Segment 9 – The Big Fix for U.S. Healthcare

Segment 9 – The Big Fix for U.S. Healthcare



This segment reviews the “Big Fix,” based on the idea of setting limits fairly. It describes the success of the Oregon Health Plan of 1994.

In the first 8 Episodes, we have reviewed the evolution of the US healthcare delivery system and insurance system. We have identified the relentless growth of healthcare spending as the root of the problem. And how rising costs are literally built into the system as it is now. Finally we have looked at American traditions and values that we all agree on, and we identified loaded political words and the seeming conflict between market justice and social justice that voters disagree on.


Based on this understanding of the US healthcare system, we are now ready to look at what I’m calling the Big Fix. It is based on the idea of setting limits fairly. You’ll be surprised to know that it was already tried 20 years ago in Oregon. And it worked!



So, let me tell you the story of the Oregon Health Plan. It all starts with a Roseburg Oregon emergency room doctor named John Kitzhaber. Half of his ER patients – as everywhere – were not real emergencies, just uninsured patients with no other place to get healthcare.


So in 1989 when the Medicaid budget was being cut, he realized that many Medicaid patients would lose coverage, and would be flooding into his ER. Unless something was done.

He came up with an idea. Rather than keep the same level of benefits and cut patients, why not keep all the patients on Medicaid but limit their benefits? He formed a non-profit group to lobby for these low-income patients. This propelled him to the state senate and eventually to the governorship. He first created a list of 709 diagnosis-treatment pairs ranked by the dollar cost per life saved by each treatment (or “quality-adjusted-life-year”).


But this produced some odd results, for example ranking lower-cost dental care above life-saving appendectomies. And so he next organized 60 town hall meetings to re-prioritize the list with common-sense consumer input. Actuaries then calculated the line (Line 581) above which the fixed Medicaid budget could cover all eligible patients. The final list gave priority to life-saving treatments such as antibiotics for pneumonia and appendectomy for appendicitis, as well as to proven effective treatments for heart disease and treatable cancers. It also included routine preventive care, maternal care, newborn care, well-child care and preventive dental care. Kidney dialysis was covered above the Line. The list did not cover conditions like remedies for the common cold that get better on their own, conditions where “home” treatment is effective like sprains, ineffective or futile care such as surgery for most back pains or aggressive treatment of end-stage cancer. For those terminal cancers, it did cover comfort care.

Here are the other main provisions of the Oregon Health Plan. By eliminating low-value health services, it was able to cover 100 percent of low-income citizens. The combination of sound research and consumer input gained it public acceptance.


Here is the time line for the Oregon Health Plan. It actually took 5 years to gather public input and then to get necessary federal waivers approved.


Here is a summary of the key successes of the Oregon Health Plan. Oregon was able to extend plan eligibility of those below federal poverty level from 57% to all 100%. This meant 100,000 more Oregonians on Medicaid. However 65,000 still did not enroll, presumably due to complicated enrollment procedures or copays up to $28. Total uninsured in Oregon did drop from 18% to 11%. Most importantly, Medicaid stayed within its budget. Medicaid physicians were paid on a par with others, resulting in robust doctor participation and 88% patient satisfaction.


Let’s pause to consider a key question, Is it ethical to limit health benefits for low-income patients? Philosopher Paul Menzel (who I introduced in the last Segment) gives a resounding Yes. Here is his thinking. The right to prioritize healthcare services is especially important for lower-income patients. If they were given their Medicaid premium in the form of cash, many would spend only 33% of it on healthcare because they have more pressing needs for food, clothing, and shelter. Menzel also points out that these low-income patients would gladly accept a package of more restricted health services in exchange for first-dollar coverage. Lower-income patients live from paycheck to paycheck and don’t want the uncertainty of a large unexpected medical bill. Medicaid patients want healthcare insurance, but neither they – nor society at large – should pay more than it’s worth to them.


In plain language, lower-income patients – and other savvy insurance buyers — need the real choice for a lower-cost package of limited health benefits that is “worth the money,” not just a menu of higher deductibles and copays but the same old package of exorbitantly costly, low-value care.

Please notice that this idea blends both market justice and social justice. It acknowledges that low-income patients are not entitled to everything, no matter what the cost. But it also provides for them a package that they – and society – think is costworthy. And does so with their consent freely given. Costworthy care is one of the key features of a fair health system, according to Menzel, as we saw in the last Segment, and consent is a key principle.

