Direct Primary Care as an alternative Payment Plan

Our health system has grown into a size that is no longer self supporting. Most of our care is in an outpatient setting which should be very inexpensive The chart below displays the huge diifferences in cost.  Just by eliminating the administrative positions in an office decreases overhead by 50% or more

Paul Thomas MD, physician-owner of Plum Health, a DPC practice in inner-city Detroit understands the needs of economically disadvantaged patients. “I intentionally selected a health professional shortage area as a place to start and grow my medical practice,” he says. “I believe that the DPC model gets us closer to the goal of truly affordable health care for our patients and communities.”

But DPC practices don’t just serve patients in inner-cities and suburbia. Donna Givens, MD, is the physician-owner of Grant’s Pass Family Medicine in rural Oregon. “Most of my patients are in the gap between qualifying for Medicaid and being able to afford insurance,” she says.

DPC practices can also provide a safety net for minority patients. Belen Amat, MD, the owner of Direct Primary Care of West Michigan, estimates that 70 percent of her patients are primarily Spanish-speaking.

Across this country, DPC practices are filling an important niche by providing care for underserved patients. But rather than indenturing themselves to a government or corporate entity, physician-owners of DPC practices are providing care on their own terms, without bureaucratic headaches and red-tape frustrations.

Direct care cuts out third-party payers like Medicare, Medicaid, and insurance companies. Instead, patients pay the doctor directly, usually through a monthly fee, which averages $77 for DPC practices.

Because direct care doctors are not beholden to the insurance company, they spend less time on unnecessary documentation and more time on patients. And because doctors don’t have to spend a fortune trying to get paid by an insurer, they can often keep their overhead remarkably low, passing savings along to patients.

It is easy to criticize a new model if you don’t really understand what DPC doctors do. The Journal of the American Medical Association (JAMA) argued that DPC is structurally flawed, in that it incentivizes physicians to accept healthier patients.

But this argument does not match with the reality that many DPC practices experience. In my practice, most patients have multiple chronic illnesses — the very reason they see the benefit in paying a monthly membership for care. New patients have sometimes been without health care and off medicines for months to years, and require frequent visits to get stabilized.

And many times, rather than being “cherry-picked,” patients come to DPC practices because they have been dismissed from conventional practices. For example, Tiffany Blythe, DO, the owner of Blue Lotus Family Medicine in Kansas City, will accept unvaccinated children who are often unwelcomed into other doctors’ offices. “I’ve found that many anti-vax parents really are trying to do the best they can for their child. They just need education, patience, and support to find their way.” And with the additional time that DPC offers, Blythe has been able to convince some parents to vaccinate their children ultimately. “It takes time to overcome fear with facts,” she notes.

In my practice, I have several patients who were dismissed from their regular doctors. One 80-year-old Medicare patient came to me tearfully with a dismissal letter from her previous doctor in hand. She was “fired” from the practice, she said because she refused to talk to a chronic care coordinator. “I was just tired of them bugging me all the time,” she told me. “They kept calling me, and a nurse would come to my house and tell me the same things my doctor did.”

If you talk to DPC doctors, you will hear many stories like these. Inspirational stories not only of patients accessing affordable, quality health care but also of physicians who are happy to practice medicine again.

DPC offers an alternative practice model for doctors to regain the joy in practicing medicine. When medical students and residents hear DPC doctors talk, they get inspired to practice primary care. And studies are clear: more primary care docs equal better health care across populations.

Affordable care, better patient experiences, better patient outcomes, and physician well-being: the quadruple aim. And this is exactly what direct primary care provides.

PLUM HEALTH BENEFITS

• A direct relationship with your doctor
• Fewer patients = more time with your doctor
• Your health and wellness are the priority
• Call us at any time, email us, or text us
• Save hundreds on labs, imaging, and prescription meds
• Clear and consistent pricing
• Peace of mind

Learn More →

  Direct Payment

Insurance Plan

     The difference in cost is huge. These differences only apply to outpatient vs Hospital Cost.  Hospital charges are difficult to analyze and are maximized because of the manner in which insurance companies reimburse them.                                                                                                                                                                                                                                                                                                

CONVENTIONAL HEALTHCARE

• Rushed appointments
• Doctor's have thousands of patients = less time
• Sometimes you'll have to see a mid-level provider
• Only available during business hours, typically 9 - 5
• 2-10x markup on labs and services
• Services billed at the highest rate possible in order to maximize reimbursement from your insurance company

Learn More →

Pamela Wibble, MD started the Ideal Medical Clinic in Oregon some years ago before anyone knew what Direct Primary Model even existed. Dr Wibble created this practice model because of her own personal experiences with physician suicide. Many physicians 'burn out' because of the moral conflict between the Hippocratic Oath and the necessity of economic realism.

There is No "Routine Procedure"

"Mrs Smith, this is a routine procedure, don't be nervous" How many times have I heard a nurse, or physician tell this to a patient in order to assuage their anxiety. Perhaps we as physicians are saying that to minimize our own anxiety when in fact we all know of the horrendous things that can go wrong during a 'routine procedure' ?

