing in qualified surgeons. This is not a guarantee of elimination of complications but it helps. The second protection is inclusion in the flat-fee package of ancillary procedures. For example, gastric sleeve surgery includes hiatus hernia repair if it is needed: no surprise bill. In some cases, such as penile implant and laparoscopic hysterectomy, we are able to also include third-party products that take financial responsibility in the event of surgical complications. Think of it like getting collision insurance when renting a car.

What explains the variations in package prices?

We are just now starting to see a geographically distributed free market of uniformly defined surgery packages. Surgeons in Houston are looking and seeing prices in Birmingham and adjusting accordingly. So some of the variation is explained by the absence of a transparent market. Variation will probably shrink as price transparency sets in as it has on Surgeo. We see surgeons routinely not wanting to the most expensive.

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.