Parents unclear about process for specialist care for kids.
No recommendations, but an interesting survey.
From the University of Michigan Press Release
Answers vary about the roles of parents and care providers in referral process, according to U-M’s National Poll on Children’s Health
ANN ARBOR, Mich. – Parents vary widely in views about their responsibilities in getting specialty care for their children, according to a new University of Michigan C.S. Mott Children’s Hospital National Poll on Children’s Health.
Most children get their health care from a primary care provider, known as a PCP, but when there are signs or symptoms of a more serious illness, the PCP often refer kids to a specialist.
According to this month’s poll, it’s a common occurrence. Among the 1,232 parents surveyed in this poll, 46 percent report that at least one of their children has been referred to a specialist.
But when asked about the process of getting specialist care for their child, parents had a wide range of views, says Sarah J. Clark, M.P.H. , associate director of the National Poll on Children’s Health and associate research scientist in the University of Michigan Department of Pediatrics.
Parents are divided over who is responsible for choosing the specialist: 52 percent say the PCP and 48 percent say the parent. They also differed in who should verify insurance coverage: 55 percent say the PCP and 45 percent say the parent.
Forty percent of parents say the PCP should make sure the wait time isn’t too long for a specialist appointment, but 60 percent say that’s the parents’ responsibility.
“This poll shows a wide range of views about who is supposed to do what, so it’s not unexpected that sometimes the process doesn’t work well,” says Clark. “If a referral is delayed or it doesn’t happen at all, a child’s health can be put at risk.”
The poll also found that parents of children with Medicaid insurance coverage are more likely than parents of privately-insured children to say PCPs should be responsible for choosing the specialist, calling to set up the appointment, and verifying that insurance will cover the specialist care. Clark says this indicates that PCPs should understand that their Medicaid patients may have different expectations about their roles.
Parents also were asked to rank the importance of different characteristics of specialists, and rated the following as very important:
- knowing how to take care of the child’s specific condition (89%)
- having training in pediatrics (80%)
- being affiliated with a highly-rated hospital (62%)
- being involved in research so child has access to latest treatment (50%)
- appointment time convenient for the family schedule (43%)
- drive time to the specialist (38%)
- other parents recommending the specialist (38%)
“For a parent, hearing that a child needs to see a specialist is often cause for concern. Confusion about their responsibilities for arranging specialty care can add to parents’ anxiety,” says Clark, who also is associate director of the Child Health Evaluation and Research (CHEAR) Unit.
“Primary care providers cannot assume that parents understand their responsibilities around making specialty appointments. Clear communication — ideally, with instructions written in plain language — will help parents ensure their kids get the care they need.”
Broadcast-quality video is available on request. See the video here:http://www.youtube.com/watch?v=uif7xpr5iy8&feature=youtu.be
Full report: C.S. Mott Children’s Hospital National Poll on Children’s Health
Website: Check out the Poll’s website: MottNPCH.org. You can search and browse over 80 NPCH Reports, suggest topics for future polls, share your opinion in a quick poll, and view information on popular topics. The National Poll on Children’s Health team welcomes feedback on the website, including features you’d like to see added. To share feedback, e-mailNPCH@med.umich.edu.
From the 1 October 2012 article at Science Daily
Patients with access to notes written by their doctors feel more in control of their care and report a better understanding of their medical issues, improved recall of their care plan and being more likely to take their medications as prescribed, a Beth Israel Deaconess Medical Center-led study has found…
“Open notes may both engage patients far more actively in their care and enhance safety when the patient reviews their records with a second set of eyes.”
“Perhaps most important clinically, a remarkable number of patients reported becoming more likely to take medications as prescribed,” adds Jan Walker, RN, MBA, co-first author and a Principal Associate in Medicine in the Division of General Medicine and Primary Care at BIDMC and Harvard Medical School. “And in contrast to the fears of many doctors, few patients reported being confused, worried or offended by what they read.”…
Of 5,391 patients who opened at least one note and returned surveys, between 77 and 87 percent reported open notes made them feel more in control of their care, with 60 to 78 percent reporting increased adherence to medications. Only 1 to 8 percent of patients reported worry, confusion or offense, three out of five felt they should be able to add comments to their doctors’ notes, and 86 percent agreed that availability of notes would influence their choice of providers in the future.