 Martha Wright had her first colonoscopy at Missouri’s Cass Regional Medical Center. She died the next day of internal bleeding, an unusual outcome that has the hospital under extra scrutiny from regulators.

Her Attorney wants accountability

At 83, Martha Wright had never had a colonoscopy, even though government guidelines call for nearly everyone to be screened for colon cancer after age 50.

The Pleasant Hill resident was scared of the test, her daughter Dena Royal said, because she was petite — less than 5 feet tall.

“What she repeatedly said was, ‘I don’t want to have a colonoscopy; it will kill me,” said Royal, a former Kansas City paramedic and respiratory therapist. “We just kind of said, ‘Oh mom, it’s routine, it’s no big deal.’”

Wright had her first colonoscopy Aug. 2 at Cass Regional Medical Center, after a doctor recommended it because she was anemic.

She died the next day of internal bleeding.

Martha Wright celebrated her 80th birthday three years ago in Kansas City.

SUBMITTED PHOTO

It was a highly unusual outcome from a very common procedure that now has the Harrisonville hospital under extra scrutiny from government regulators.

State inspectors came out to investigate Wright’s death in late November after Royal filed a complaint. They found that Wright showed several signs of distress after the procedure, but Cass Regional staff didn’t properly respond. They also said 348 more colonoscopies had been performed there since Wright’s death, without addressing the deficiencies in care.

The inspectors passed their findings to the federal Centers for Medicare and Medicaid, which classified the situation as an “immediate jeopardy” that "placed all patients at the facility at risk.” It’s one of the agency’s most serious designations. If the situation is not promptly addressed, hospitals can lose their ability to bill Medicare.

THE TEST

In a colonoscopy, patients are under general anesthesia while a doctor inserts a small flexible tube with a tiny camera through the patient’s rectum and into the large intestine. It’s a key tool for detecting colorectal cancers, but according to the Centers for Disease Control, about one-third of Americans who should be getting the test aren’t.

Still, it’s one of the most common medical procedures in the United States and it’s usually safe. Serious complications occur in only about 1.6 percent of patients, though experts say that’s still too high, given that millions of colonoscopies are done each year.

Deaths are even more rare.

In one of the largest studies done on the topic, researchers examined 16,318 colonoscopies performed in Kaiser Permanente hospitals between 1994 and 2002. They found only one death they could attribute to the procedure — a rate of 0.006 percent. A 2008 study on Canadian colonoscopy patients came up with a similar number. 

By contrast, the five-year death rate for people with localized colorectal cancer is about 10 percent, and it spikes to almost 30 percent once the cancer spreads to surrounding tissues or organs.

According to the inspection report and medical records provided by Royal, Wright’s colonoscopy was, at least at first, the type everyone wants to get.

There was no sign of colon cancer. There were no polyps to be removed. It was a “clean” test that was “completed without difficulty or complications,” according to medical records reviewed by the inspectors.

Wright was sedated for the procedure, and because she didn’t have anyone to drive her home and watch her for 24 hours, she had to stay at the hospital overnight per Cass Regional policies.

The test was in the morning. By 5 p.m. she was complaining of pain in her left upper abdomen, but said it was tolerable: a 3 on a scale of 1 to 10. By 10:15 p.m. the pain had increased to 7 out of 10 and had spread to her left shoulder. According to medical records, a nurse told her she probably had gas and gave her Tylenol.

The inspection report said this is when nursing staff should have contacted the surgeon to inform him or her of the change in Wright’s condition.

Instead, the doctor wasn’t notified until about 2:30 a.m., when Wright awoke complaining of nausea, clammy skin and shortness of breath, in addition to the abdominal pain. The doctor ordered some tests, including a CT scan, but Wright kept getting sicker.

She was taken to the intensive care unit at 4:50 a.m., but by then she was unresponsive, with no breathing and no pulse. Hospital staff tried CPR, but at 5:14 a.m. Wright was declared dead.

The radiologist who read the CT scan found a “large amount of hemorrhage ... within the abdomen and pelvis,” which the emergency room physician listed as her official cause of death .

“She basically bled to death,” said Aaron Woods, the Lee’s Summit attorney Royal hired.

Royal said she knew something must be wrong when the phone rang early in the morning. But it was still a “gut-wrenching” shock to hear that her mother was dead.

“I mean, my mom was 83 but I thought she still had a lot of life left,” Royal said. “This was just so unexpected.” 

It wasn’t the incident itself that drew the most concern from government officials, though. Medical mistakes happen. Cass Regional rate of re-admitting patients after a colonoscopy is 15.5 per 1,000. That is actually slightly better than the national average (16.4 per 1,000 patients), according to federal data.

What was most concerning to regulators was the hospital’s response. They said Cass Regional officials should have recognized Wright’s death as a “sentinel event” that signaled potentially broader problems, immediately investigated to find out how it happened and then educated staff about how to keep it from happening again.

