Dr. Ed Pullen is a family physician who sees patients at Sound Family Medicine in Puyallup, WA. The following piece is excerpted from a previously published post on his blog, DrPullen.com.
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Twice a year, each of the major health insurance plans sends me a report card showing how I compare to my peers on prescribing generic medications, formulary medications, and overall cost of medications. For a few years, I always felt good about these reports. I consistently look favorable when compared to my peers. I figured I was doing my part to control the cost of health care. I don’t believe that having good insurance and being able to afford the higher tier co-payments for brand name expensive meds is a good enough reason to skip less expensive generics when I have reason to believe the less expensive meds will be more efficacious. I try to be both informed and conscientious in attempting to manage the costs of prescriptions for my patients. Probably as a result I always look pretty good on the comparison graphs.
Diabetes is one of the conditions where use of only generic medications simply will not get many patients to the goals we are encouraged to pursue. I am proud to be a Diabetes NCQA and Bridges to Excellence Diabetes Recognized Provider, but am certain this would not be the case if I didn’t prescribe the medications I’m encouraged to find alternatives for on these report cards. I’m also encouraged to substitute an ACE inhibitor for any patients I have on an angiotensin receptor blocker (ARB). I know that I rarely prescribe an ARB to patients who have not had unacceptable side effects, usually refractory cough, from an ACE inhibitor. I am reminded of the minority of my patients who are on trade name SSRIs or SNRIs for depression, and non-generic statins. Most of these have been prescribed by their psychiatrists or their cardiologists, and it is difficult for the primary physician to get these substituted if the patient is at goal for their LDL numbers, or is doing well from a mental health standpoint.
Overall, now I look at these reports as what I believe they really are, marketing propaganda insurers use to show prospective large company buyers of their product what they are doing to keep the costs of medical care low. What I’d really like to see is more helpful information from insurers, like which of my consultants spends more money than others in treatment of various conditions. Then I can use the information insurers are the best at collecting to refer patients to specialists whom I believe provide quality care (which I am better positioned to judge than the insurers), and who are cost-conscious as well.
I’d also like to have insurance companies contact my patients directly to get them to have their preventive services done. Rather than scold me for not having all my female patients between the ages of 50 and 65 up-to-date on their mammograms, why not notify them and ask them to see me for an examination and referral? I am already working hard on my patients' health and disease management. Third party payers could make better use of their data than merely sending me report cards on costs of my prescriptions. They could be encouraging patients to get their preventive and disease management care done, too.
Tuesday, September 14, 2010
Thursday, September 9, 2010
Required reading
"Lessons from the Mammography Wars" is a terrific commentary by physicians Kerianne Quanstrum and Rodney Hayward that appears in today's New England Journal of Medicine. After recapitulating the now-familiar controversy that ensued last November when the U.S. Preventive Services Task Force determined that the decision to begin breast cancer screening for a woman in her 40s should be an individual choice rather than a mandatory requirement, the authors succinctly explore the concept of "gray areas" in the assessment of the net benefit of a health intervention and suggest that a policy of separating self-interest from guideline creation (which does not occur when breast imaging societies make guidelines regarding mammography) would be most likely to benefit patients. Here are two of my favorite passages:
Recent proposals to increase spending on comparative-effectiveness research are certainly laudable, but it is unrealistic to think that an investment in research alone will have a sizable effect on the practice of medicine without a concomitant investment in a credible process for vetting medical evidence and clinical care guidelines.
If there is overutilization in health care, we can be sure that it will continue unabated as long as those with a vested interest are allowed to win the public-relations wars by shouting about "rationing" or "death panels" whenever anyone suggests that more health care, in fact, may not be better.
The entire article, in fact, should be required reading for health policy makers, clinicians, and informed patients.
Recent proposals to increase spending on comparative-effectiveness research are certainly laudable, but it is unrealistic to think that an investment in research alone will have a sizable effect on the practice of medicine without a concomitant investment in a credible process for vetting medical evidence and clinical care guidelines.
If there is overutilization in health care, we can be sure that it will continue unabated as long as those with a vested interest are allowed to win the public-relations wars by shouting about "rationing" or "death panels" whenever anyone suggests that more health care, in fact, may not be better.
The entire article, in fact, should be required reading for health policy makers, clinicians, and informed patients.