It is instructive to look at the fate of the Oregon Health Plan over the 8 years of its existence. Here is what happened. The legislature cut taxes. Healthcare costs rose with inflation. Oregon tried to get the poor to accept higher co-pays, but they could not afford them and so dropped out. Eventually these patients went back to traditional Medicaid or became uninsured again, spelling the end of the Oregon Health Plan.


What are the lessons to be learned?


First, limit-setting is politically feasible, ethically acceptable and pragmatically successful in controlling cost, access and quality.

Second, priority setting takes years to plan and years to implement.

Third, healthcare priority setting should be informed by cost-benefit research but driven by public participation, respecting minority rights and protection of the sick and vulnerable.

Fourth, two-tiered health benefits packages – one lower-cost and one higher-cost – is politically feasible and ethically acceptable (but so-called Essential Benefits should not arbitrarily cut entire categories of benefits like maternity care).

Fifth, sufficient primary care provider pay is needed to ensure doctor participation and patient access.

Sixth, sustaining healthcare system restraints and cost controls requires continual monitoring and periodic updating to keep up with new medical research and changing public values.

This is a critical point, because the casual observer might conclude that the Oregon Health Plan failed in 2002.

But I argue that the fact that the Plan was designed, politically adopted, implemented and sustained for 8 years proves the concept that limit setting can work, but also shows that something so big and so intricate needs ongoing political and administrative energy to sustain it.

Of course I have over-simplified the Oregon Health Plan. There are innumerable technical, legal, budgetary and administrative details involved.

Also, adopting a plan like Oregon’s today would need us to take into account 20 more years of research since then, with some very expensive but very effective treatments newly available. There are also many ethical nuances, such as should we budget for one patient needing a $100,000 treatment in place of 100 patients with $1,000 treatments, or vice-versa? But Oregon showed that all these issues can be managed in an orderly fashion.

I have also over-simplified that merely adopting the Oregon Health Plan cost-benefit method for limit setting would solve the entire cost problem. For example, many commentators have exposed the quirks of the US healthcare system that result in over-pricing, as discussed in Segment 5. That means that the same drugs, tests or treatments cost 2 to 10 times more in the US than in other countries. Those quirks should each be addressed in policies and regulations.

But the basic idea of fair limit setting – call it rationing, if you like – is the key, in my opinion. Limit setting would firmly challenge the common presumption that all healthcare is equally cost-worthy. It would put on notice the vested interests: if they play games with exorbitant pricing, they would ultimately lower their benefit-for-cost below the cut-off point, and drop themselves off the covered list altogether.

In the final Segment, I will talk about what each of us can do to promote health system reform and cost control.

I’ll see you then.


Asking the wrong question about physician consolidation

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A paper out this week from Rice University healthcare economist Vivian Ho is the latest analysis to posit that vertical integration of doctors and hospitals does little to improve care quality. Researchers evaluated 29 primarily hospital-focused quality and patient satisfaction measures and found that higher levels of vertical integration were associated with improved performance on just a small number of metrics—and increased market concentration was associated with lower scores on all patient satisfaction measures.

Before concluding that vertical integration generates little improvement in quality, it’s worth looking a little deeper at the methodology of this study, as well as the larger drivers of hospital-physician integration. Researchers used a blunt measure of vertical integration, combining health systems’ self-reported physician alignment model with a standard index of hospital market concentration (on the theory that lower hospital-to-hospital competition indicates greater vertical integration). The performance measures examined are hospital-focused, ignoring outpatient care quality, as well as the nuance of whether the “integrated” physicians in any market are responsible for the outcomes measured (employing primary care doctors and orthopedic surgeons would have little impact on measures of hospital treatment of heart attacks).

In a press release, the author notes: “If patient welfare doesn’t improve after integration, there may be other reasons why physicians and hospitals are forming closer relationships—perhaps to raise profits.” That’s right: there are many motives for vertical integration. Surely profitability has been a driver, as well as the rising complexity and deteriorating economics of running an independent practice. In the real world, physician alignment strategies are rarely driven by the primary goal of improved quality. However, many health systems have begun to recognize that closer financial alignment is a necessary (but far from sufficient) requirement to enable real progress on quality improvement. Regardless of alignment approach, though, quality improvement results from the hard work of care process redesign and cultural change, not as the inevitable result of vertical integration. Success stories are still too few and far between, but we believe there is value in leveraging vertical integration to make this work easier. Condemning vertical integration seems a harsh verdict; a more appropriate criticism would be that much of the heavy lifting of care redesign is yet to begin.