Instead it was more than a month before the internal investigation started, and “the facility also failed to educate nursing staff in a timely manner,” the federal report said. When staff were eventually trained more on assessing patients’ conditions, it “was informal and without documentation of who attended.”

Cass Regional correction plan includes many policy changes to keep that from happening in the future.

Upon reviewing the case it was apparent that staff failed to notify the surgeon of a change in her postoperative condition shortly after discharge in a timely manner.

Addendum

Several things readers should note:

1. There is no such thing as a routine procedure. Routine only means they do a lot of the procedure. If there is a problem the surgeon will make a note of it. If there is an abnormal postoperative course nurses must notify the responsible surgeon. The surgeon is responsible for making a decision, not the nurse

Familiarize yourself by watching the following videos.*******

Getting Ready for your Colonoscopy

Some things to think about

Colonoscopy woman bled to death. Hospital investigated | The Kansas City Star:

Virginia law aims to save people thousands in cost for emergency medical attention |

Rooftop landing pad for Riverside Community Hospital

Or

Surface travel by EMS

A horseback ride accident leads to thousands in air ambulance medical cost Sonna Anderson was enjoying a horseback ride through the Badlands in North Dakota in September 2017 when her horse, Cody, got spooked, jerked toward a fence and tripped on a cow track in the dirt. The horse rolled onto Anderson, who hit her head, briefly lost consciousness and broke three ribs. The 911 transcript shows that an ambulance reached the 60-year-old judge from Bismarck within 20 minutes. Anderson was secured on a backboard and ready to go when an air ambulance, a helicopter with a medical crew, also landed at the scene. Anderson says her husband asked repeatedly whether the ground ambulance crew could take her by ground; there was a hospital less than an hour’s drive away
“But he was told that [the air ambulance] was necessary. They never told him why it was necessary or how much it cost, but they insisted I had to go by air ambulance,” Anderson said. “But it’s so odd there is nothing in the record that indicated it was time-sensitive or that I needed to be airlifted.”
For that one helicopter ride, to a hospital farther away in Bismarck, records show that Valley Med Flight charged Anderson $54,727.26. Sanford Health Plan, her insurance, paid $13,697.73. That left Anderson with a $41,029.53 bill.

Rural Hospitals Closing

There are large areas of rural America that have become health care deserts. In an effort to contain rising health care costs, CMS has made it economically unobtainable to provide adequate hospitals in rural areas. A number of alternatives are in use, telehealth, remote monitoring, access to lower level providers such as physician assistants and nurse practitioners

Virginia law aims to save people thousands in cost for emergency medical attention | WTKR.com:

These Patients Had Sickle-Cell Disease. Experimental Therapies Might Have Cured Them. - The New York Times

A slide of blood showing abnormal red blood cells (sickle cells). Note the bizarre shapes. Normal red blood cells are round or spherical.  This is caused by abnormal hemoglobin which interferes with the transportation of oxygen to the cells of the body.

Success against sickle-cell would be “the first genetic cure of a common genetic disease” and could free tens of thousands of Americans from agonizing pain.  

Employment can be difficult because the disease is debilitating. Yet many who apply for Social Security disability are denied, Dr. Tisdale said. They end up at emergency rooms when they are in crisis.

And treating the disease, with its complications, is expensive: annual costs per patient are estimated at $10,000 a year for children and $30,000 for adults. Those with the disorder go in and out of hospitals.

Tantalizing science

Doctors and Hospitals Say E-Record Goals Are Unrealistic - The New York Times

This article dates back to the dawn of electronic health records in 2009.  Not much new today, 9 years later. Most medical practices utilize electronic health records despite being unrealistic, inefficient, and reducing physician time with patients.  Most doctors spend their time gazing at a computer screen rather than engaging with their patient face to face.



The feds accomplished their goal. to set up a system whereby they could extract data to analyze.  I have yet to see any studies regarding the use of Electronic Health Records vs ballpoint technology in regard to changes in quality improvement.



The shape of this article give one little hope for following any recommendations by the federal government.  One thing is for certain, those physicians who advised our system were either ignored or they gave bad advice.

WASHINGTON — In February 2009, as part of legislation to revive the economy, Congress provided tens of billions of dollars to help doctors and hospitals buy equipment to computerize patients’ medical records.

But the eligibility criteria proposed by the Obama administration are so strict and so ambitious that hardly any doctors or hospitals can meet them, not even the most technologically advanced providers like Kaiser Permanente and Intermountain Healthcare.

Doctors and hospital executives, who have expressed their frustration in meetings with White House and Medicare officials, said the issue offered a cautionary tale of what could happen when good intentions meet the reality of America’s fragmented health care system.

The goal of the law is to provide financial incentives, through Medicare and Medicaid, to encourage doctors and hospitals to adopt and use electronic health records. When the bill was passed, the Congressional Budget Officeestimated that the incentive payments would total $34 billion.

