Stanley Feld M.D.,FACP,MACE
I have pointed out that all the stakeholders are to blame for the dysfunction of the healthcare system.
I have also explained the difference between the healthcare system and the medical care system.
In the past two weeks I have explained that both the medial care system and the healthcare system are ripe for disintermediation with innovative software just as the publishing system was dis-intermediated with amazon.com, the music industry with ITunes and the movie industry with Neflix.
The core problem has developed over the last 40 years. The government and the healthcare insurance industry have created a huge payment hairball between patients and physicians.
ICD and CPT coding has created complications beyond belief for patients and physicians. The ICD 10 is more confusing that ICD 9.
Instead of closing the window for fraud and abuse it has opened it further.
The problems with coding can be dis-intermediated by innovative software with its focus on patients and physicians.
A retired physician wrote the following note to me after reading my posts about innovative software and the destruction of the patient-physician relationship. His narrative was in response to the WSJ article “Should Physicians Use Email to Communicate With Patients?”
The writer is a retired physician with 40 years of private practice experience. He has lived through the development of the dysfunction in the healthcare system.
This observation has been on my mind for a long time. The health issues in the 4th section of the WSJ today January
23,2011 caused me to put the ideas down on paper.
“In doctors’ offices all across the country, a scenario like this is being played out as I write these comments.
The patient has a complaint, the physician listens (or not), performs an examination (or not) makes a decision regarding the probable cause of the complaint, writes a prescription (or two, or three), offers some instructions regarding what the patient should be doing to help himself (or herself), says goodbye and asks that the patient return at some future date for reassessment (or not).”
This is an excellent description of the disconnect between the care of patients by physicians. Patients and physicians should have a relationship where patients are at the center of the physicians’ healthcare team. The physicians are coaches. The physicians’ team is the assistant coaches helping physicians treat patients.
“What happens next is where I’d like to spend a little time in this essay.
The written prescription/s may be hand-carried to the pharmacy, the doctor may telephone the prescription/s to the pharmacy, or more commonly these days, the prescriptions may be sent on line or by fax, with the doctor’s assistant doing the sending.
The government is now paying an incentive bonus to the physicians for e-prescriptions. Unfortunately 60% of physicians’ offices cannot afford the software.
This is a place for a fully functional ideal electronic medical record in the cloud.
“Now here is where the situation can get dicey. Up to 20% of all those prescriptions are never picked up by the patient. After an interval, they are returned to stock in the pharmacy. It is unlikely that the doctor will be made aware that this has happened.”
The e-prescription must be a two way street. The physician should be notified electronically by the pharmacy if a patient does not pick up a prescription.
The physician’s office should automatically contact the patient and explain the importance of the medication.
Other results can also happen. The patient picks up some, but not all of the prescriptions because of the cost versus what he/she can afford.
In the fully functioning EMR software can be included to enable the pharmacy to inform the physician.
Or the patient picks up all of the medications ordered. Once at home, the patient may or may not take the medications as prescribed.
The instructions from the doctor may be recalled incompletely or inaccurately.
The healthcare team can electronically reinforce instructions and goals for the medication using the Internet sites picked by the physician.
Freestanding organizations will fail if they are not an extension of physicians’ care.
The CBO recently revealed that President Obama’s pilot studies using freestanding chronic disease management organizations have failed to lower the cost of care.
The medications may not be tolerated by the patient, and as a consequence, he/she may elect to discontinue one or more of them, or may elect to take them in some manner other than as directed by the doctor.
The patient may not notify his physician of his difficulty taking the medication.
Social networking between physicians and patients and patients in that physicians practice could solve this problem.
Patients understand that most cognitive physicians are reimbursed for coded procedures. Advice over the telephone or email is not reimbursed. A mechanism for reimbursement must be developed for using social networking.
The medications may prove effective in alleviating the problem that caused the patient to see their physician in the first place, or they may not.
Most of the events described will not be known to the patient’s physician until the patient is next seen in the office, and maybe not even then.
E-mail could have malpractice liability in the current malpractice environment. This is one more reason Tort reform is essential.
In a perfect world, a lot of the issues raised above could be made better by a few simple moves. The pharmacy could make the physician’s office aware that the prescriptions were never picked up.
Someone in the physician’s office could call or email the patient 3-4 days after the visit, and inquire whether the patient is taking the medication,
Reinforcing the physician’s instructions, and inquiring whether the medications are helping the patient, asking if there have been any problems arising from the use of the medication, and passing what is learned back to the physician.
The reinforcement of the instructions can be very helpful, and the awareness of issues relating to the medication can lead to more timely resolution of problems the patient is experiencing.
It has always seemed to this writer that the doctor-patient relationship would be well served if we all started to use what I call “The Doctor Phil Question”, which goes like this: “How’s that working out for you?”
It is all about patients’ responsibility for their healthcare and their healthcare dollar. It is about consumer driven healthcare and the patient physician relationship.
As long as the government and the healthcare insurance industry continues to drive a wedge between the patient and physician the cost of healthcare will continue to rise.
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone
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