Among doctors, a maximum of 5 percent reported longer visits, and no more than 8 percent said they spent extra time addressing patients’ questions outside of visits. A maximum of 21 percent reported taking more time to write notes, while between 3 and 36 percent reported changing documentation content…
Walker suggests that so few patients were worried, confused or offended by the note because “fear or uncertainty of what’s in a doctor’s ‘black box’ may engender far more anxiety than what is actually written, and patients who are especially likely to react negatively to notes may self-select to not read them.”..
About 10 years an area health care provider told me she did a study on prescription adherence.
The results included a shocking low percentage of folks taking their prescriptions as prescribed.
She said that no journal would publish the results, because the rates of adherence were so low. (This seemed odd to me, this reasoning).
I’ve been prescribed a cholesterol lowering drug, for being a bit over the HDL threshold. I decided to stop taking it, because after all I have read, I don’t really believe in either the tests, the thresholds, and the efficacy of the drug. No, I haven’t discussed this with my prescribing physician, but I think I’m going to catch hell on the next annual exam. For the past 5 years (age 58) I’ve only seen the doctor about once a year, just for the annual wellness.
From the Rand report summary
Analyses indicated that although physicians uniformly felt responsible for assessing and promoting adherence to prescriptions, only a minority of them asked detailed questions about adherence.
“Medicine left in the bottle can’t help.”
— Yoruba proverb
Lack of adherence to prescriptions (that is, patients failing to take medicine either as instructed or at all) afflicts medical care in the United States. Nonadherence affects up to 40 percent of older adults, especially those with chronic conditions, and is associated with poor outcomes, more hospitalizations, and higher mortality. The health care cost of nonadherence is estimated at $290 billion per year. Prior RAND research has shown that some nonadherence is cost-related and can be addressed through insurance benefit designs that keep copayments low.
Physicians also play a key role in addressing nonadherence. Yet physician perspectives on their responsibility for nonadherence and strategies for promoting adherence are not well understood. A team from RAND; the University of California, Los Angeles; and the University of California, Davis, examined physicians’ views about their responsibility for medication adherence and explored how physicians and patients discuss nonadherence. The team conducted focus groups with physicians in New Jersey and Washington, D.C., and audiotaped primary care visits in Northern California doctors’ offices.
The results point to a contrast between what physicians believe and what they do:
- Although physicians uniformly felt responsible for assessing and promoting medication adherence, only a minority of them asked detailed questions about adherence.
- Although providers often checked which medications a patient was taking, they rarely explicitly assessed adherence to these medications.
- Many physicians expressed discomfort about intruding on patients’ privacy to detect nonadherence. In the office, they rarely asked about missed medication doses.
- Most cases of nonadherence detected during office visits were revealed through unprompted patient comments.
Physicians’ reluctance to intrude has important implications for the vast array of new information that is becoming available from pharmacy benefit plans, managed care plans, and other data repositories. In addition, the reluctance to inquire that the physicians described contrasts sharply with the physician role in the increasingly prominent concept of the medical home, where primary care doctors are envisioned as playing a central and active role in managing and coordinating care.
The authors conclude that addressing nonadherence will require a different approach than the one they observed in the study. Given the importance of patients’ shared responsibility, a new paradigm that clarifies joint provider-patient responsibility may be needed to better guide communication about medication adherence. In this context, developing new protocols to guide discussions of adherence is worth exploring.
By BRIAN KLEPPER AND PAUL FISCHER in their 9 August 2012 post at The Health Care Blog
Excessive health care spending is overwhelming America’s economy, but the subtler truth is that this excess has been largely facilitated by subjugating primary care. A wealth of evidence shows that empowered primary care results in better outcomes at lower cost. Other developed nations have heeded this truth. But US payment policy has undervalued primary care while favoring specialists. The result has been spotty health quality, with costs that are double those in other industrialized countries. How did this happen, and what can we do about it.
American primary care physicians make about half what the average specialist takes home, so only the most idealistic medical students now choose primary care. Over a 30 year career, the average specialist will earn about $3.5 million more. Orthopedic surgeons will make $10 million more. Despite this pay difference, the volume, complexity and risk of primary care work has increased over time. Primary care office visits have, on average, shrunk from 20 minutes to 10 or less, and the next patient could have any disease, presenting in any way.
