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Barry – you are right on about the heterogeneity of the population in the US as well as the healthcare system and its approach to diagnostics and treatment for the illnesses.
Barry – I applaud your perspective and what drives you in healthcare. Your patients are lucky to have you and your clinic. I, too, appreciated many concepts highlighted by Dr. Emanuel, but he did not change my underlying beliefs or values for healthcare providers.
The US cannot simply import or export healthcare systems due to the heterogeneity of each country’s healthcare system. One considerable limitation is the various ways that countries maintain records and statistics on disease prevalence and outcomes. With variation in these areas, comparisons are not similar and don’t consistently provide meaningful information.
Having definitions in place for comparisons to be made is critical as well. “Timely access to healthcare” is a judgment and portrays an opinion. In the US, the expectation is that healthcare is received when it is desired/needed. In other countries, with residents who are accustomed to waiting several months for healthcare, their opinion may be similar to those in the US, despite waiting several weeks for care.I found Prescription for the Future to be very informational and enlightening. It allowed me to understand more about medicine in areas that I don’t practice. However, I don’t think it has changed my perspective on choosing a physician as I already had firm beliefs in this area. Honesty, respect for me as an individual, and accessibility are the three main characteristics important to me in a personal physician.
Juby – you bring up a good point and that is that by implementation of healthcare resources, such as the EMR, while initially is a great expenditure, in the long-term patients in India will benefit as healthcare costs will go down. In effect, the patients will ultimately have less costs as they reap of benefit of decreased national healthcare costs. The hub and spoke model is essentially what we strive for in neonatal care in the US, similar to India. The goal is a central regional NICU which can provide a wide-array of critical services with subspecialists, if needed. Smaller NICUs take care of less ill babies and route them to the regional centers when indicated.
One action that can be taken from the US Healthcare system and applied to LMIC would be to pay public healthcare providers a higher stipend for applying evidence-based practices which have been modified for the healthcare system in their respective country for their patient population. This will result in improved care and better outcomes for patients in these countries.
One action that can be taken from LMIC and applied to the US Healthcare system is as recommended in South Africa where the proposal of a national health service utilizes public funds to secure a comprehensive healthcare bundle which includes public and private providers who are certified (helping to ensure standards of care are enforced).Barry – You describe the benefits of virtual care very well. I appreciate your approach of charging less for a virtual visit as it takes less physician time and little (if any) nurse time. I agree with your point of needing to see your patient at least part of the time. Although my patients are always present for rounds in the NICU, if I practiced in a clinic setting, I would want to see them occasionally too.
Question #1: One healthcare process in my work that would improve satisfaction is virtual visits with pregnant mothers. Currently, our consults occur in-person and only those individuals who travel with the mother to the appointment can listen to our medical counseling (we discuss potential outcomes, prognosis, and plan once admitted to the NICU).
Currently, we complete these consults when they are at the clinic for a follow up with the Maternal-Fetal Medicine specialist. An issue that could occur by allowing virtual prenatal consults with the neonatologist is that the mother is disencentivized to appear for her visit with the MFM, knowing she could get the neonatology counseling via phone.
These virtual prenatal consults were highly rated by neonatologists at the University of Oklahoma Children’s Hospital in a cross-sectional study performed during the pandemic.Lapadula MC, Rolfs S, Szyld EG, Hallford G, Clark T, McCoy M, McKnight S, Makkar A. Evaluating Patients’ and Neonatologists’ Satisfaction With the Use of Telemedicine for Neonatology Prenatal Consultations During the COVID-19 Pandemic. Front Pediatr. 2021 Mar 3;9:642369. doi: 10.3389/fped.2021.642369. PMID: 33748048; PMCID: PMC7966517
Question #2: All healthcare is not local as there are so many aspects of healthcare that need to be outsourced. Oftentimes, the radiology interpretation of imaging comes from a distant location electronically. The supplies we use in the hospitals and the clinics come from around the world. Tele-medicine is frequently not local.
