The Slow, Painful Death of the Doctor-Patient Relationship

The Slow, Painful Death of the Doctor-Patient Relationship

Dr. Mark Siegel appears on a weekly FOXNEWS television show.

Marc Siegel is an American doctor and author. He is an associate professor of medicine at NYU Langone Medical Center, a Fox News medical correspondent, and a columnist for several news outlets, including the New York Post and Forbes.Wikipedia

I’ve been taking care of a particular patient for more than 20 years. She first came to see me after suffering a stroke, which severely weakened her right side. She has always arrived in my office in her wheelchair. She has diabetes, which I manage, as well as a heart condition. I’ve treated her through several urinary and skin infections. I also manage her blood pressure, but mostly I hold her hand and smile and look into her eyes. We talk about our families. She has many grown children, and she has always maintained an active interest in my growing children and remembers their birthdays. Re 

Recently, as she has gotten older and sicker—she is now approaching 90—she has required more frequent hospitalizations and her medical problems have grown more complex. Her family expects me to be responsive to their concerns for every decline in her health. Unfortunately, her decline is taking place at a time when much of health care is delivered semi-automatically without a human face attached. The new technology may even keep her alive longer, but her family is not used to the change. They say it was the frequent face-to-face interactions and instructive phone calls with me that always gave her the confidence to follow my recommendations. But these days my time is so consumed with computer management that I find I have less time for direct patient care. Patient expectations haven’t changed, but there is less time available now to seek the undercurrent of illness rather than focusing on the “chief complaint” that rides the surface. Read more at http://observer.com/2015/07/the-slow-painful-death-of-the-doctor-painter-relationship/#ixzz3gliEGgOL  

With Medicare on the verge of approving payment to doctors for end-of-life discussions, I can’t help but wonder exactly when and where these discussions will take place. Don’t get me wrong, it is as crucial as ever for a doctor to know under exactly what circumstances a patient wants to be placed on a respirator or have someone pound on their chest or shock them with electricity if their heart stops. But it is harder and harder to find the time for such a dedicated conversation. The wheels of health are turning ever forward, in constant step with technical progress and the implementation of exciting new discoveries. Medicare is moored in the nostalgic past, in a time when an ineffable rapport with our patients was the most important thing we had. We need to find a better way to preserve that relationship. Simply asserting its importance isn’t enough.  Read more at 

http://observer.com/2015/07/the-slow-painful-death-of-the-doctor-painter-relationship/#ixzz3glidmDaT Follow us: @newyorkobserver on Twitter | newyorkobserver on Facebook Read more at: http://tr.im/jjOJB

VA hospitals in danger of closing unless lawmakers fix newest funding mess | Fox News

VA hospitals in danger of closing unless lawmakers fix newest funding mess | Fox News

VA hospitals in danger of closing unless lawmakers fix newest funding mess

Is the VA FUBAR ?  The Veterans Administration seems to fumble and fall into the next disaster at least once a year.  Despite a new man at the helm who is a proven expert in consumerism, and the leader of a fortune 500 company another fiasco....this time financial.  Perhaps Congress needs to have it's own committee and the IG keep a ready eye on this mega-operation. 

The VA is still managing post Vietnam PTSD and now has a new wave of Desert Storm, Iraqi, and Afghanistan warrriors who have returned home.  

Why can't the VA get it correct......Medical care seems to be up to par, if veterans can get in, and the Congress keeps funds flowing.

Over a Quarter-Million Vietnam War Veterans Still Have PTSD | Science | Smithsonian

Over a Quarter-Million Vietnam War Veterans Still Have PTSD | Science | Smithsonian

The 49 Best Health and Fitness Apps of 2015 | Greatist

The 49 Best Health and Fitness Apps of 2015 | 

Here it is....all you have been looking for health and fitness on your phone, tablet, wearables.

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This information is not intended as medical device recomendation and we do not endorse any product. It is intended as a reference source.  None of these products have been approved by the FDA, nor is their reliability.

Statistics, Statistics, Lies and More Damn Lies, or is it just Ignorance ?

Health Care     A Tree of Life

It is becoming harder to surf the web looking for health related article without stumbling over another article about  HIT and Data. So here is the latest finding.