By contrast, specialists’ work most often has a narrower, repetitive focus, but with richer financial rewards. Ophthalmologists may line up 25 cataract operations at a time, earning 12.5 times a primary care doctor’s hourly rate for what may be less challenging or risky work.
These differences in physician worth and payment didn’t just happen. Instead, they have been driven by a 31 doctor – 26 specialists and 5 primary care physicians – American Medical Association panel, the Relative Value Scale Update Committee (RUC), which for 20 years has been Medicare’s sole advisor on the value of physician services. The Centers for Medicare and Medicaid Services (CMS), the federal agency overseeing the program, has historically accepted nearly 90 percent of the RUC’s recommendations with no further due diligence. So the RUC has huge financial impact throughout health care, not only for Medicare but for many commercial health plans that follow Medicare’s lead on payment…
t is clear that it will be impossible to get American health care under control unless we can recapture regulation and reconfigure it to act in the common rather than the special interest. Until that is accomplished, America’s and our children’s diminishing prospects will be directly tied to our failure to stop the health industry’s rapaciousness.
From the 28 March 2011 Eureka news alert
WASHINGTON — The traditional separation between primary health care providers and public health professionals is impeding greater success in meeting their shared goal of ensuring the health of populations, says a new report from the Institute of Medicine. Integration of these fields will require national leadership as well as substantial adaptation at the local level, said the committee that wrote the report.
[ The report is free and available at http://www.iom.edu/Reports/2012/Primary-Care-and-Public-Health.aspx
The above link also includes a briefing slides (an overview) and a report brief.]
The report recommends ways that the Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA) could foster integration between primary care and public health through funding, policy levers, and other means. Collaboration presents an opportunity for both primary care and public health to extend their reach and achieve the nation’s population health objectives, the committee noted.
The committee’s recommendations are based on its review of published papers as well as case studies in specific cities — Durham, N.C.; New York City; and San Francisco — where integration efforts have taken place. The review showed that successful integration of primary care and public health requires community engagement to define and tackle local population health needs; leadership that bridges disciplines and jurisdictions and provides support and accountability; shared data and analyses; and sustained focus by partners.
The Patient Protection and Affordable Care Act (ACA) authorizes HRSA and CDC to launch several new programs. The agencies should coordinate these programs and funding streams with other partners at the national, state, and local levels to spur momentum. Promising opportunities include building incentives to promote interactions with local public health departments into HRSA’s funding for community health centers; encouraging hospitals to treat primary care and community health as priorities as they strive to earn federal tax exempt status through demonstrated community benefits; and fostering collaboration among health departments and community health centers to improve the provision of preventive clinical services to Medicaid recipients.
The medical home model and the new accountable care organizations (ACOs) established by ACA also offer opportunities for integration. As more primary care practices move toward the patient-centered medical home model, public health departments could work with these practices and spread the benefits of care coordination to the community, the committee said. As ACOs — groups of hospitals and clinicians that work together to provide primary care and other health care services to Medicare beneficiaries — begin operating, they should reach out to health departments to forge links to community programs and public health services.
Training primary care and public health professionals in aspects of each other’s fields will help promote a more integrated work force, the report adds. HRSA and CDC should work together to develop training grants and teaching tools that can prepare the next generation of health professionals for shared practice. For example, HRSA should use its Title VII and VIII primary care training programs to support curriculum development and training opportunities that involve aspects of public health, and CDC’s Epidemic Intelligence Service officers could assist HRSA-supported community health centers in using public health data to guide the care they provide.
“While integrating fields that have long operated separately may seem like a daunting endeavor, our nation has undertaken many major initiatives, such as building both a national hospital system and an extensive biomedical research infrastructure and significantly expanding high-tech clinical capacity through investments in specialty medicine,” said committee chair Paul J. Wallace, senior vice president and director, Center for Comparative Effectiveness Research, The Lewin Group, Falls Church, Va. “It’s time we did the same for primary care and public health, which together form the foundation of our population’s overall well-being. Each of these foundational elements could be stronger if they were better coordinated and collaborated more closely.”
The report was sponsored by the Centers for Disease Control and Prevention, Health Resources and Services Administration, and United Health Foundation. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The Institute of Medicine, National Academy of Sciences, National Academy of Engineering, and National Research Council together make up the independent, nonprofit National Academies. For more information, visit http://national-academies.org or http://iom.edu. A committee roster follows.