‘Told’ is the word most linked to negative hospital reviews on Yelp

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When looking at hospital reviews on Yelp, researchers found the word most associated with negative reviews, including those with one-star ratings, was “told,” a study published in the Journal of General Internal Medicine found.

The researchers, from Philadelphia-based Penn Medicine, analyzed 51,376 reviews for 1,566 U.S. hospitals and found the word “told” appeared in 20 percent of the posts (9,578 in total). Reviews that included the word “told” averaged 1.78 stars out of five stars.

The one-star reviews the researchers saw that contained “told” highlighted frustrations about information that was ostensibly shared (“They never told me the cost of any of the procedures”), anger at a lack of listening (“I told her I did not want to discuss it any more but she persisted to badger me”) and feelings of futility (“Some examined me and told me there was nothing they could do for me”).

“Oftentimes, words such as ‘told’ hint at a breakdown in communication,” Anish Agarwal, MD, a National Clinician Scholars fellow and emergency medicine physician at Penn Medicine, said in a news release. “I suspect that patients are not feeling listened to or heard and this could be driving poor experiences and low reviews.”

For the positive hospital reviews, the word “friendly” was found in about 11 percent of them (5,594 in all). Along with the word “great,” “friendly” correlated the most with five-star reviews. In these reviews, patients often focused on hospital staff’s demeanor and attentiveness (“The entire staff was very friendly and made sure we were taken care of”).

“Patients value communication highly in their overall experience when they’re in the hospital,” Dr. Agarwal said. “As healthcare transitions to being more patient-centered, I think hospitals and providers need to continue to work on how we improve communication, how we listen and how we approach all patient interactions.”




Patient Financial Experience the New Focus for Revenue Cycle Tech

Facing healthcare consumerism and high deductibles, providers are seeking revenue cycle technology to deliver a high-quality patient financial experience.

Hospitals and practices have traditionally relied on public and private payers to cover the bulk of patient charges and costs for their services. Everything from their revenue cycle technologies to billing workflows has been tailored to create cleaner claims, reduce denials, and collect payer reimbursement.

But in an environment of record spending and changing attitudes towards purchasing and payment, payers are starting to shift more financial responsibility to their consumers. Nearly 21 million Americans had a high-deductible health plan or health savings account in 2017, and AHIP experts anticipate enrollment in high-deductible plans to continue climbing.

Increases in patient out-of-pocket spending are driving individuals to become more discerning healthcare consumers who demand more value for the medical services they receive. Plans and policymakers argue that the rise in healthcare consumerism will ultimately result in lower cost, higher quality care.

In the meantime, however, high-deductible health plans and other increases in out-of-pocket spending are presenting challenges to providers who are not used to this new player: the patient as a payer.

Three-quarters of providers report that they are seeing a noticeable upward trend in what patients must pay out of pocket.   At hospitals, total revenue attributable to patient balances after insurance rose 88 percent from 2012 to 2017.

While payers have been steadily shifting the financial responsibility to consumers, providers have yet to adapt their workflows and systems to collect revenue from this new source while delivering a satisfactory experience to consumers.

For example, nearly all 900 healthcare financial executives recently surveyed by HIMSS Analytics said their organizations still use paper-based billing and collection strategies – despite the fact that the same survey revealed more than half of patients prefer electronic billing methods.

Patients in the survey even said they were more likely to pay their medical bills if they had the option to do so online.

In light of these statistics, providers are facing the difficult task of transforming their manual patient collection processes to address this changing, consumer-focused trend.

“What we’ve seen historically has been that the revenue cycle has been not as well funded or not as strategically prioritized for healthcare delivery networks. A lot of the decision making has been either reactive or more short-term oriented,” Joe Polaris, Senior Vice President of Product and Technology at the health IT company R1 RCM, recently told

“But we’re starting to see more of a long-term strategic vision coming together for their revenue cycles,” he added. “Organizations understand they need to make transformative change in light of some of the challenges that are only growing in the market, especially the need to be consumer-friendly.”

Revenue cycle technologies that cater to the patient financial experience are part of that transformative change, added Matt Hawkins, the CEO of Waystar, the newly combined revenue cycle management company formed by ZirMed and Navicure.

“Innovators are beginning, more so than ever, to treat the patient as a consumer,” he said. “A lot of health systems are demanding or embracing services or technologies that get them closer to patients from the earliest interaction point.”

