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Suzanne I agree that the system of care in the US is very heterogenous, especially since insurance or not, type of insurance and out of pocket expenses can be barriers to access and therefore may affect outcomes.
importing or exporting healthcare systems: The US has a much more diverse population than many countries in the world, where the populations may be much more homogenous. Secondly, the ways in which diseases are diagnosed and identified are very different from one country to another. Therefore, the prevalence of a disease and the stage at which the disease is identified will not be the same from one country to the next. On the other hand, those differences should not stand in the way from humbly evaluating what is working in other countries and seeing where improvements can be made in our own system of care.
Suzanne, I agree with your assessment. The values I use to select a doctor do not match up with what the author has recommended, and the book has not influenced my values.
3 important characteristics/ influence of “Prescription for the Future.” I appreciated much of what Ezekiel Emanuel had to say in the book, and many of his insights were helpful. However, in the last chapter, he completely lost me. I began looking on the internet for a way to contact him to respond to his comments about Direct Primary Care, but gave up when it was apparent that the only way to reach him was through some agents or secretaries. So much for accessibility. After reading his assessment of Direct Primary Care, I began examining our principles of practice. Patient centered care. Accessibility. Fairness in pricing. Transparency in pricing. Negotiating to reduce costs for medicines, labs and imaging studies for uninsured patients and those with high deductible plans. Shopping and advocating on behalf of our patients to find the best deals in healthcare. And I asked myself, “who else in my community does this for their patients? Who else advocates for the uninsured and the homeless and creates a place for them?” So, if I had the chance to speak with Ezekiel Emanuel, this is what I would say to him: “you are using the wrong yardstick to measure quality.” Why not measure diagnostic acumen? Why not measure accessibility for those who have no insurance? Direct care does not leave out the insured so much as the standard practice of medicine leaves out the uninsured.
He’s missing the point. Best expressed by a patient last week: “I went to see my new provider, but because it was a new visit, my wife and I were each charged $550- out of pocket. I went for my wellness physical, and because my doctor put ‘sleep apnea’ as something she was investigating, the insurance threw out the visit as a wellness exam and I had to pay another $350. I had a sleep study in December but can’t get in to see my provider for the results until late February. I pay tens of thousands per year for health insurance for a ‘Cadillac plan’ but have a $5000 deductible. But I can call and see you within a day and pay $100 to get answers to my health questions. So, you are my doctor now.”
What do I want in a doctor? The same things my patients want. Competency, compassion, accessibility. The book hasn’t changed those values.Abanda, I have viewed Rwanda’s healthcare system as well, and I have found it to be highly organized and well designed, and certainly community based. The one flaw I would mention is the old-style European division or medical care into four categories- surgery, internal medicine, pediatrics, and ob/gyn. Family medicine, which could really help with the care of the great majority of the medical needs, is virtually non-existent.
1. responses from LMIC and from the US. I’m not sure what the question is. I think what is being asked is whether the means of care or provision of care from one of these entities is transferable to the other? I’ll talk about the Cuban model of care. Cuba emphasizes broad physician training, physician run team based primary care neighborhood clinics. Their health outcomes for major health measures such as longevity, maternal and infant mortality are comparable with the US, yet cost of care is miniscule by comparison. I think that such an emphasis on primary care, physician education and neighborhood team approach to healthcare with relatively few specialists would save the US public tons of cash in their healthcare, with similar outcomes.
The US’s emphasis on high quality education for all categories of healthcare providers is exemplary and markedly different from what is received in many parts of the world. I think the export of such high quality education to other areas of the world such as Africa would make a dramatic difference in health outcomes in many areas.Suzanne, good example of how we outsource a number of healthcare services and provide those services from distant sites.
is all healthcare local? yes, to a large degree. Several years ago, when direct primary care was just in its infancy in Washington state, our large physician owned clinic decided to create a “direct care clinic” within our large insurance model system. Patients who did not have insurance or who had a high deductible plan could purchase a monthly membership which covered primary care services at about $50 per month. The number of members was very modest, never more than 50 members in our 16 physician member clinic, so the idea was abandoned as not of significant benefit in our community. However, since 2019 when Heartland Medicine was created, our membership has grown to over 800 direct care members besides our urgent care patients. Our revenue last year was over $700,000, from which we can create a solid budget and provide benefit to our community from profits. We have not raised prices in 3.5 years. We are affordable, with transparent pricing, accessible with expanded hours, reduced costs for medicines, imaging studies, lab testing. We advocate for the most vulnerable in our community. But here’s why I don’t think our clinic is reproducible: 1. it’s based on my name and reputation in the community from the past 30+ years. Those years of service are of inestimable value when giving credibility to our clinic. Relationship, commitment, compassion are not easily duplicated. 2. the other primary care clinics are in shambles. I had a conversation with a patient today who told me “the other clinic charged both me and my wife $550 for a ‘new member fee.’ Then I was charged $350 for my ‘physical’ which was supposed to be covered because my physician put down ‘sleep apnea’ in her note. If anything else is mentioned, the insurance charges me. I can’t get in for the results of my December sleep apnea test until the end of February. I’m coming to see you. I can get in to see you, there are no hidden costs, and you provide great service.” Another patient who works for the big hospital system told me “send the order for my MRI to Spokane (90 minutes away by car). An MRI here (in our local town) costs $4000 more.” (within the same system of care.) The principles which guide our clinic can be integrated into another such clinic, but the specifics of what makes our clinic successful are unique to us.