Monday, September 6, 2010
Quality assessment in primary care: an imperfect science
Several years ago, when I was a very junior faculty member at a well-regarded medical school, I was asked to give a lecture to first-year students about, among other things, medical licensure and specialty board certification. I considered this task to be unenviable because these processes 1) are boring; and 2) don't happen until after medical school graduation, and thus are probably the last things on the minds of first-years who are spending most of their waking hours memorizing anatomical and biochemical trivia.
So, to get them interested, I began the lecture with a question: how does society assure that medical schools like their own produce "good" doctors who are worthy of the trust that patients have traditionally placed in them? More to the point, how do processes such as licensure and board certification assure the quality of practicing physicians? As it turns out, not well at all. Only the worst offenders (doctors who abuse or divert prescription painkillers, for example) are typically disciplined by state medical boards, and there was no publicly available information then or now that would allow an average citizen to determine how his or her doctor measured up against others.
More recently, in an attempt to provide feedback about their performance, some institutions have started giving primary care (and other) physicians "report cards" that summarize their performance on objective measures of care quality; for example, what percentage of patients with a hypertension diagnosis met blood pressure goals at their most recent visits. In theory, this type of reporting should motivate physicians who receive lower scores than their peers to improve their practices, and, therefore, the quality of care they provide their patients.
A few weeks ago, general internist Danielle Ofri, MD, PhD (a frequent guest contributor to Common Sense Family Doctor) wrote a commentary in the New England Journal of Medicine that portrayed current methods for assessing quality in individual primary care physicians as inadequate and potentially misleading. Ofri writes:
Quantitative analysts ... will see it as a sign of medical arrogance that physicians insist that everyone simply trust us to do the right thing because we are such smart and noble people. I've always wanted to ask these analysts how they choose a physician for their sick child or ailing parent. Do they go online and look up doctors' glycated hemoglobin stats? Do they consult a magazine's Best Doctor listing? Or do they ask friends and family to recommend a doctor they trust? That trust relies on a host of variables - experience, judgment, thoughtfulness, ethics, intelligence, diligence, compassion, perspective - that are entirely lost in current quality measures. These difficult-to-measure traits generally turn out to be the critical components in patient care.
Notwithstanding the firestorm of blog responses that Dr. Ofri's editorial provoked (most of whom misunderstood her as arguing for discarding quality measurement in general, rather than the crude tools being used to measure it in primary care), she has a point. Quality measurement in primary care needs to move beyond what is easy to measure. For example, current metrics target underuse of health services (e.g. not ordering enough recommended screening tests) rather than overuse (e.g. ordering tests too often or for no good reason). They have a myopic focus on individual chronic conditions rather than assessing overall quality of care for a patient with multiple diseases, where some disease-oriented goals might be inappropriate. They provide retrospective information rather than real-time feedback. And they fail to measure at all many of the personal qualities that most patients would agree are essential to a good primary care physician.
This doesn't mean that we should throw up our hands and stop trying. Not at all - in fact, I think it's critical for family physicians to be open to novel methods of quality measurement to in order to support our role in the changes that will be taking place in the U.S. health system over the coming years and decades. As I've said in this blog again and again, there will be no real health reform without meaningful investment in good primary care. To that statement I now add this corollary: there will be no meaningful investment in good primary care until we develop much better tools to measure what, exactly, good primary care is.
So, to get them interested, I began the lecture with a question: how does society assure that medical schools like their own produce "good" doctors who are worthy of the trust that patients have traditionally placed in them? More to the point, how do processes such as licensure and board certification assure the quality of practicing physicians? As it turns out, not well at all. Only the worst offenders (doctors who abuse or divert prescription painkillers, for example) are typically disciplined by state medical boards, and there was no publicly available information then or now that would allow an average citizen to determine how his or her doctor measured up against others.
More recently, in an attempt to provide feedback about their performance, some institutions have started giving primary care (and other) physicians "report cards" that summarize their performance on objective measures of care quality; for example, what percentage of patients with a hypertension diagnosis met blood pressure goals at their most recent visits. In theory, this type of reporting should motivate physicians who receive lower scores than their peers to improve their practices, and, therefore, the quality of care they provide their patients.