The demand for technologies that cater to the patient financial experience is on the rise. And providers could face significant financial losses and patient retention problems if they fail to adapt to healthcare consumerism.

Becoming a patient-centered entity that can collect what it’s owed without alienating its consumers is a significant challenge, experts agree.  But embracing a handful of high-impact strategies could help to ensure that both patients and their providers complete the payment process feeling satisfied.


“Consumerism” may be a popular buzzword in the healthcare industry, but providers still have a long way to go before their patients can accurately compare their clinical journeys to their retail experiences.

For one thing, patients often agree to services or procedures with no clear idea of what they will ultimately cost.

Providers rarely offer prices or price estimates to patients prior to service delivery. In fact, the percentage of hospitals that are not able to give consumers price estimates actually increased from 14 percent in 2012 to 44 percent in 2018, a recent JAMA Internal Medicine study revealed.

With patients expecting the ability to plan their expenses, providers are looking to implement new revenue cycle technologies that can deliver accurate cost estimates and boost overall healthcare price transparency.

“How do we give patients shoppable experiences, so they can find out the cost of an MRI?” asked Christy Martin, Senior Vice President of Product Management at Optum360. “In their local care market, where is the best place to go in terms of both quality and cost? Then, if they go to a certain location, what are they expected to pay based on their insurance coverage? What would the out-of-pocket costs be at this point in the year?”

Informing consumers of their patient financial responsibility before the point-of-service is critical for providers seeking to improve the patient financial experience.

“In the immediate future, one of the things that we can unlock using technology is an understanding upfront about what the payment responsibility will be, and have that help inform all of the things that happen subsequent to presenting that to the patient,” Hawkins said.

Providing price estimates up front helped one health system in Oklahoma increase point-of-service collections by $17 million in seven years.

The Consumer Priceline tool at INTEGRIS Health is a database of charges for most procedures and services. The health system also promises to deliver written price quotes to consumers within two days if the service is not already included in the database.

INTEGRIS may be seeing significant patient collection improvements using price estimates, but providers should be aware that databases like the Consumer Priceline tool require a wealth of historical financial data.

“In the immediate future, one of the things that we can unlock using technology is an understanding upfront about what the payment responsibility will be.”

Merely posting chargemaster prices for common services and procedures is not necessarily helpful for patients. Giving consumers information about their patient financial responsibility and out-of-pocket costs is supposed to prevent sticker shock. Yet chargemaster prices are primarily used to start negotiations with payers, and the numbers can seem exorbitant to consumers.

“Chargemaster prices serve only as a starting point; adjustments to these prices are routinely made for contractual discounts that are negotiated with or set by third-party payers. Few patients actually pay the chargemaster price,” the Healthcare Financial Management Association (HMFA) explained to policymakers in May 2018.

Despite reservations about chargemaster prices, CMS recently required hospitals to publish a list of their standard charges online. And providers are scrambling to understand how to present the information in a meaningful way to consumers.

About 92 percent of providers in a recent poll said they were concerned about the new hospital price transparency requirement, and the majority also expressed concerns about how the public would perceive their standard charges.

Now more than ever, revenue cycle technologies that aggregate and analyze information on what patients actually pay will be critical for health systems.


Healthcare is nothing like going grocery shopping. Not only do consumers not have access to prices, but the funding mechanism for medical services is also vastly different from a traditional retail experience.

Unlike what happens during a retail transaction, healthcare consumers rarely pay providers directly for services or procedures rendered. Instead, healthcare consumers use insurance plans, health savings accounts, and a wide range of other funding mechanisms to eventually pay providers after a service is delivered. They may also receive several bills and benefit documents from providers and insurers before receiving the final bill listing their financial responsibility.

As patients become more responsible for their healthcare spend, the onus is on providers to simplify the patient financial experience if they want to boost collections and save their bottom line.

Delivering a navigable and consistent financial experience is key to making the most of the newly consumer-driven environment, Polaris advised providers.

“The patient wants to have a clear and transparent journey through the healthcare system, and that’s much more challenging when they have to navigate different departments on different systems, asking for the same data over and over again, never coordinating, and never communicating a holistic end-to-end experience,” he said.

Integrated and seamless revenue cycle technologies aim to deliver a consistent patient financial experience by simplifying medical bills and bringing all providers in a practice, hospital, or health system under the same billing brand.

For example, a multi-specialty physician group in central Texas boosted patient collections by 24 percent and reduced the amount of patient cash sitting in A/R from 14 to two percent in one year by unifying the patient financial experience across their organization.