It is no surprise that tiny hospitals in the Midwest and doctors practicing by themselves would grumble about the White House proposals.

Continue reading the main story

But elite institutions have similar concerns. Among those expressing deep reservations about the proposals are pioneers in the use of health information technology like Kaiser, Intermountain, the Mayo Clinic and Partners HealthCare System in Boston, which includes Brigham and Women’s Hospital and Massachusetts General Hospital.

One of most revealing assessments came from Dr. Thomas H. Lee, president of the physician network at Partners HealthCare.

“Effective use of electronic health records will greatly improve patient safety, quality and efficiency,” Dr. Lee said in a letter to Medicare officials. But he said the approach taken by the administration was based on “unrealistic expectations” and “unachievable timelines.”

“We are very concerned about the requirement that hospitals and eligible professionals must meet each and every one of the objectives to demonstrate meaningful use and thereby qualify for incentive payments,” Dr. Lee said.

In meetings at the White House, doctors and hospital executives have conveyed the same message: the president’s all-or-nothing approach could discourage efforts to adopt electronic health records because some of the proposed standards are impossibly high and the risk of failure is great. They pleaded with the administration to take a more gradual approach and reward incremental progress.

At least 27 senators and 245 House members echoed those concerns in letters to the administration.

Administration officials said they took the concerns seriously, but refused to say whether they would relax the proposed requirements.

“We want to strike a balance,” said Jonathan D. Blum, deputy administrator of the Centers for Medicare and Medicaid Services. “We will provide flexibility for doctors and hospitals, but push them to elevate their performance. Final rules will be out in early summer.”

Anthony A. Barrueta, the vice president for government relations at Kaiser Permanente, said his company, the nation’s largest nonprofit health plan, had years of experience with electronic health records, but could not meet all the criteria for incentive payments.

Dr. Brent E. Wallace, chief medical officer at Intermountain Healthcare, in Utah, said the administration’s criteria were “too rigid, requiring too much change in too short a time.”

Doctors and Hospitals Say E-Record Goals Are Unrealistic - The New York Times: Critics say the Obama administration’s criteria for computerizing medical records are too strict and ambitious.

Transparent Hospital Pricing Exposes Wild Fluctuation, Even Within Miles | California Healthline

The federal government’s new rule requiring hospitals to post prices for their services is intended to allow patients to shop around and compare prices, a step toward price transparency that California has mandated since 2005.

California Healthline examined the price lists — known in hospital lingo as “chargemasters” — of four large acute care hospitals in Oakland, Calif., and another four in Los Angeles, using the documents California hospitals have been reporting annually to the California Department of Public Health — the same information the federal government is now requiring all hospitals to post on their websites.

The comparison of some basic procedures found wide-ranging prices, sometimes between hospitals that are part of the same network or located just miles from each other. For instance, the list price on a liter of basic saline solution for intravenous use ranged from $56 to $383, nearly seven times as much. A brain MRI with contrast was priced from $3,200 to $8,800 at the hospitals.

While more information is always welcome, the new data will fall short of providing most consumers with usable insight.

That’s because the price lists displayed this week, called chargemasters, are massive compendiums of the prices set by each hospital for every service or drug a patient might encounter. To figure out what, for example, a trip to the emergency room might cost, a patient would have to locate and piece together the price for each component of their visit — the particular blood tests, the particular medicines dispensed, the facility fee and the physician’s charge, and more.

“I don’t think it’s very helpful,” said Gerard Anderson, director of the Johns Hopkins Center for Hospital Finance and Management. “There are about 30,000 different items on a chargemaster file. As a patient, you don’t know which ones you will use.”

And there’s this: Other than the uninsured and people who are out-of-network, few actually pay full charges.Whether you will be able to determine the best prices when you have a need for a hospital is another question. KHN senior correspondent Julie Appleby and California Healthline’s Barbara Feder Ostrov recently wrote about this new rule and found price lists befuddling to most anyone without an advanced medical degree.

Harriet Blair Rowan: hrowan@kff.org, @HattieRowan

Transparent Hospital Pricing Exposes Wild Fluctuation, Even Within Miles | California Healthline: A new federal rule requires hospitals to post their prices online. These lists reveal the wildly different charges for basic procedures and services, but consumers will have a hard time putting this information to use.

FDA Approves Verily Health EKG Watch

 

FDA clears Verily’s prescription-only ECG smartwatch

Verily, the Alphabet research division formerly known as Google Life Sciences, has received a 510(k) clearance from the FDA for its own clinical study smartwatch, complete with an on-demand ECG. But as a prescription-only device, it’s far from a competitor to Apple’s publicly availablesmartwatch.

Verily’s Study Watch was first launched as an investigational device in April 2017 to help capture health information from participants in studies such as Project Baseline—a longitudinal venture by Google, Stanford Medicine and Duke University that aims to track 10,000 volunteers for four years using a variety of metrics.

The FDA cleared a new version of the watch as a class II device for adults, including those with known or suspected heart conditions, for use as a single-lead ECG.

