As debate over the cost of health reform intensifies, it is worth repeating that significant savings will result from making fundamental changes in the way health care is delivered. Here at Healthbeat, we have written extensively about how cutting the waste and over-treatment out of the current health care system will not only reduce the cost of care, but also lead to better outcomes for patients. But there is nothing like a real-life experience to drive this message home.
Recently, my neighbor called and asked if I would walk with her to her internist’s office just two blocks away. Mary is 80 years old and had been feeling dizzy and unsteady on her feet for over a week. Since she has hypertension, she wanted the doctor to check her blood pressure to make sure it wasn’t contributing to her symptoms.
After the doctor spent a few minutes with Mary in the examining room he came out to speak with me. “Have you noticed that Mary’s been upset about anything recently? Has she told you that there’s something going on in her life that’s been stressful?”
I wasn’t exactly sure how to answer this. I’ve lived next door to Mary for thirteen years and for the first eight her gregarious husband was the focus of her life. His slow death from heart failure three years ago was obviously upsetting and stressful. I also know that two of Mary’s sons died when they were young adults—but all of this was old history. She’s been alone, probably depressed, anxious and dealing with a variety of health issues for many years. I didn’t have an answer for the doctor, but I did sense his frustration with my neighbor’s frequent visits for health complaints that seemingly had no cause. He’d ordered blood work, a sonogram and an endoscopy just last month—with no significant findings.
On our way home, Mary was angered by the doctor’s insinuation that her dizziness and other problems were “all in my head.” She told me that on her visit two weeks ago he had sent her home with Xanax; she looked it up later in a reference book and was shocked to learn it was a strong sleeping pill that was also addictive. She said she took one-half a pill and didn’t wake up for 10 hours; she remained groggy and even dizzier for a while afterward.
When I asked her what other medications she was taking, Mary invited me in to her home to have a look. Out came a tray with at least ten pill containers on it. I lost track of the different medications and what they were for, but it sounded like her doctors—including the internist, a cardiologist and a rheumatologist—had ended up prescribing some pills to treat side-effects of others. Medications were updated as new versions and combinations came out and as her ability to tolerate side-effects changed.
But, I asked, was there anything new? It turns out that Mary had recently switched cardiologists. Although the old one was satisfied when treatment kept her diastolic pressure below 90, the new cardiologist—perhaps responding to recent guidelines from the American Heart Association—prescribed two different (and stronger) medications that were designed to bring her diastolic pressure down to 70 or 80. We looked at the labels on the new pill bottles—they both indicated that they could cause drowsiness and dizziness. And, Mary added, she had been seeing a nutritionist and had lost 25 pounds over the last few months.
I’m not a doctor, but the answer to this dizziness problem seemed so obvious: Mary was probably taking too much medication. Although people over 65 comprise only about 14% of the American population, they consume over a third of all medications. According to the American Society of Consultant Pharmacists, the average 65-69 year old takes nearly 14 prescriptions per year; those aged 80-84 take an average of 18 prescriptions per year. The net result: According to CNN.com;
“Every year, 38 million older Americans suffer drug complications, 180,000 of which are life-threatening, according to research by Dr. Jerry Gurwitz, chief of geriatric medicine at the University of Massachusetts Medical School."
The follow up to this real-life story is that I encouraged Mary to talk with her cardiologist. He immediately took her off her blood pressure meds and is reworking her regimen. The half-dozen or so visits to the internist, the invasive tests, the anxiety and suffering (and of course, the costs to Medicare)—all could have been avoided by someone asking the simple question; have there been changes in your medication?
Right now, the Medicare pay structure isn’t designed to encourage these kinds of conversations. It also doesn’t encourage the kind of coordinated care that includes an electronic health record that could have been easily accessible by Mary’s doctors. Instead, it encourages doctors to go it alone; performing costly tests and interventions aimed at finding new ailments—and prescribing more medication. A shortage of doctors who specialize in geriatrics, along with a dearth of research on how drugs effect older people, are other barriers to effective senior care.
Despite Medicare’s clear deficits, seniors are the group most opposed to health care reform—some 51% believe it will weaken the program. Republicans have been stoking this fear by warning seniors that they will face rationing, “death panels” and other restrictions on care. According to the Huffington Post, a recent mailer sent out by the Senior Citizen’s League (a conservative group that footnotes former New York Lt. Governor Betsy McCaughey as its source of data) warns seniors that health reform will lead to “the creation of a massive database that would endanger the privacy of personal medical information” and be used to justify rationing.