“Even though we were one clinic with 60 providers, our collection process treated every healthcare encounter separately,” explained Abilene Diagnostic Clinics CFO Andrew Kouba, CPA. “Patients were receiving bills for each physician they saw, which allowed them to pick and choose which bills to pay. When you get four statements and you think you got one experience, you’re confused as a patient.”

Consolidating all of Abilene’s providers under one billing system helped the group to deliver a consistent patient financial experience, which in turn simplified the payment process for consumers.

Revenue cycle departments are finding that end-to-end systems or interoperable bolt-on solutions are worth the investment. The integrated technologies allow healthcare organizations to guide the patient through the financial experience.

But to truly advance the patient financial experience, revenue cycle technology experts agreed that clinical and financial data integration is also vital.

“Being able to leverage the clinical and billing data to provide a better patient experience all the way around is a key capability,” Martin of Optum360 stated.

“While hospitals are certainly focused on providing high-quality care, there’s also this focus on how they can improve the overall patient financial experience to reduce the confusion, complexity, and lack of understanding around patient responsibility. Health systems are looking to provide ease of doing business to address patient responsibility and reduce patient bad debt.”

Revenue cycle technologies that can leverage both clinical and financial data are crucial to transforming the patient experience into a consumer-friendly encounter. Understanding the whole patient can help providers offer a consistent experience from the front office to the billing department.


Price transparency tools and integrated revenue cycle technologies lay the groundwork for a consistent, intuitive patient financial experience. But revenue cycle technology vendors are also observing an increased interest in self-service portals and kiosks for the ultimate retail-like experience.

The disjointed, manual processes involved in the patient financial experience have not been convenient for consumers. Patients often have to interact with a call center or sit down with a staff member to complete basic tasks like scheduling, filling out insurance forms, or paying a medical bill, Polaris explained. In other industries, these tasks have already been replaced by mobile apps or automated systems.

“With digital self-service, we automate tasks like they do in the airline industry,” he said. “We let the patient book an appointment right on their mobile phone, get all the paperwork, fill out the forms they need, and check in at a kiosk.”

“Automation takes repetitive tasks that are frankly not patient- or consumer-friendly out of the process and makes the whole healthcare experience much more satisfying,” he stressed.

Self-service portals and kiosks have the potential to truly transform the patient financial experience into a more convenient, navigable journey. But healthcare organizations would need to invest in large amounts of revenue cycle automation to achieve this goal, Polaris acknowledged.

“Automation takes a lot of forms,” he explained. “There’s always been robotics, user emulation, and basic automation to complete individual tasks. But very few organizations have driven automation of entire processes, and that’s where we’re seeing more investment in transformative automation.”

Healthcare consumers have already voiced their support for more self-service options and more automation. A recent survey of over 500 individuals showed that in addition to offering more payment options and sending simpler bills, expanding access to self-service tools was a top suggestion for improving the patient financial experience.

“Automation takes repetitive tasks that are frankly not patient- or consumer-friendly out of the process and makes the whole healthcare experience much more satisfying.”

Providers are also expressing interest in implementing the relatively new technology in the revenue cycle space. Kouba from Abilene Diagnostic Clinic in Texas said he wanted to create a type of Disney FastPass for the patient financial experience.

“We want to simplify the process from pre-registration through bill collection and try to automate that similar to Disney’s FastPass,” Kouba stated. “Disney is one of the best experiences of all time and when you go there, they want you to interact with the people, all their products, and just enjoy yourselves. The last thing Disney wants you to think of is the terrible lines.”

“If we can remove the pain points and strive to ease that front piece, the patient will be focused on a friendly conversation when they walk in the door with the person that can answer questions, rather than being pestered to pull out their wallet.”

However, Kouba is not convinced that full automation will take over the healthcare industry any time soon.

As much as adopting retail-style approaches can improve the patient financial journey, providers must still ensure their technologies and processes work for them, too.

For example, Kouba decided that self-service technology that automates scheduling is not ideal for Abilene.

“In our group, most of our physicians like to follow their patients to the hospital, so the difficult piece with self-scheduling, especially from the provider’s side, is their schedules depend on what their rounds look like for the day. It’s very difficult to get them to commit to blocks of time,” he continued.

Self-service and automated tools may still be maturing in the revenue cycle technology space. But providers still have the option to improve the patient financial experience through systems that estimate patient financial responsibility and unify the billing experience.