“One area of focus for Study Watch has been cardiovascular health, as heart disease remains the No. 1 killer of men and women in the United States,” Verily’s cardiovascular health innovations head, Michael McConnell, wrote in a company blog post.

RELATED: Apple, J&J to put the Apple Watch’s ECG through large-scale clinical testing

“This work may ultimately give us insights into the utility of integrating mobile health data into the clinical care environment, and how these data can support the physician-patient relationship,” McConnell said. Verily plans use both the investigational and the FDA-cleared versions in studies going forward.

Verily recently announced a $1 billion investment round to catapult new global partnerships, business development and potential acquisitions.

On another note:

RELATED: Verily, Alcon halt work on glucose-sensing smart contact lens

The glucose-sensing lens was one of Verily’s first projects, launched in January 2014. Since then, it’s evolved into an electronics platform mounted on a soft contact lens, capable of transmitting data using integrated circuits, sensors, batteries and wireless communication hardware, the company said.

Our take-away for this device is that wearing a contact lens requires signifcant training, and for the inexperienced could lead to corneal infections.  Diabetics are more prone to corneal ulcers.  Technology is one thing, however assessing risks vs benefits are important.  There are now skin sensors which accomplish this monitoring feature without the attendant risks of contact lenses.  Skin monitors can also be easily attached to glucose infusion pumps.

The Future of Global eHealth -

Access to health care providers is not only necessary in the U.S.A. but a necessity for many nations of the world. Access to affordable, effective health care continues to be a major concern for people around the world. But governments that adopt eHealth policies can find ways to use communication and technology advancements to help ensure more people receive better healthcare. Here, we look at government strides in adopting eHealth, the barriers to maximizing eHealth’s full potential, and what some countries have learned along the way. What is eHealth? Electronic health, or eHealth, represents information and communication technologies used by the health sector. These include electronic patient records, remote patient medical care through telemonitoring, and connecting with health practitioners over the phone through telehealth. How did it Start? The Internet There are concerns about the quality of health info patients can access, yet doctors are now realizing the Internet can assist them with their jobs. Patients’ access to internet searches increased their information, which changed their relationship with doctors and created a shift in the patient-provider dynamic. How Widespread is eHealth? A 2015 World Health Organization (WHO) survey revealed 160 WHO member countries have some form of universal health coverage, and 74% of these countries mention eHealth as a component. 153 countries have legislation protecting a person’s privacy data relating to their electronic health record, and 134 countries have a national eHealth strategy or policy. The survey also found that nearly 80% of healthcare organizations in WHO member states use social media to distribute their health messages. Additionally, the survey pinpointed telepsychiatry as the telehealth service that increased the most between 2009 and 2015. How eHealth Can Help Health care systems the world over are facing rising costs, system inefficiencies, access issues, and quality issues. However, these pressures are some of the issues eHealth initiatives aim to solve. These initiatives strive for this goal through many ways. Digitizing personal health information helps build more complete histories. The creation of electronic health records can also make it easy to share patient data between systems. eHealth can also empower patients with their own electronic records and can also be used to implement various telehealth and home health options to improve chronic disease management. The process of adopting eHealth initiatives is not without its core challenges. These include insufficient communication of eHealth goals, concerns regarding system standardization, and a current lack of governance and funding. WHO has also tied the implementation of eHealth to a goal of achieving universal health coverage in remote and underserved communities. However, this takes a lot of work. Some of the Challenges Facing Specific Types of eHealth Telehealth Telehealth uses information and communication technologies to provide advice and reminders, handle remote admissions, and remotely monitor patients directly and remotely. It allows specialists to see more patients, and it makes it easier for remote patients to get services. It can also help cut costs linked to hospital visits and can lower the number of patients that need emergency transfers. There are several challenges to implementing telehealth. These include insufficient system development funding, inadequate equipment and internet-related infrastructure, a lack of synchronicity between health system priorities, and a lack of regulatory guidance.

