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The Myriad Problems with Medicine


There are myriad problems besetting medicine that affect outcomes, medical and financial. One of the inherent ones is that many of these problems have intertwining relationships, making it that much harder to parse out for analysis and improvement. Let's look at a few, keeping in mind our blood pressure.

There are myriad problems besetting medicine that affect outcomes, medical and financial. One of the inherent ones is that many of these problems have intertwining relationships, making it that much harder to parse out for analysis and improvement. Let's look at a few, keeping in mind our blood pressure.

I recently became aware that the American Health Information Management Association offers 12 -- count 'em 12 -- courses in coding that lead to an exam to become a Certified Coding Associate. Any system that requires such expensive and extensive effort for an arguable result, seems to me, to coin a phrase, "Nuts." Especially with the ICD-9 in all its befuddling complexity due to be replaced in 2013 with the order-of-magnitude more daunting ICD-10.

Many doctors confess to essential ignorance of the whole coding process, leaving this vital area for reimbursement to semi-trained, front-office staffers who have no skin in the game. This is a powerful driver to paradoxically run up the cost of healthcare, while minimizing the net amount of money doctors earn for treating patients.

It’s also yet another argument for scrapping the fee-for-service system in favor of a salaried approach. Then everyone could use a simple descriptor for diagnosis and treatment that does not require a trained staffer or a supplementary education for the already task-overwhelmed physician. It is the doctor who knows what service he or she performed, not a second-party staffer -- even one blessed with the above mentioned certificate. It's another case of, "Who are you going to believe, me or your eyes?"

If that problem wasn't enough to get you going, how about the whole ugly area of "referral silence”? The American Medical Association recently published stats that quantify what practicing doctors know in their gut: 70% of primary care physicians (PCPs) said they send information on their referred patients to the specialists, but only 35% of the self-same specialists polled said that they received anything! Not surprisingly, 80% of specialists said they send referring PCPs a follow-up note, while only 60% of the PCPs polled said they ever got one. That seems about right, based upon my experience.

To confuse matters further, there is no standard for what, when or how each group should fill their obvious responsibilities to the other. I once sent out a questionnaire to the 200 (!) specialists that my group of 15 had referred to in the previous year, asking the same questions about how and what or whether they wanted supplemental information on patients. Amazingly, considering how economically important our referrals were to some of those folks, only a third even responded. Those who did respond were all over the map, showing no clear preferences at all. The result? Poorer medical care due to the delay in accessing patient records, and some unnecessary repetitive testing.

One unintended result is a re-routing of future referrals from the nonresponsive, costing some specialists a lot in lost revenue. Oh, and by the way, I never received one follow-up from any of the specialists queried. No "Thanks for the new business!" or "Why did you stop referring to me?" or "What did your survey show?" or "What would you like me to do now?" Amazing, as I said.

Now that I've got your attention, and your heart rate elevated, let's look at the area of rechecks and follow-ups. They are important for many medical outcome reasons that we're all familiar with, so I won't go there. But let's look at the economic impact. I have heard business lecturers recommend them solely as a way to build a practice, improve patient satisfaction and drive revenue. Cynical, I'm afraid, but they are right.

On the managed-care side, the "unnecessary" costs of this practice of questionable rechecks are avoided by having the doctor, or even more cost effectively, a nurse, physician’s assistant, etc., make the call or email. Better care and more patient satisfaction without the hassle and expense of an office visit for many. Enough savings are involved to have made this switch a fixture going forward.

Another breakdown point, only now being addressed head-on, is the appalling re-admission rate of recently discharged (30 days or less) hospital patients. This costs the patient and the system, rather than the physician, whose activity and fees are usually inadvertently supplemented. And outcomes certainly suffer.

Again, the AMA has recently released stats, this time showing that some Medicare diagnoses, such as congestive heart failure, have 30-day readmit rates as high as 30%. And it turns out that this rate can be halved simply by a more-attentive program by doctors and the nursing staff of pre-release prep for the patient and/or the family. Sometimes it’s just as simple as making sure that there is a follow-up visit scheduled, instead of asking or hoping the patient will make one.

For instance, some two-thirds of re-admits seems to be related to drug issues, confusion, wrong dosage or timing of dosing, adverse drug interactions, and etc. All are easily prevented or corrected with attention. My experience is that everyone, from insurance company, to administration to nursing staff to doctor to patient want to have the discharge as soon as possible and move on. Fair enough. But that's where aligned wishes too often can overcome thoughtful planning and patient preparation. Happily, there is good evidence that improving the process works for the betterment of patient outcome and long-term cost savings.

And so it goes. There are other areas of correctible, irrational process that are being addressed and I will be happy to visit them with you. That is after we've had our blood pressures checked. Holy systole!

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Victor J. Dzau, MD, gives expert advice
Victor J. Dzau, MD, gives expert advice