And providers should be looking to the revenue cycle technology market for help. The rise of patient financial responsibility has been steady. Deductibles and out-of-pocket costs have been growing, particularly since healthcare spending growth rates rapidly accelerate.

Implementing the right tools for their patients and their providers will be key to empowering patients to choose the highest value care while ensuring providers get paid for it.





Financial worries keep hospital CEOs up at night

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Dive Brief:

  • Financial challenges, including increasing costs, shaky Medicaid reimbursement, reductions in operating costs and bad debt, ranked No. 1 on the list of hospital CEO worries in 2018, according to an American College of Healthcare Executives poll.
  • Government mandates and patient safety and quality tied for second place in ACHE’s survey of top issues facing health systems. Workforce shortages came in third.
  • A little more than 350 execs responded to the survey and ranked 11 concerns their facilities faced last year. Behavioral health and addiction issues, patient satisfaction, care access, physician-hospital relations, tech, population health management and company reorganization filled in the remaining slots.

Dive Insight:

No matter which cog in the healthcare system one blames for the skyrocketing costs of healthcare (big pharma inflating the list prices of drugs; hospitals for upmarking services; insurers for leaving gaps in care resulting in surprise bills) consumers’ pocketbooks aren’t the only ones affected.

A separate American Hospital Association-backed study predicted health systems will lose $218 billion in federal payments by 2028, and private payers (whose dollars would normally help hospitals make up the difference) have been curtailing reimbursements as well.

Bad debt was another fear in the ACHE report. Uncompensated care costs peaked in 2013 at $46.4 billion and, though the figures have decreased slightly since then, hospitals shelled out $38.3 billion in 2016. Wisconsin alone was on the hook for $1.1 billion in uncompensated care in fiscal year 2017.

“The survey results indicate that leaders are working to overcome challenges of balancing limited reimbursements against the rising costs of attracting and retaining talented staff to provide that care, among other things,” ACHE president and CEO Deborah Bowen said in a statement.

Other financial concerns included competition, government funding cuts, the transition to value-based care, revenue cycle management and price transparency.

And 70% of hospital CEOs were worried about shifting CMS regulations in 2018, along with regulatory/legislative uncertainty (61%) and cost of demonstrating compliance (59%) — unsurprising, given the current administration’s track record of unpredictability.

Patient safety and quality of care was also top of mind for health system CEOs, with over half of respondents anxious about the high price of medications, involving physicians in the culture of quality and safety and getting them to reduce unnecessary tests and procedures.

Also of interest was the high rank given to addressing behavioral health and addiction issues, according to Bowen, which ranked fifth in its first year of being included in the survey. The topic has been front and center in the industry of late, in line with the increasing recognition of social determinants of health and the breakdown in silos of care.

Ranking of the issues has remained largely constant since 2016, though in 2017 more hospital CEOs were concerned about personnel shortages than patient safety and quality.


When Your ‘Regular Doctor’ Could Be Anyone

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Just what duty, if any, exists for doctors to keep tabs on their sickest patients?

“Will you be my regular doctor?” a new patient seeing me in my primary care clinic asked.

“Sort of,” I honestly answered.

She looked back at me quizzically.

“Technically speaking I will be your doctor,” I explained. “But you may have trouble scheduling an appointment with me and may have to see another doctor here at our group clinic at times. And if you need to get admitted to this hospital, other doctors who work there will take care of you.”

The patient seemed disappointed.

“I’m sorry,” I said. “But I’ll do my best to be available for you.”

It was not long ago that such words, coming from a doctor, would have been almost heretical. But logistical and philosophical changes in medicine have dramatically altered the doctor-patient relationship.

In clinic-based practices such as mine, patients may be told they may need to wait weeks or months in order to see their doctor. In the world of private medicine, some physicians now charge their patients extra annual fees for the privilege of seeing or speaking with their doctor more promptly.

Just how bad is this situation? Do patients followed by just one doctor do better or worse? And just what duty, if any, exists for doctors to keep tabs on their sickest patients?

My father, an infectious diseases specialist who practiced medicine from the 1950s to the 1990s, would have answered these questions: “Very bad,” “worse” and “a tremendous duty.” My dad was constantly vigilant, going to the hospital seven days a week, giving patients our home phone number and staying in touch with covering physicians when we were on vacation.