eLearning Programs These health care training models are conducted online. This helps circumvent potential shortages in necessary instructors, bridges skills gaps amongst some workforces, and makes it possible for isolated care providers to receive needed training. However, there’s a hesitancy to move to less conventional teaching methods, as well as concerns around the existence of suitable eLearning programs. There are also challenges stemming from an HR and funding perspective. Mobile Health This concept utilizes mobile phones, personal digital assistants, and other wireless devices for public health services. It doesn’t require much infrastructure, and it’s cheaper than in-person services. Plus, several low- to middle-income countries still have high cellphone subscriptions. The challenges facing this concept include the cost and functionality of different plan types, as well as insufficient network infrastructure in some places. There are also questions concerning some patients’ digital literacy and the relevancy of the health content. The concept itself is also not always accepted culturally or socially. The Need Ultimately, the key to overcoming these challenges is to treat eHealth as a key part of health planning, and not just as an add-on. After all, a trained workforce proficient in eHealth systems can provide proper leadership and oversight to others. How eHealth is Being Used Globally While there are several challenges to eHealth program implementation, that’s not stopping countries and regions from investing in the concept. The U.S. has contributed the most, followed by the EU, Canada, Japan, and Latin America. One of the biggest ways eHealth is being used is text messaging. For instance, the Stockholm-based blood donation service Blodcentralen uses texts to retain and build its donor pool. They also send out “thank you” texts every time donated blood is used in patient treatment, something that helps people to continue donating. How Some Countries Facilitated the Spread of eHealth England contributed £6 billion to eHealth over a 10-year period with an emphasis on regional deployment. The investment yielded positive dividends relating to data sharing and data entry protocols. However, they realized that clinical implementation and regional-centric adoption is tricky. They also learned sharing health records is ineffective. Canada created a federally funded organization to establish an eHealth blueprint that allowed for regional governance, the establishment of standards, and a focus on electronic health records, telehealth, public health surveillance, and various health systems. The program helped them focus on funding eHealth-related projects, initiatives, and models. Their approached also revealed insufficiencies with record integration, program standardization, and underfunding. The U.S. contributed $30 billion for a host of eHealth-type programs and provided financial incentives for providers who used IT in a “meaningful” way. This program helped to establish Funding Regional Extension Centers to implement this meaningfulness, and it allowed them to acknowledge the need for training, education, and communication to properly adopt eHealth initiatives. Along the way, they learned lessons regarding system connectivity and post-funding support – lessons that can also be learned from observing other countries’ successes and failures. Ultimately, as more countries look to eHealth to provide better healthcare, we’re getting a better sense of what does and doesn’t work. What’s clear is that the health sector has plenty to gain from relying on information and communication technology advancements. Early success stories show that comprehensive strategies, good education and training, and careful program monitoring to see what works and what doesn’t are critical to making the most of what technology can offer.

The Old Days of Medicine are Gone

MICHAEL WEISS, MD | PHYSICIAN | JANUARY 17, 2019


In the last decade, specifically in the last five to six years, we have seen the gradual disempowerment of America’s physicians as well as their unfortunate patients.

Starting with health management organizations, managed care, all the way to the insurance exchange, doctoring has been forcefully wrestled away from physicians only to be placed into the hands of large insurers, administrators and the United States government.

The common denominator was never about improving the quality of care for the American people but rather an obscene money-grabbing agenda by the above powers that be and the pharmaceutical industry.

The writing was always on the wall as physicians’ incomes were and constantly are chiseled away as health insurers and pharmaceuticals continue to explore their limitless profits. It’s evident that physicians whose incomes were strapped, whose costly and highly burdensome administrative responsibilities they were unwittingly strapped with, had no choice but to flee private practice and work for huge conglomerates including hospitals. This further added to their unsurmountable stress levels causing many to exit their professions, experience burnout and even attempt and often succumb to suicides.

Sadly, the Health Train has left the tracks. Health Train was derailed several times during the past decade, sabotaged by health payors, and government regulation.  It picked up speed with constant changes in direction, lack of an engineer, and a motivation to save money by going to fast and for too long.

Like many physicians I have been in the cross hairs, an unwilling target for unrelenting pressure on my practice and others.

There is no going back. We have subjugated ourselves to an incompetent congress.  The recent shutdown of almost 1/2 of the government as a negotiating point for controlling immigration is another example of the distorted mindset of an uncontrolled government far from the rule of the constitution

In the last decade, specifically in the last five to six years, we have seen the gradual disempowerment of America’s physicians as well as their unfortunate patients.

Starting with health management organizations, managed care, all the way to the insurance exchange, doctoring has been forcefully wrestled away from physicians only to be placed into the hands of large insurers, administrators and the United States government.

The common denominator was never about improving the quality of care for the American people but rather an obscene money-grabbing agenda by the above powers that be and the pharmaceutical industry.

The writing was always on the wall as physicians’ incomes were and constantly are chiseled away as health insurers and pharmaceuticals continue to explore their limitless profits. It’s evident that physicians whose incomes were strapped, whose costly and highly burdensome administrative responsibilities they were unwittingly strapped with, had no choice but to flee private practice and work for huge conglomerates including hospitals. This further added to their unsurmountable stress levels causing many to exit their professions, experience burnout and even attempt and often succumb to suicides.

Gone are the Wednesdays off for golf. The health insurance and pharmaceutical executives would soon pick up the battered physicians clubs and golf memberships at a mere fire sale.

Gone are the days when physicians would be called “doctors” instead of “providers” and with it the respect that was once ascribed to the title.

Gone are the days when a patient would ask: “But what does the doctor say?” instead of asking: “Will the insurance pay?”

Gone are the days when a physician can direct the care of the patient or prescribe a medication or service(s), they deemed necessary. Even their prescription pads have lost most of their value as once any prescription reaches the pharmacy it will mostly join the lot of those that will not be covered by insurers.