A few weeks ago, general internist Danielle Ofri, MD, PhD (a frequent guest contributor to Common Sense Family Doctor) wrote a commentary in the New England Journal of Medicine that portrayed current methods for assessing quality in individual primary care physicians as inadequate and potentially misleading. Ofri writes:
Quantitative analysts ... will see it as a sign of medical arrogance that physicians insist that everyone simply trust us to do the right thing because we are such smart and noble people. I've always wanted to ask these analysts how they choose a physician for their sick child or ailing parent. Do they go online and look up doctors' glycated hemoglobin stats? Do they consult a magazine's Best Doctor listing? Or do they ask friends and family to recommend a doctor they trust? That trust relies on a host of variables - experience, judgment, thoughtfulness, ethics, intelligence, diligence, compassion, perspective - that are entirely lost in current quality measures. These difficult-to-measure traits generally turn out to be the critical components in patient care.
Notwithstanding the firestorm of blog responses that Dr. Ofri's editorial provoked (most of whom misunderstood her as arguing for discarding quality measurement in general, rather than the crude tools being used to measure it in primary care), she has a point. Quality measurement in primary care needs to move beyond what is easy to measure. For example, current metrics target underuse of health services (e.g. not ordering enough recommended screening tests) rather than overuse (e.g. ordering tests too often or for no good reason). They have a myopic focus on individual chronic conditions rather than assessing overall quality of care for a patient with multiple diseases, where some disease-oriented goals might be inappropriate. They provide retrospective information rather than real-time feedback. And they fail to measure at all many of the personal qualities that most patients would agree are essential to a good primary care physician.
This doesn't mean that we should throw up our hands and stop trying. Not at all - in fact, I think it's critical for family physicians to be open to novel methods of quality measurement to in order to support our role in the changes that will be taking place in the U.S. health system over the coming years and decades. As I've said in this blog again and again, there will be no real health reform without meaningful investment in good primary care. To that statement I now add this corollary: there will be no meaningful investment in good primary care until we develop much better tools to measure what, exactly, good primary care is.
Thursday, September 2, 2010
Writing awards
I've mentioned previously that Common Sense Family Doctor started as the result of a science writing workshop taught by David Taylor at The Writer's Center in Bethesda, Maryland in the summer of 2009.
Earlier in the same year, I took a workshop in prose writing, taught by novelist Nancy Lemann. During this workshop, I wrote a piece titled "Failure to Progress" that chronicled the true story of my son's birth and the somewhat fictionalized impact of that experience on my career as a family physician and writer. I learned today that a revised version of "Failure to Progress" has won 3rd place in the Prose category of the 2010 Family Medicine Education Consortium (FMEC) Creative Writing Awards. Pretty exciting stuff, since the last time I won an award for non-scientific writing was in high school!
After this piece is officially published at the FMEC Northeast Region Meeting at the end of October, I plan to post it on this blog.
Earlier in the same year, I took a workshop in prose writing, taught by novelist Nancy Lemann. During this workshop, I wrote a piece titled "Failure to Progress" that chronicled the true story of my son's birth and the somewhat fictionalized impact of that experience on my career as a family physician and writer. I learned today that a revised version of "Failure to Progress" has won 3rd place in the Prose category of the 2010 Family Medicine Education Consortium (FMEC) Creative Writing Awards. Pretty exciting stuff, since the last time I won an award for non-scientific writing was in high school!
After this piece is officially published at the FMEC Northeast Region Meeting at the end of October, I plan to post it on this blog.
Saturday, August 28, 2010
Care management for chronic health conditions
When my three-year old son began having recurrent coughing fits and shortness of breath after exercise, my wife and I knew the probable diagnosis. We made an appointment with our family doctor who confirmed that our son, indeed, had asthma. After prescribing medications to prevent and manage the symptoms, our doctor would have—had we not been medical professionals—taken just 10 or 15 minutes to explain how to administer the medications and avoid triggers like tobacco smoke, mold, pollen, and hairy pets. She would have also had to cram in lessons on recognizing the early warning signs of an asthma attack, what actions to take to treat it, and when to call the office or go straight to the emergency room.
Our son's doctor didn't have go into detail about any of those things and, given her crowded waiting room, I suspect she was grateful. But what about the 7 million other parents whose children are diagnosed with asthma? Or those who live with chronic conditions like diabetes and heart disease who don't have the benefit of medical school training?