But things were different then. For one thing, it was expected that my father would follow his patients both in and out of the hospital. Today there are hospitalists — specialists in inpatient medicine who are in charge of admitted patients and specially trained to diagnose and treat illnesses requiring hospitalization. And my mother, like most doctors’ wives of a generation ago, did not expect my dad to be a co-parent. Medicine, after all, was a calling.

The reasons for the changes are diverse. For one thing, the growing number of women in medicine has helped bring a better work-life balance among physicians. In addition, the 1984 Libby Zion case, in which a young woman died while under the care of young doctors working 36-hour shifts, pointed out the potential dangers of sleep-deprived providers.

When I was a medical resident in the 1980s, the first “night floats”— doctors who covered the wards at night so other physicians could sleep or go home — appeared. To many doctors of my father’s era, this development was heresy. Medicine, they feared, was becoming “shift work.” Patients were passed from doctor to doctor, none of whom really “knew” them. With the advent of hospitalists, this fragmentation has gotten worse.

Fortunately, researchers are studying how well patients do in these competing types of systems. The 2016 FIRST trial, which received a lot of attention, found that patient safety was not compromised when doctors in training worked longer shifts.

But even when the data show that limiting work hours leads to as good or better care, physicians should not be content to play “doctor tag,” in which a physician or clinic simply designates a new provider to “take over” treatment. Just because a physician takes good care of someone during his or her shift does not mean that responsibility ends there.

It may be helpful to think about specialties within medicine that have long been associated with limited continuity, such as emergency or intensive-care medicine. In both of these venues, patients move in and out of treatment quickly and follow-up may be difficult. But it is not impossible.

In her new book, “You Can Stop Humming Now,” Dr. Daniela Lamas, a critical care specialist, recounts visits she made to patients after they had left her unit. In one case, she attends a party thrown by a man whose severe West Nile virus infection had initially made it unlikely he would ever return home. But now there he was, eating, chatting, “working the crowd” and reminding his son to videotape the event.

Dr. Lamas did this on her own time. But she found it immensely rewarding. “We rarely have the opportunity,” she writes, to follow patients “through long-term acute care hospitals, infections, delirium, readmissions, and maybe, if they are very lucky, back home to a life that looks something like what they left.” The patient and his wife seemed thrilled that she had come — not as his current doctor but as his past doctor who still cared.

And what of my patients? I have made a decision not to try to imitate my father, as much as I admire the type of doctor that he was. But patients deserve to have a “doctor,” despite the caveat to my new patient. Plus I have found that most physicians, at the end of the day, are control freaks, wanting to be in charge of their own patients.

So I try to stay in touch, by phone, computer or other messaging strategies. Patient portals, being implemented at many hospitals, now allow patients to leave messages for their physicians in secure ways that do not threaten confidentiality. And I “sneak in” patients with urgent issues when I am not scheduled in clinic but there are open rooms, such as early in the morning or during lunch. The generous staff members at my clinic help make this happen by registering these patients and getting their vital signs. My clinic is also pursuing strategies to increase the chance that patients can see their regular doctors.

My patients seem pleased when I go the extra mile. If I am willing to squeeze them in, they are willing to move around their schedules to come. But I just can’t promise I can or will always be available.



Medicine Must Start Caring for the Caregivers

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Practicing medicine is bad for your health. Mounting evidence shows that stress-related burnout is a significant and growing threat to doctors – and their patients. If there is a silver lining, it is that the medical community is beginning to acknowledge and address the complex factors at play, recognizing that good health care must include caring for the caregivers.

Numerous studies reveal that physician burnout – generally defined as a loss of enthusiasm for work, feelings of cynicism and a low sense of personal accomplishment – is a major problem.

A Medscape survey found that 51 percentof doctors surveyed in 2016 said they suffered from burnout, an increase of more than 25 percent since 2013. This dovetails with a 2015 paper published in Mayo Clinic Proceedings, which reported a burnout rate of 54.4 percent in 2014, compared with a 45.5 percent rate in 2011. These burnout rates are almost twice as high as those found in the general population.

A 2015 Mayo Clinic study reported that roughly 40 percent of physicians suffer depression each year and almost 7 percent had considered suicide within the prior 12 months. It is estimated that 300 to 400 doctors take their lives every year.

The pain and suffering those statistics only hint at is bad enough. They are compounded by findings that burnout corrodes the doctor-patient relationship, resulting in lower levels of patient satisfaction, job satisfaction and productivity as well as higher levels of medical errors and disruptive behavior.