Do You Really Need a Yearly Checkup? | Yahoo! Health By Lisa Collier Cool
Typically, a routine visit with your primary care doctor involves a slew of tests and screenings. While patients are often told that all this poking and prodding is crucial to protect their health, is there any scientific evidence to support that? A decade ago, the US Preventative Services Task Force (USPSTF), an independent group of medical experts appointed by Congress, concluded that yearly physicals are unnecessary for healthy, symptom-free adults.
What’s more, a new study published in Archives of Internal Medicine*** reports that primary care doctors often order unnecessary and inappropriate tests, screenings and treatments, costing the healthcare system—and patients—$6.8 billion in 2009. The annual checkup is a prime culprit in needlessly driving up medical bills, the researchers found, with dubious or worthless tests ordered in up to 56 percent of these exams.
Find out how to save big on rising healthcare costs.
Instead of a yearly checkup, the new thinking is that healthy patients should “check in” with their doctors periodically, on a schedule tailored to their individual needs, to discuss any medical concerns and which tests truly are appropriate for their age, gender, and family history. Here’s a look at routine screenings that primary care doctors are most likely to use needlessly, according to analysis by the National Physicians Alliance (NPA)—and when these tests are worthwhile….
Read the article (it includes comments about specific tests)
***The article, “Top 5″ Lists Top $5 Billion, is available online only through paid subscription.
Click here for suggestions on how to get this article (and other science/medicine articles) for free or at low cost
Here are the first 150 words of the Top 5 article from the Archives of Internal Medicine Web page
Minal S. Kale, MD; Tara F. Bishop, MD, MPH; Alex D. Federman, MD, MPH; Salomeh Keyhani, MD, MPH
Arch Intern Med. 2011;171(20):1856-1858. doi:10.1001/archinternmed.2011.501
|Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.
The Good Stewardship Working Group presented the top 5 overused clinical activities across 3 primary care specialties (pediatrics, internal medicine, and family medicine), as chosen by physician panel consensus.1 All activities were believed to be common in primary care but of little benefit to patients. We examined the frequency and associated costs of these activities using a national sample of ambulatory care visits.
We performed a cross-sectional analysis using data from the 2009 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS). The NAMCS and NHAMCS survey patient visits to physicians in non–federally funded, non–hospital-based offices and non–federally funded hospital outpatient departments, respectively.2
We limited our sample to visits by patients to their primary care physicians. Visits for each “top 5″ primary care activity were identified . . . [Full Text of this Article]
by KEVIN PHO, MD at KevinMD.com
The following column was published on November 10, 2011 inMedical Economics.
I recently saw two patients in my primary care clinic, each with new-onset hypertension.
The first, a middle-aged executive, brought printouts from the Internet and already had researched the various treatment options for high blood pressure. During the visit, we discussed this information, and I gave my thoughts on what to do next. He considered and appreciated my input but made it clear that the ultimate decision was his.
The second was an elderly gentleman in his 70s. Again, I discussed the various management approaches and then gave my opinion on what we should do. In contrast to the other patient, he said, “I want to do whatever you suggest. After all, you’re the doctor.”
As a publisher of a social media health Web site, I’ve observed closely the growth of the patient empowerment movement, facilitated by the Web making health information more accessible. According to the Pew Internet and American Life Project, 80% of Internet users go online to research their health, and this effort gives patients a greater voice in their care. Paternalistic decision making that traditionally drove the doctor-patient relationship slowly is being replaced by shared decisions. But not all patients embrace their new decision-making role.
In a recent study from the Journal of Medical Ethics, researchers interviewed more than 8,000 patients. Almost all wanted doctors to offer choices and help consider their options, but two-thirds preferred that the final medical decision to be left to the physician.
According to Farr A. Curlin, MD, an associate professor of medicine at the University of Chicago and one of the authors of the study, “the data [say] decisively that most patients don’t want to make these decisions on their own.”
There is a spectrum of how much physician involvement patients want. Some may want physicians only to suggest and inform but leave the ultimate decision to them. Others prefer doctors to have the final say.
The only way to know a patient’s preference is through a continuous relationship where that comfort level can be developed over time. After several encounters, a clinician should have a sense of how much, or how little, direction a patient needs.