On the flip side, if you refine the definition of healthcare to include only the care received by a provider, one may agree with the statement that all healthcare is local. This is true especially if a patient only seeks care in their community and not via virtual visits.Juby,
I appreciate the point you make regarding available information at the patient disposal regarding actual prices of procedures. The price available may include the price of a surgery, but fail to include the billing of the anesthesiologist, overnight hospital care (or more inpatient days), radiology charges, etc. These activities could definitely add prices to the actual cost of the surgery and be misleading to patients.
Abanda,
I love your story about the success you achieved by convinvcing the oldest child (the leader) to perform the easy task of washing dinner dishes, which in effect resulted in his younger brothers following his behavior. This was genius!! It makes sense to approach the oldest child as the one with the most maturity and most likely to set the stage for the others. It would be wonderful if this solution worked in various other behavioral situations in the future!
Some of the barriers to price transparency in healthcare include incentivizing the insured employee to actually utilize the service (10% of employees used the tool). This proved to be a big factor in the study from the manuscript. Also, the tool focused on outpatient care, which is the most inexpensive healthcare, particularly compared to inpatient or emergent healthcare. The study states that only 40% of spending comes from shoppable services. Finally, outpatient clinical services would seem to most “qualify” for the objective of the transparency tool, but most people have established relationships with their PCPs, and they are not interested in changing providers, even if it would save a few dollars.
The price transparency tool did not result in less spending – in fact, the study participants spent more for outpatient services after introduction of the tool.Question #1: Positive Peer Perception/Pressure is what is occurring when our neonatology section socializes outside of the hospital. We typically meet for dinner or outside activities but there is very little cursing amongst group members. In fact, if someone were to curse it would stand out amongst the easy conversation and relaxed atmosphere we are a part of. Now, during critical situations/codes in the hospital, this is a very different atmosphere and cursing definitely occurs.
Question #2: I have long had a vision of a mental health program/provider on site in our NICU to serve the mental health needs of the parents whose infants are hospitalized (sometimes for 12+ months). It seemed like a pipe dream of mine until I read about the Level 3 NICU at Brigham and Women’s Hospital in Massachusetts where just such a behavioral mental health program is available.
Universal mental health screening occurs for all parents when their infant is admitted to their NICU, and the program provides short-term contact with mental health providers during the hospitalization. An article published in the Journal of Perinatology encourages the use of these same behavioral health providers to offer support and education to the NICU staff as well (RNs, social workers, respiratory therapists).
Barry,
Your post this week resonated with me. As you mention, having health insurance has been critical for me and my family too, although in the 24 years we have had children, we have never once met our deductible (thank goodness). And for this, I am especially thankful to have insurance just in case. However, as you mention your habit of regular exercise, positive attitude, and growing a garden have all contributed far more to your overall health and longevity than health insurance. Likewise, my family, daily runs, love for salads (at least daily), and optimistic outlook have contributed to my health in a similar fashion. Thanks for making that point!
Hi Abanda,
You make very good points about diabetes care and transforming that care to improve patient outcomes. First, it is so important, as you state, to understand the culture from which the patient is from. Culture is composed of behaviors and language, but also foods and traditional diets that can play a big role in disease management. Second, you mention the family the caregivers. These people play an enormous role in the life of the patient and may prepare meals which will directly impact disease severity. They are also the people who will most likely motivate and/or care for the patient too.
The ACA has shown a decrease in bill collections, bankruptcies, and large unpredictable medical expenses as more widespread health insurance coverage.1
(1Chua KP, Sommers BD. Changes in health and medical spending among young adults under health reform. JAMA 2014; 311:2437-9).
Also highlighted in the manuscript was an increase in ED use as well as hospitalizations as revealed in the Oregon Health Insurance Experiment, a randomized, controlled trial of health coverage trial, since implementation of the ACA.1,2
(1Finkelstein A, Taubman S, Wright B, et al. The Oregon Health Insurance Experiment: evidence from the first year. Q J Econ 2012;127:1057-106.
2Taubman SL, Allen HL, Wright BJ, Baicker K, Finkelstein AN. Medicaid increases emergency-department use: evidence from Oregon’s Health Insurance Experiment. Science 2014;343: 263-8).