The mailer text includes the following concern;
"How would you like it if your doctor, your clinic, or other healthcare providers — without either your knowledge or consent — gathered up your, along with your family's medical history, and sent your most intimate conversations to a central data bank in Washington D.C. to become a part of the largest computer network ever created?"
This “largest computer network ever created” is undoubtedly a reactionary spin to the government’s plan to use (de-identified) Medicare data to help pinpoint the best treatments and practices for the elderly. This kind of comparative-effectiveness research is one of the keys to cutting out the waste, over-treatment and just plain bad treatment that drives up the cost of our health care system and harms patients.
Reforming health care is an enormous undertaking. Mary’s dizziness problem was minuscule in the scheme of things. But for me, this one experience really drove home some fundamental failings in our health care system—uncoordinated care, an emphasis on procedures rather than conversations, and a lack of evidence-based treatment guidelines, to name just a few. Health care reform will undoubtedly change Medicare—but for Mary and the 41 million other seniors who are enrolled in the program, this can only be for the best.
Excellent example of how a proper history can be applied to get to the root of the problem. There is no reward under the current system however (other than the satisfaction of doing the best for your patients) in efficiently reaching this diagnosis. Better to shuffle the patient off to the neurologist or cardiologist since spending the additonal time on a proper history and physical is a money loser under current Medicare payment schemes. This needs to change and primary care needs to be strengthened to do this. It has struck me that what our current system benefits from the most is a dumbed down primary care sector that serves as nothing more than a triage system to determine what specialist should be seen. How else can you see patients every 5 minutes and do an adequate job?
In my opinion, this should have been the first question the doc should have asked (are there any changes in your medication). It is the one question that always has the greatest yield of finding the cause for the symptoms in my experience.
One other question I think this example might highlight concerns the coming attempt to measure quality of care in physicians. Undoubtedly, we will be measured in the future on the basis of how many of our patients have their blood pressure well controlled. Your neighbor did not tolerate having her blood pressure controlled to the proper level, and many elderly patients have the same difficulty. What will happen to the doctors measures of “quality” when Mary’s blood pressure is judged to be inadequately controlled and the physician is dinged for his poor care? If only patient care was easily subject to some cookbook approach. But then we wouldn’t need doctors; just give the a copy of the cookbook to everyone!
A systemwide EMR would have solved the problem. These type of issues rarely happen in our system, because we have a fully integrated web based hospital, specialty clinic, primary care clinic emr with e-prescribing.
all true enough, but there’s a simpler way to get coordination of care — simply use doctors who talk to one another and practice within the same institution. for most of us who live in big cities, that’s not an overwhelming task. patients should be told of the risks of uncoordinated care. that will not only protect them, but also could drive more practitioners into systems if that’s where the patients were headed.
This is a failure by a lack of technology. A properly integrated system will coordinate care every time not because they feel like it one day or are being paid to do it the next.
Federal funding may be encouraging a move toward EHR, but there’s more to it than just installing systems. How can healthcare data pooling lead to a better system? More at http://www.healthcaretownhall.com/?p=1499
Excellent post, Naomi. I hope you are being consulted by Congress. They need to hear these stories in addition to the stories of people being denied coverage. Anybody who knows enough to read this blog realizes that merely paying for more people to join the current system will not be sustainable.
yep…
Great story. In response to Jenga’s comment: EMRs are a tool. It takes a good mechanic with the proper mindset to use that tool to see the obvious and know how to fix it.
If you set up a system where physicians get bonuses for controlling costs in a high quality setting, you get a much better result. Unfortunately Original Medicare’s incentives are the opposite. This is what Medicare Advantage HMOs are supposed to do! They actually do it in certain areas where the physician infrastructure can efficiently “manage care”, eg. Southern CA.
The Administration should demand such results and savings from managed care rather than just trashing them. We need the private sector to help. Maggie, your example is an embarassment to medicine in general.
Thank for highlighting the common problem of inappropriate or over-prescribing in older patients. My father had a similar experience, which I blogged about here [http://www.jhartfound.org/blog/?p=177%5D. These stories are perfect examples of why it is so important that we not only train more geriatricians, but also make sure that all primary care doctors receive training in how to treat and manage older patients.
the doctor who tried to get her blood pressure low enough to satisfy a guideline will have higher “quality scores” than a doctor who carefully considers whether or not that makes sense for Mary.
We need to be very careful how we measure quality.
Whatever happened to personal responsibility? Is it unreasonable to ask the patient to provide an accurate list of the pills they take on a regular basis? For ANY provider, getting an accurate history of meds is an essential first step in the patient encounter. And patients should be taught to keep an up to date list in her (his) wallet, by EVERY provider they see. You docs can have your nurses do it!