Sadly, two factors in healthcare today work against such a sustained doctor-patient relationship. One is the fragmentation of medical care. More patients are seeing not only a primary care physician (PCP) in a clinic, but also a hospitalist when admitted to a hospital, along with an array of specialists both in the hospital and the clinic. According to a New England Journal of Medicine study, Medicare beneficiaries saw an average of two primary care physicians and five specialists working in four different practices. Without knowing the patient well, each provider may differ with his or her input in the medical decision process, which can frustrate patients who may have their own ideas of how much their doctors should be involved.
Next, consider the decay of primary care itself. There is a profound shortage of PCPs, with the American College of Physicians noting that “primary care, the backbone of the nation’s healthcare system, is at grave risk of collapse.” Patients who cannot schedule timely primary care appointments go to the emergency department, where they encounter clinicians they’ve never met before. The shortage is compounded by what is shown in the results of an Annals of Internal Medicine survey, which revealed that 30% of PCPs were likely to leave the field, citing burnout from time pressures, a chaotic work pace, and little control over their work. Both the shortage and attrition of primary care providers worsen the odds of forming long-term relationships with patients.
Having known my two patients with hypertension for years, I anticipated how much physician involvement they would need to make a treatment decision and was able to tailor my approach to meet their individual expectations. During this turbulent period of healthcare reform, we cannot lose sight of the importance of a continuous relationship between doctors and patients. Otherwise, our fragmented health system and deterioration of primary care will make it challenging to provide the proper amount of guidance for patient medical decisions.
Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today. He is founder and editor of KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn.
The internet has changed people’s relationships with information. Our data consistently show that doctors, nurses, and other health professionals continue to be the first choice for most people with health concerns, but online resources, including advice from peers, are a significant source of health information in the U.S.
Background Although medical ethicists and educators emphasise patient-centred decision-making, previous studies suggest that patients often prefer their doctors to make the clinical decisions…
Conclusions Almost all patients want doctors to offer them choices and to consider their opinions, but most prefer to leave medical decisions to the doctor. Patients who are male, less educated, more religious and healthier are more likely to want to leave decisions to their doctors, but effects are small.
From the November 2011 Report
An international survey of adults living with health problems and complex care needs found that patients in the United States are much more likely than those in 10 other high-income countries to forgo needed care because of costs and to struggle with medical debt. In all the countries surveyed, patients who have a medical home reported better coordination of care, fewer medical errors, and greater satisfaction with care than those without one.
- Sicker adults in the U.S. stood out for having cost and access problems. More than one of four (27%) were unable to pay or encountered serious problems paying medical bills in the past year, compared with between 1 percent and 14 percent of adults in the other countries. In the U.S., 42 percent reported not visiting a doctor, not filling a prescription, or not getting recommended care. This is twice the rate for every other country but Australia, New Zealand, and Germany.
- In the U.S., cost-related access problems and medical bill burdens were concentrated among adults under age 65. Compared with Medicare-aged adults 65 or older, adults under 65 were far more likely to go without care because of the cost or to have problems paying bills.
- Adults with complex care needs who received care from a medical home—an accessible primary care practice that knows their medical history and helps coordinate care—were less likely to report experiencing medical errors, test duplication, and other care coordination failures. They were also more likely to report having arrangements for follow-up care after a hospitalization and more likely to rate their care highly.
- Sicker adults in the U.K. and Switzerland were the most likely to have a medical home: nearly three-quarters were connected to practices that have medical home characteristics, compared with around half in most of the other countries.
Image via Wikipedia
From a 22 July KevinMD.com posting by Mark Novotny, MD
The emerging literature on chronic disease management suggests that successful programs rely on patient self management skills. Having been in the primary care role for 20 years, that initially seemed self evident and a bit “so what?” to me, thinking it meant that we just need to teach our patients a bit more in the primary care office.
However self-management skills refer to specific curricula of skills that can be taught to patients in formal programs, without doctors. Coordinating these activities with what goes on a primary care office, and the community, and other care-giving settings is critical. These specific skills involve patients setting their own goals, and then creating plans to reach those goals with the assistance of their primary care team and others, but not at the direction of their primary care team. This is a real mind shift for the primary care doctor also.
Read entire article