Gone are the days where health insurance had a certain value. Instead, the ever limiting and continuously more expensive and less valuable commodity has become the new descriptive of having but a false security crutch called health care coverage.

Gone are the days when physicians could perform thorough examinations on their patients. Instead, they have become thorough typists, chaotic clerks, mindlessly clucking away at meaningless electronic health records benefiting only large entities. This mechanical nonsense, in lieu of a meticulous history and physical examination, has become the new norm of a medical visit. Even if a hasty examination is possible, an Orwellian sludge of mandated data entry will rob the physician of most of the time required for any meaningful patient care. It is, therefore, no wonder that this same mindless data entry is also required of nurses as well as well as hospital-based 

physicians. And has, in my opinion, resulted in increased national morbidities and mortalities over the past two years. Please don’t try to convince me of the media-propagated “culprit” being only the opioid epidemic or the increase in suicides that have caused a precipitous increase in mortality and a decline in the health of our nation. If you throw in an average of 400 or more annual physicians’ suicides, it still won’t account for the real culprit.

Gone are the days when physicians have had the luxury of utilizing their scrupulous and meticulous clinical skills of observation. Instead, cookbook guidelines have now become the puppet masters of our national flock of sheepish physicians. I will never forget in one of my first lessons in anatomy during medical school how the importance of “the spirit of observation” is. This article is written with the same “spirit of observation” although my observations have become those of incremental disenchantment and that of a disheartened physician.

Gone are the days when patients would actually have adequate hospital stays. Insurers made sure of that.

Gone are the days when patients would be cured of infections, instead of being kicked out of hospitals prematurely and bringing these agents to their communities, nursing homes, and rehabilitation centers. It is now a quite common corridor these agents have been given the luxury to become resistant, and I believe jumping on a brand-new bandwagon of further increasing our national mortalities.

Gone are the days of reasonable doctor visits and drug co-pays. Instead, copays have now spiraled in sync with unaffordable and growing premiums inversely proportional to the value they bring.

Gone are the days of visiting an emergency room where your immediate illness was their priority. Instead, you will first be required to pay a copay. I’m uncertain what will happen to you and the consequences of this if you do not.

Gone are the days where you could visit a physician without that physician having to worry about your insurance. After all, neither insurance companies, the government or pharmaceutical companies will ever give you anything for free, let alone affordably. Instead, they have encouraged “minute clinic” and the like in drugstores, where a nurse practitioner — and I am confident, soon, a pharmacist — will be gladly doling out medical advice which will further increase morbidities and mortality. Of course, these alternate quick fix options of the poorest quality will save insurers a couple of bucks in the short term. But what is less obvious is that they have put your life on the line to achieve it.

If you take all that is gone you might rightfully ask what is left?

What’s left is certainly not a pretty picture for patients, burned out physicians and our nation’s families at ever-increasing risk.

Physicians’ voices have been drowned out, their plights buried, leaving their patients helpless — all the while as marketing and media have painted a desirable picture of what is in actuality a gray and gloomy disaster waiting to self-destruct.

Where is this all heading? It appears that once the nation will no longer put up and won’t be able to afford further being ravaged by these powerful entities, the latter will never have to worry about counting their loses. It will be our nation and its burned out physicians who will be too busy and distraught doing just that.

Leaving Canada for Medical Care 2017

How are things going in Canada for patients ?  Not too badly, except for long waiting periods

In 2016, an estimated 63,459 Canadians received non-emergency medical treatment outside Canada. Physicians in British Columbia reported the highest proportion of patients (in a province) receiving treatment abroad (2.4%). The largest number of patients estimated to have left the country for treatment was from Ontario (26,513). Across Canada, otolaryngologists reported the highest proportion of patients (in a specialty) travelling abroad for treatment (2.1%). The largest number of patients (in a specialty) travelled abroad for general surgeries (9,454). One explanation for patients travelling abroad to receive medical treatment may relate to the long waiting times they are forced endure in Canada’s health care system. In 2016, patients could expect to wait 10.6 weeks for medically necessary treatment after seeing a specialist—almost 4 weeks longer than the time physicians consider to be clinically “reasonable” (7.0 weeks)

Introduction 
By estimating how many Canadians receive health care outside the country each year, and the type of care they receive, we gain some insights into the state of health care and medical tourism. Canadians who choose to seek treatment abroad do so for several reasons, many of which may relate to their inability to access quality health care in a timely fashion within Canada’s borders. Some patients may be sent out of country by the public health care system due to a lack of available resources or because some procedures or equipment are not provided in their home jurisdiction. Others may choose to leave Canada because they are concerned about quality (Walker et al., 2009) and are seeking more advanced health care facilities, stateof-the-art medical technologies, or better outcomes. Others may leave in order to avoid some of the adverse medical consequences of waiting for care, such as worsening of their condition, poorer outcomes following treatment, disability, or death (Esmail, 2009; Barua et al., 2013; Day, 2013). Some may leave simply to avoid delay and to make a quicker return to normal life. While there is no readily available data on the number of Canadians travelling abroad for health care, it is possible to produce an estimate of these numbers from data gathered through the Fraser Institute’s Waiting Your Turn survey and from the Canadian Institute for Health Information (CIHI), which tallies the numbers of procedures performed in Canada.