• Percent of adults who had contact with a health care professional in the past year: 82.1%
• Percent of children who had contact with a health care professional in the past year: 92.8%
• Number of visits (to physician offices, hospital outpatient and emergency departments): 1.2 billion

Source: Selected patient and provider characteristics for ambulatory care visits to physician offices and hospital outpatient and emergency departments: United States, 2009-2010[PDF - 127 KB]

• Number of visits (to physician offices, hospital outpatient and emergency departments) per 100 persons: 408.2

Source: National Ambulatory Medical Care Survey: 2010 Summary Tables, table 1[PDF - 382 KB]
National Hospital Ambulatory Medical Care Survey: 2010 Outpatient Department Summary Tables, table 1[PDF - 330 KB]
National Hospital Ambulatory Medical Care Survey: 2010 Emergency Department Summary Tables, table 1[PDF - 481 KB]

E pluribis Unum

Freedom is one of the features of a nation known for  "exceptionalism" . The term we all have heard is used as a global adjective to describe the United States.  In truth we do not excel in many areas.

In health we do excel in research and development and technology as applied to medicine. We fail miserably in access to health care and the bureaucracy surrounding it. We probably earn a C- in regard to social programs, not that we don't invest billions of dollars into helping certain segments of society to survive with basic necessities of life, food, shelter (inadequate) and a safety net for health-care.

Fee-for-Service is not Dead.......It is not even Wounded

Most industry leaders believe that, in the near future, fee-for-service payment will be replaced by “population-based payment,” intended to reduce incentives to over-treat patients and to encourage prevention. However laudable these goals, we believe the expected shift to population-based payment is unlikely to materialize.

We take population-based payment to mean time-limited fixed per-capita payment for a defined population of covered lives. Much of the inevitability of the trend toward population health is attributed to the Medicare ACO/Shared Savings programs created by the Affordable Care Act. The accountable care organization has been touted as the eventual successor to DRG and Part B payments in regular Medicare. Medicare's ACO programs now cover about 8 million of its beneficiaries (compared to 17 million in Medicare Advantage).

While advocates in the CMS claim hundreds of millions in savings (in an overall program spending more than $600 billion a year), the Pioneer ACO program and its much larger younger sister, the Medicare Shared Savings program, have struggled to gain industry acceptance. Medicare ACOs have so far had minimal impact in reducing costs. (PDF)Managed-care veterans (hospital- and physician-based) that have succeeded in Medicare Advantage or commercial HMO markets have largely failed with ACOs.

After a decade of experimentation, the pattern in these ACO programs is that a small fraction of ACOs generate most of the bonuses, and that excessively high prior Medicare spending, rather than excellent infrastructure and clinical discipline, may be the real reason for those successes. For the majority of ACOs, the return on investment for setting up and operating them is negative and likely to remain so. The recently issued ACO regulations did not materially improve the ROI calculus. In our view, it is extremely unlikely that ACOs will evolve into a “total replacement” for regular Medicare's current payment model.

Kaufman

On the commercial side, about 15 million patients participate in ACO-like commercial insurance contracts. More than 90% are so-called “one-sided” contracts, where there is no downside risk for providers who miss their spending targets. Yet some providers are giving up 30% discounts upfront to enter commercial ACOs that are really narrow-network PPOs. The discounts function as withholds with an earn-back if providers can meet spending and quality targets.

The commercial ACO deals we've looked at are one-sided in more than one sense: they frequently limit future rate increases, so nearly all inflation risk is borne by providers. As structured, they are a no-lose proposition for insurers that deliver real benefits to providers only if their competitors are excluded from the networks. Shifting more insurance risk to providers is unnecessary since insurers have already shifted a large amount of the first-dollar risk to patients (and therefore providers) through deductibles and copayments.

Moreover, with commercial medical-cost growth trends continuing in the mid-single digits, there is no cost emergency requiring a major change in insurers' contracting strategy; the present hybrid discounted fee-for-service model is doing its job. Deeply discounted fee-for-service with a small fraction of payments tied to “performance'” is not population health.

While many healthcare executives have embraced population health in concept, it is our experience that many of their physicians are not participating in a meaningful way. A recent RAND study of clinician acceptance of these models concluded that they have not substantially changed how physicians deliver face-to-face care, and that the additional nonclinical work required (mostly documentation) is perceived to be irrelevant to patient care.

Economists remind us that pursuing a given strategy means sacrificing gains from pursuing alternatives—the concept of “opportunity costs.” Not only are the potential gains from public or private ACO models limited, but the opportunity costs are steep. For hospitals and systems, they include recruiting and retaining physicians; improving hospital operations and profitability; reducing patient risk and improving their clinical experience; and commitment of clinician time to actual practice. Squandering scarce resources on a low-payoff strategy could prove costly for many health systems.

As industry veterans well know, our field is prone to periodic spasms of groupthink. The inevitability of population health is one of them. Though some may succeed in mastering population-health models, fee-for-service is likely to remain the core of the U.S. healthcare payment system for some time to come.

Jeff Goldsmith is president of Health Futures and an associate professor of public health sciences at the University of Virginia. Nathan Kaufman is managing director of Kaufman Strategic Advisors.