Burnout is also connected to the decision to switch jobs or leave medicine altogether – an ominous trend as the U.S. experiences a growing doctor shortage.

Many forces are driving this trend: long work days (doctors work an average of 50 hours per work, 10 more than other Americans), the demands of juggling busy careers with family obligations and the pressures caused by student debt (the average medical school graduate with student loans owes about $190,000 upon graduation).

These and other factors – especially the challenges of balancing work-home obligations – take a special toll on female doctors, whose burnout rates as twice as high as their colleagues, making them more likely to leave the profession.

Still, there is one significant new development that seems to be driving the recent increase in burnout: electronic health records (EHRs). It is no coincidence that the spike in burnout rates has come at the same time as the broad adoption of EHRs. Someday, EHRs may revolutionize health care by dramatically increasing our ability to share and review patient information. But today, EHRs are turning many physicians into clerks. It can take 32 clicks to order and record a single flu shot. Some studies show that doctors now spend about two hours on paper and desk work for every hour they devote to deliver direct patient care.

It is hard to overstate how much this dispiriting lack of personal contact, which is the major reason people choose careers in medicine, leads to the depersonalization and depression that are the hallmarks of burnout.

Perhaps the best evidence that practicing medicine is bad for one’s health is studies showing that medical students begin their training with stronger mental health profiles than their fellow college graduates. This advantage vanishes and a deficit emerges as they progress through their schooling, residency and professional practice.

As in medicine, we must identify the problem before we can treat it. A crucial step was taken in July when the National Academy of Medicine called on researchers to identify interventions that ease burnout. Many universities and academic hospitals have already been exploring ways to address the problem.

At the University of Michigan we established two groups earlier this year – one to look at burnout among our doctors, the other among our younger residents. It is still too early to say what might work. But ideas to help physicians achieve a better work-life balance, including more flexible scheduling that recognizes family commitments as well as better child care assistance, seem promising. So, too, does the use of “scribes” to handle some paperwork chores and drawing a sharper distinction between the care only doctors can deliver and that which can be provided effectively by physician’s assistants and other trained personnel.

Above all, we must allow doctors to ask for help and provide them with the care they need without penalty. Medicine has long been hampered by the ancient myth of invincibility – the notion that physicians must never show weakness, every embodying grace under pressure. This is not only wrong, it’s dangerous.

Physician burnout is a national crisis. Unfortunately, it does not offer a quick fix. Medicine will always be a uniquely demanding profession, requiring years of training and long hours of service to be ready to make life and death decisions.

Fortunately, a broad consensus has emerged in the medical community that doctors cannot provide the best care for their patients if we don’t figure out how to take care of them.


When Dying Man’s Last Wish Is Against Hospital Rules, Nurse Goes Above And Beyond To Fulfil It

Carsten Hansen’s dying wish wasn’t a complicated one. The 75-year-old man wanted to smoke a cigarette, drink a glass of white wine, and watch the sun set. His wish was, however, against hospital rules.

After suffering an aortic aneurysm, Hansen was admitted to a Denmark hospital in April. The surgery to repair the aneurysm was long and complicated, and Hansen would need to stay in the hospital for the recovery.

However, Hansen was too weak and sick to survive the surgery. Without it, he probably wouldn’t live more than a few hours, since the aneurysm had caused significant internal bleeding. Knowing that he had just a few hours to live, Hansen told nurses that he wished to smoke a cigarette, drink white wine, and watch the sun set.

Working together, the nurses found some white wine. Hansen’s hospital room had a view of the setting sun, so that part of his wish would be taken care of. Finding a cigarette proved to be a challenge, though. The hospital had a no-smoking policy to help protect its patients’ health. However, Rikki Kvist, Hansen’s nurse, decided that just this one time it would be okay to break that rule.

Nurses wheeled Hansen out onto the balcony, lit a cigarette for him, and gave him a glass of white wine. Hansen was able to watch the sun setting with his family.

According to Kvist, the atmosphere was a relaxed one. Hansen’s family was doing their best to cope with the fact that he was going to die, but the moment was also filled with love and humor.

When the nurses shared the special moment through a Facebook post, other Facebook users praised their actions in fulfilling Hansen’s last wish.

Users posted comments in support of the nurses, stating that the hospital provided hope, and some users even posted that they wished their own relatives had had such an experience.

Hansen passed away on April 28, but thanks to a special team of nurses, he got to live out his dying wish.

What do you think of the nurses’ actions in fulfilling Hansen’s wish?