Across Canada, otolaryngologists reported the highest proportion of patients (in a specialty) travelling abroad for treatment (2.1%), while the lowest proportion of patients (in a specialty) travelled abroad for ophthalmology (0.8%) (see table 1). Combining these percentages2 (table 1) with the number of procedures3 performed in each province and in each medical specialty gives an estimate of the number of Canadians who likely received treatment outside the country.

Results

Table 2 indicates that a significant number of Canadians—an estimated 63,459 people—may have received treatment outside of the country in 2016. This is a significant increase from the 45,619 who were estimated to have travelled abroad in 2015 (Barua et al., 2016) and also higher than the 52,513 who were estimated to have travelled abroad in 2014 (Barua and Ren, 2015). Increases between 2015 and 2016 in the estimated number of patients going outside Canada for treatment were seen in seven provinces: British Columbia (10,315 to 15,372), Alberta (4,616 to 9,067), Ontario (22,352 to 26,513), Manitoba (702 to 2,052), Quebec (3,360 to 4,603), Saskatchewan (from 712 to 1,888), and Nova Scotia (1,466 to 2,438). Conversely, in that period there was a 2 Readers should note that this calculation uses the exact values, not the rounded values that appear in table 11 in Barua and Ren (2016). 3 Data are for 2014/15 from the Discharge Abstract Database (CIHI, 2016a) and the National Ambulatory Care Reporting System (CIHI, 2016b), and the Hospital Morbidity Database (HMDB) (CIHI, 2016c). For further details see Barua and Ren (2016). decrease in the estimated number of patients who received treatment outside Canada in Newfoundland & Labrador (from 1,151 to 669), Prince Edward Island (52 to 7), and New Brunswick (894 to 851).

Table 2 also shows the estimated number of patients receiving treatment outside of Canada by specialty. For example, we estimate that approximately 9,454 Canadians travelled abroad in 2016 to receive general surgery. On the other hand, we estimate that only about 210 Canadians went abroad to receive radiation oncology treatment in 2016. Limitations There is a temporal mismatch between the timing of the Fraser Institute’s Waiting Your Turn survey and the CIHI’s annual data release. Specifically, procedure counts data used for Waiting Your Turn are typically one year behind (e.g., the 2016 edition of Waiting Your Turn used procedure counts from 2014/2015). While the calculations above use the temporally mismatched procedure counts to provide up-todate information, previous calculations adjusting for the temporal mismatch show that it does not appear to materially affect the trend witnessed in the overall count of Canadians. However, it does, as expected, affect the actual counts of Canadians (Esmail, 2007).4

The number of patients receiving treatment outside Canada each year produced by this methodology is likely to be an underestimate. This is the result of a few factors. Most impor4 Specifically, the Canadian counts with the temporal mismatch for 2004, 2005, and 2006 were 49,392, 44,022, and 39,282, respectively. Accounting for the mismatch, the counts for 2004 and 2005 were

Discussion

These numbers are not insubstantial. They point to a sizeable number of Canadians whose needs and health care demands could not be satisfied within Canada’s borders. There are a number of possible reasons why this may have been the case. Some patients may have been sent out of country by the public health care system due to a lack of available resources or the fact that some procedures or equipment are not provided in their home jurisdiction. Others may have chosen to leave Canada in response to concerns about quality (Walker et al., 2009), seeking more advanced health care facilities, more state-of-the-art medical technologies, or better outcomes. Another explanation may relate to the long waiting times that patients are forced endure in Canada’s health care system. For example, in 2016, patients could expect to wait 10.6 weeks for medically necessary treatment after seeing a specialist.6 This wait time (which does not include the 9.4 week wait to see a specialist) is almost 4 weeks longer than what physicians consider to be clinically “reasonable” (7.0 weeks). Thus, it is possible that some patients may have left the country to avoid some of the adverse medical consequences of waiting for care, such as worsening of their condition, poorer outcomes following treatment, disability, or death (Esmail, 2009; Barua et al., 2013; Day, 2013). At the same time, others may have left simply to avoid delay and to make a quicker return to normal life.

Conclusion

In 2016, an estimated 63,459 Canadians received non-emergency medical treatment outside Canada. In some cases, these patients may have needed to leave Canada due to a lack of available resources or a lack of appropriate procedures or technologies. In others, their departure may have been driven by a desire to return more quickly to their lives, to seek out superior quality care, or perhaps to save their own lives or avoid the risk of disability. Clearly, the number of Canadians who ultimately receive their medical care in other countries is not insignificant. That a considerable number of Canadians travelled abroad and paid to escape the well-known failings of the Canadian health care system speaks volumes about how well the system is working for them

Leaving Canada for Medical Care 2017