1. virtual care: We have used virtual visits fairly extensively during and since COVID. Virtual visits allowed us by phone or video to assess patients who were sick and in remote areas. This improved quality of care because patients who were sick could remain at home and reduce exposure to other vulnerable patients in the clinic. This was especially true at times when many clinics were closed to people with COVID like symptoms or made patients wait outside in their vehicles. There were many disastrous health outcomes during this time as a result of limited access to care. We kept our doors open, but were flexible in allowing patients to schedule virtual visits. We charged a lower amount for virtual visits because these generally took less of the nurses’ and physicians’ time. We could prescribe medicine or dispense medicine from our clinic- patients would drive up and call us and we would run the medicine out to their vehicles. In our setting, rural remote underserved, virtual visits helps to stretch our limited physician time to serve as many as possible. It also makes follow up visits for acute illness easy- I often call a sick patient the following day- a manic patient, a child with pneumonia, a young female with pelvic pain- phone calls I will need to make tomorrow morning- assures the patient of the quality of care we are holding ourselves to, and eases the burden for them, since they can remain at home and report on their progress to us. The problem that I see with more widespread implementation is that there are times when you just need to see a patient face to face. I need to see all of my patients suffering from chronic pain or addiction face to face at least part of the time. Human contact and interaction face to face is still the standard.
Suzanne, thank you for your insights. I agree with you that patients are unlikely to change PCP’s to save a few dollars, because primary care is based on relationship. Your other evaluation of the transparency tool is also helpful. I don’t think a tool like this will make much of a difference. I think the investigators weren’t asking the right questions. Patients in our experience will value and reap the benefits of pricing transparency and fairness when these are integrated into the system of care routinely, as they are in our practice.
Barriers and transparency/evidence: Patients are unable to navigate the pricing complexity for a number of reasons. First, the systems of care hide their pricing. Often the same hospital system has very different pricing in different locations for the same procedures (Spokane vs Colville.) Rural sites routinely bear the brunt of the higher pricing because the hospital systems have a monopoly at those locations and they fully take advantage of this. Additionally, rural patients are loyal to their local providers and systems of care, so unlikely to move to another provider for pricing reasons. On the other hand, in our direct primary care practice, we shop around on behalf of our patients for large ticket items such as ct scans and mri’s, and patients are willing to travel one or two hours away to obtain these services when pricing is substantially different. For medicines, cash paying patients routinely appreciate and obtain their medicines from our dispensaries when offered fair pricing. Our goals of fairness and transparency in pricing are valued and utilized by our patients. A pricing tool or transparency tool is not sufficient to make a difference for patients in their medical choices. On the other hand, when transparency and fairness in pricing are integrated routinely into the practice, patients value and make decisions based on these. The evidence is in our direct model of primary care.
Suzanne, thank you for the report of the use of behavioral health professionals in the NICU, a practice that makes sense but I never would have considered. It makes sense that at this most vulnerable time in people’s lives, they would have access to someone who could help to guide them through the difficult emotional responses the parents and staff must experience as they see the suffering of children.
2. co-locating behavioral health: When I worked at another clinic, we experimented with co-locating behavioral health in our primary care clinic. The presence of a counselor allowed treatment of addiction with medication assisted therapy from me and behavioral health treatment from the counselor at one location, meaning that the barriers to attending appointments at the behavioral health clinic down the street, with the accompanying stigma of showing up at such a clinic, and everyone in the waiting room knowing why you are there, were gone. (In a primary care clinic, as far as anyone in the waiting room knows, the patient is just there to see the doctor. Culturally, this is much more acceptable.)
1. positive peer pressure: we have a project, a grass roots not for profit organization called Hope Street, which provides basic human services to homeless people in a way that is meant to humanize them and give them an opportunity to improves their lives. Because of our emphasis on treating homeless individuals with respect, and our clinic providing compassionate care to the community, our staff have begun connecting with people who are homeless, including an illiterate gentleman with a terrible speech impediment, Each morning when we open, he comes in the door, garbles a greeting, and our receptionist provides a bowl of oatmeal and some hot chocolate in our waiting area. It seems a small matter, but kindness is contagious, and transforms the attitudes of the entire clinic, as the conversation turns to seeing him in his humanity, his life story, and looking for chances to ease his suffering.
Suzanne, I’m glad that you pointed out that reduction in bankruptcy as one of the most compelling arguments for retaining or expanding ACA coverage. Personal finances are very much at risk when people lack healthcare insurance, especially for catastrophic medical events. Medical events are the frequently cited cause for personal bankruptcy in the US, and annual costs per person for healthcare are now well over $12,000, reaching 20% of our GDP. Healthcare coverage, particularly for catastrophic events, helps people to retain their wealth and avoid the brink of financial disaster.