One solution that's becoming more widespread: care management or disease management programs now offered by many health insurance plans and some large employers like IBM to help patients manage their care between doctor's visits. Basic programs generally offer round-the-clock telephone or e-mail access to health educators and informational brochures. More intensive programs may include home visits by nurses and/or remote monitoring of pharmacy usage to keep track of prescriptions written by multiple physicians. Employers and health insurance companies hope to benefit in the long run by keeping employees on the job and defraying costs of multiple hospitalizations for poorly managed conditions.
Patients at Johns Hopkins Hospital in Baltimore can, as outpatients, enroll in the hospital's ambitious Guided Care program. A specially trained nurse in each primary care practice affiliated with Hopkins coordinates care from various specialists—for those with multiple health problems—making sense of various, sometimes contradictory, care instructions. The nurse also provides individualized counseling on diet, exercise and medications, and links the patient to nutritionists and physical activity programs. Recent studies have shown that the Guided Care program improves patients' perceived quality of health care and their satisfaction; it isn't yet known, however, whether it results in fewer emergency room visits and hospitalizations.
Unfortunately, most care management programs haven't been subjected to the same degree of scientific scrutiny, so it's not clear which components help patients most. In order for you or your loved one to get the most out of a care management program, I recommend that you do the following:
1) Make sure to tell your doctor that you've enrolled in a program and provide the name and contact information. Insurance companies and employers who provide care management programs don't necessarily keep patients' individual physicians in the loop.
2) Find out from your doctor what's unique about your condition and relay that to your care manager. Chances are you deviate somewhat from the "typical" patient with your condition. Everyone has a different mix of symptoms, concurrent health problems, and medical history, so find out where you deviate from the norm.
3) Check with your doctor about the accuracy of any educational materials you receive. Such materials are usually generic and not meant to cover every conceivable situation.
4) Peruse your local library. You'd be amazed how many health books are out there for every conceivable condition. Becoming more informed about your chronic health conditions not only helps you manage them better but also gives you the freedom to worry less about day to day complications, allowing you to live each day more fully.
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The above post is an excerpt from "Multiple Health Problems? Try Care Management," first published on my Healthcare Headaches blog on USNews.com.
Our son's doctor didn't have go into detail about any of those things and, given her crowded waiting room, I suspect she was grateful. But what about the 7 million other parents whose children are diagnosed with asthma? Or those who live with chronic conditions like diabetes and heart disease who don't have the benefit of medical school training?
One solution that's becoming more widespread: care management or disease management programs now offered by many health insurance plans and some large employers like IBM to help patients manage their care between doctor's visits. Basic programs generally offer round-the-clock telephone or e-mail access to health educators and informational brochures. More intensive programs may include home visits by nurses and/or remote monitoring of pharmacy usage to keep track of prescriptions written by multiple physicians. Employers and health insurance companies hope to benefit in the long run by keeping employees on the job and defraying costs of multiple hospitalizations for poorly managed conditions.
Patients at Johns Hopkins Hospital in Baltimore can, as outpatients, enroll in the hospital's ambitious Guided Care program. A specially trained nurse in each primary care practice affiliated with Hopkins coordinates care from various specialists—for those with multiple health problems—making sense of various, sometimes contradictory, care instructions. The nurse also provides individualized counseling on diet, exercise and medications, and links the patient to nutritionists and physical activity programs. Recent studies have shown that the Guided Care program improves patients' perceived quality of health care and their satisfaction; it isn't yet known, however, whether it results in fewer emergency room visits and hospitalizations.
Unfortunately, most care management programs haven't been subjected to the same degree of scientific scrutiny, so it's not clear which components help patients most. In order for you or your loved one to get the most out of a care management program, I recommend that you do the following:
1) Make sure to tell your doctor that you've enrolled in a program and provide the name and contact information. Insurance companies and employers who provide care management programs don't necessarily keep patients' individual physicians in the loop.
2) Find out from your doctor what's unique about your condition and relay that to your care manager. Chances are you deviate somewhat from the "typical" patient with your condition. Everyone has a different mix of symptoms, concurrent health problems, and medical history, so find out where you deviate from the norm.