Yes, it will be nice when we have a decent central EMR, but even then, the individual will STILL need to be vigilant about ensuring its accuracy. Mary, and all patients, need to take ownership of their medication history and it is OUR job to teach them how to do it.
Jane & Everyone —
This is Naomi’s post, and I know she’ll be responding to all of you.
I just wanted to weigh in with a response to Jane:
As a nurse, I’m sure you know that elderly people sometimes have problems with memory loss and confusion. To demand that an elderly person take “personal responsibility” for knowing the (often difficult to remember and pronounce) names of all of her medications, (or keep an entirely accurate, updated list) shows a lack of compassion and understanding that I find surprising–especially coming from a nurse.
“Personal responsiblity” is all well and good, but we need to remember that, for a variety of reasons (lack of education, age, the fact that they are very, very ill) many members of society are not in a position to “take repsponsibility” for their healthcare.
A word in support of Jane. I don’t think she meant to be cruel to an elderly person. Her idea that people should have a list of their prescriptions is a good one. This is particularly true of elderly people with failing memory.
I managed my parents prescriptions for a number of years before they went into assisted living. Both of them had lists of their prescriptions and took them along to doctors appointments. There was no way that my parents could have remembered all the names and doses of meds they were on.
Obviously a doc treating the patient should also know all their patients meds, and in an ideal world they would. But with a patient seeing a number of different doctors
there can be confusion about exactly what drugs and in what doses patients are on.
An alternative way to handle this problem is to have a unified electronic medical record. But I am a big believer in the ability of things to get royally fouled up electronically even more than if they are on paper.
From the concern information,I agree with that the Medicare pay structure isn’t designed to encourage these kinds of conversations. It also doesn’t encourage the kind of coordinated care that includes an electronic health record that could have been easily accessible by Mary’s doctors.
The fear tactics coming from the right are shocking, to say the least.
The notion that electronic medical records is somehow a conspiracy to ‘get your information and share it with the world’ is insane.
It’s worth noting that George Bush spearheaded the electronic medical records issue and had as his goal that all medical records would be online, so to speak, by 2014, I believe it was.
Obama added funding for the measure, but the language used to describe the goal is relatively the same.
I wonder how many Republicans shouted “government takeover” when Bush introduced the idea?
Steve,
“The fear tactics coming from the right are shocking, to say the least.
The notion that electronic medical records is somehow a conspiracy to ‘get your information and share it with the world’ is insane.”
I support the push toward an electronic medical record, although I think its proponents are engaging in some wishful thinking about what it can do in terms of cost savings.
It should be recognized that the electronic medical record could result in significant privacy problems. Everyone’s medical record will be more easily available to more people. Lapses in security will definitely occur.
If you have been following the news you have heard about government laptops filled with Soc. Sec numbers and other data going missing. You may have also heard about the transcriptionist in India who posted medical records on the Internet – this was part of the genesis of HIPAA. Who is going to police all of this?
I’ve been wondering: Why is the cost of health care procedures and treatments so mysterious? How come I don’t know the cost of a test or an office visit?
In all the talk about health care reform, there’s a vital aspect that gets overlooked: understanding the real cost of health care. All of us want better quality and better value, and so we’ve got to stop just nodding along and start getting good health care and lifestyle choices in our own control. Where they belong.
We shouldn’t hesitate to ask “Why?,” “How much?” and “Is it necessary?” I got a kick out of this fun, short video. Check it out. It makes you wonder why out health care system is set up the way it is.
http://www.whatstherealcost.org/45secondstoshare
What in the heck is a cardiologist doing managing blood pressure? As as family doc, that’s my job. If I can’t get it under control, which is unusual, I call the nephrologist at Sacred Heart in Spokane who gives me some advice over the phone. The cardiologist doesn’t enter into it. What the heck are you all doing there in New York? Sounds like too many cooks in the kitchen.
jrossi said:
“What in the heck is a cardiologist doing managing blood pressure?”
I was about to ask the same question, but thought it would have been somewhat presumptuous as a Radiologist to do so.
Dr. Rossi practices in a low cost area of the country where primary care docs manage hypertension without Cardiologists. Mary lives in a high cost area. Would Mary (and other New Yorkers) be happy without their specialists?
It’s funny to connect the experience of Mary to the modern and electronic medical record. Well, it’s true. The doctor can easily give dosage for the patient depending on the age and condition.
-nj
Today where time is of extreme importance, Electronic Medical Record Software can quickly provide the information for decision making. EMR software not only offers better health care but also upgrades the overall functionality.
So now the key question is: if health care reform is repealed, will the Meaningful Use dollars get pulled back too? Any thoughts?