3) Check with your doctor about the accuracy of any educational materials you receive. Such materials are usually generic and not meant to cover every conceivable situation.
4) Peruse your local library. You'd be amazed how many health books are out there for every conceivable condition. Becoming more informed about your chronic health conditions not only helps you manage them better but also gives you the freedom to worry less about day to day complications, allowing you to live each day more fully.
**
The above post is an excerpt from "Multiple Health Problems? Try Care Management," first published on my Healthcare Headaches blog on USNews.com.
Monday, August 23, 2010
Air, space, and primary care checklists
There is a mesmerizing - some would say hypnotic - air traffic control display at the National Air and Space Museum in Washington, DC that shows the flight paths of every airplane over the United States during a 24-hour period in 2006. At any given moment, up to 6,000 planes were in the air, and the total number of flights numbered in the many tens of thousands. Immediately after the 9/11 terrorist attacks, air traffic controllers were instructed to land every one of them at once. And miraculously, they were able to do so without a single runway collision or plane running out of fuel.
After reading Harvard surgeon Atul Gawande's bestselling book The Checklist Manifesto several months ago, I learned that a feat that seemed miraculous to an outsider really wasn't. Since the early days of aviation, when planes became too complex for even the most experienced pilots to control without making an occasional devastating error of judgment or omission, pilots have depended upon checklists to manage both routine tasks and once-in-a-lifetime emergencies, such as last year's "Miracle on the Hudson" landing of a crippled US Airways jet in the Hudson River in which every passenger was rescued. Gawande's book goes on to describe how checklists have revolutionized industries as far apart as skyscraper construction and his own studies of safety in surgery.
Since reading Gawande's book, I've thought about how checklists might be applied to improve the performance and efficiency of primary care. On one hand, we already have many checklist-type procedures in family medicine: obtaining vital signs (which can include smoking status and body mass index in addition to height, weight, temperature, and blood pressure), paper or electronic applications that help family physicians to remember recommended immunizations, screening tests, checklists for diabetes care, and so forth. And through trial and error while developing the patient-centered medical home, we've found that regular practice meetings called "huddles" can serve much the same purpose as a surgical team organizing itself for a major operation.
On the other hand, primary care is, by nature, inherently less predictable than surgery or construction or piloting a commercial airliner. Beyond patients scheduled for health maintenance visits or chronic care checkups, we are trained to expect the unexpected, never knowing who is going to walk into the door on any given day with a limp, fracture, shortness of breath, chest pain, or other undifferentiated symptom, each with its own particular diagnostic approach. How can we possibly design a checklist for these? Does it even make sense to do so? I'd love to hear your ideas.
After reading Harvard surgeon Atul Gawande's bestselling book The Checklist Manifesto several months ago, I learned that a feat that seemed miraculous to an outsider really wasn't. Since the early days of aviation, when planes became too complex for even the most experienced pilots to control without making an occasional devastating error of judgment or omission, pilots have depended upon checklists to manage both routine tasks and once-in-a-lifetime emergencies, such as last year's "Miracle on the Hudson" landing of a crippled US Airways jet in the Hudson River in which every passenger was rescued. Gawande's book goes on to describe how checklists have revolutionized industries as far apart as skyscraper construction and his own studies of safety in surgery.
Since reading Gawande's book, I've thought about how checklists might be applied to improve the performance and efficiency of primary care. On one hand, we already have many checklist-type procedures in family medicine: obtaining vital signs (which can include smoking status and body mass index in addition to height, weight, temperature, and blood pressure), paper or electronic applications that help family physicians to remember recommended immunizations, screening tests, checklists for diabetes care, and so forth. And through trial and error while developing the patient-centered medical home, we've found that regular practice meetings called "huddles" can serve much the same purpose as a surgical team organizing itself for a major operation.
On the other hand, primary care is, by nature, inherently less predictable than surgery or construction or piloting a commercial airliner. Beyond patients scheduled for health maintenance visits or chronic care checkups, we are trained to expect the unexpected, never knowing who is going to walk into the door on any given day with a limp, fracture, shortness of breath, chest pain, or other undifferentiated symptom, each with its own particular diagnostic approach. How can we possibly design a checklist for these? Does it even make sense to do so? I'd love to hear your ideas.
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