Sunday, September 30, 2007
While they are aware of their professional fees, many are blissfully unaware of how much the hospital charges for its services - and how the hospital pads its bills. While many doctors fume about this in private, they usually put up with these evils as "the cost of doing business" - and since they are not united, they cannot fight the hospital management effectively. In the long run, it's their patients who suffer. It's quite funny to see the "sticker shock" which doctors get when they seek medical treatment for their family members in their own hospitals.
Why are doctors so poorly informed regarding the financial burden they levy on their patients as a result of their advise ? Many feel that money is a grubby topic which is below their dignity to consider. Others take the attitude that they need to prescribe the " best " - never mind the costs. This can be counterproductive - and many patients are driven to bankruptcy because of the high costs of medical treatment.
This is why offering all inclusive packages which cover all costs can be so helpful. This prevents last-minute financial surprises - and allows the patient to select the package which suits his budget.
In our clinic, we go one step further. IVF treatment can be very expensive - and since the outcome of a given cycle is always uncertain, the expense on IVF is potentially open-ended and limitless. This is why we offer our patients a money back option . Not only does this serve as a guarantee of our confidence in the high quality of medical care we provide; it also allows the patient to limit their financial exposure, thus putting a cap on their expenses. It also allows them to approach the IVF treatment with more realistic expectations,since they are mentally prepared that it may not be a single shot affair .
I found that while the medical care was fine ( after all my friend got VIP care since I was with him - some perks of being a doctor !); the customer service was extremely poor !
We spent a long time at billing counters and filling up forms - and everytime a new test was ordered, we had to go back to pay more money to get the test done. Finally, we spent more time with the billing department than we spent with the doctor !
It would be so easy to fix this problem ! Hospitals should have more counters to fulfill their administrative duties - and each department could have their own billing station, so patients would not have to run down to the central billing counter each time to pay bills !
Since all the billing is computerised, this would be very easy to do.
I also think hospitals should have escorts ( or concierges) to help patients make their way through the complex maze the hospital represents. I am sure it would be easy to recruit volunteers from the community to perform this task - a win-win situation in places like Bombay, where there is no shortage of people !
Why does customer service get such low priority in hospitals ?
The rest of the scan was normal, but seeing this "abnormality" on the report, the obstetrician referred the patient to a fetal medicine specialist.
The trouble with specialists is that they see life through a specialised prism - a prism which is full of the problems in their field. If you have screwdriver in your hand, you tend to see only screws, and he then promptly advised an amniocentesis, to confirm that the baby was normal.
He even went so far as to suggest a termination, if she didn't want to take a risk !
It is true that life is full of risks - but these should be calculated risks ! While his advise was perfectly appropriate from a medical point of view, imagine the amount of emotional harm his words caused to the couple, who are now worried out of their wits. Rather than enjoying their long - awaited baby, each day is full of tension and suspense !
Tests are meant to reassure patients, but they often end up causing anxiety and worry - most of which is needless.
Tests are not always foolproof, and all medical tests have two major limitations.
1. False negatives , which refers to patients who have the disease, but the test fails to pick this up. Doctors worry like hell about these , because they can get sued for missing a diagnosis
However, far more common than there are the
2. False positives . These are the results which are reported as positive even though the person is healthy and does not have any disease. These results create more busy work for doctors , who then need to "run more tests" in order to clarify the situation , and rule out the "true positives" ( patients with the disease who have a positive test result ). However, these false positive results can create a lot of unnecessary anxiety in the patient's mind - as well as causing distress for family members. Unfortunately, none of anxiety is ever reported or considered by the specialist, who are blissfully unaware of the harm they have done.
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However, I cringe when I see misinformation being peddled on the net - and unscrupulous people taking infertile couples for a ride. I have already blogged about how the net is being misused to sell ineffective "medicines" such as Ovulex, so I won't go into that right now.
What's worse is women who now sell "info-products" or "e-books" to "educate" couples about infertility. While educating couples is important and there's nothing wrong with making money by doing this either , what I object to is the misleading way the information is being sold.
Basically, they prey on an infertile couple's vulnerability and ignorance. They promise the earth and can do so safely, because they are not doctors, which means they are not accountable or answerable. They create attractive websites ( for example, the identical sites at www.pregnantgetting.com and www.trickforgettingpregnant.com) using sophisticated marketing techniques developed by clever internet entrepreneurs, and sell these using google adwords, thus pushing couples into buying their products. And since their products are priced very reasonably, most couples are happy to buy - even though the same information is available for free elsewhere !
What's my objection ? Aren't they just fulfilling a need ? I strongly object to their bad-mouthing doctors on their sites. For example, one site which sells an e-book says,
So do not lose your chance to get the secret and the never been told methods that Doctors, Obstetricians & Gynecologist, may not be telling you just to protect dollars in their pockets and their entire line of businesses as well.
Please sell if you want to - but don't knock doctors in order to do so !
At this time, the only thing I can give them is a shoulder to cry on - and a copy of the Serenity Prayer.
God grant me the serenity
to accept the things I cannot change;
courage to change the things I can;
and wisdom to know the difference.
Living one day at a time;
Enjoying one moment at a time;
Accepting hardships as the pathway to peace;
Taking, as He did, this world
as it is, not as I would have it;
Trusting that He will make all things right
if I surrender to His Will;
That I may be reasonably happy in this life
and supremely happy with Him
Forever in the next.
I try to explain the ABCs of Rational Emotive Therapy to them - that's it not the Action ( the negative HCG because of the failure of the embryos to implant) which causes the Consequence ( the depression and sadness); but rather their Belief about the event ( that they are "worthless " because they cannot produce a baby) which causes the problems. I need to remind them that they are far more than just "baby-makers".
It's always hard for humans to deal with failure. Many infertile couples are young and successful and used to having their life going the way they want it to. They are smart and hardworking - and they are used to topping in their exams; getting the jobs they desire; the spouse they pursue; and advancing rapidly up their career path. They earn more money; buy a new car; buy a new house - everything falls into place for them ! And when they find out they cannot have a baby, this is a rude shock. This is often the first time they are confronting failure - and the reason this is so scary is that it's often the first time in their lives they are being forced to come to terms with their own biological limitations - their own mortality ! This is not a comfortable feeling , and the fact that the outcome of what they do is not in their hands , and that they may never get what they so strongly desire, can be very difficult to accept for many of them.
Many make a bad situation worse by blaming themselves for the failure. They feel that God is now punishing them because they were " selfish " and pursued a career and postponed childbearing. Also, the social stresses add insult to injury when well-meaning fertile friends and relatives say hurtful things - without even realising the damage they cause !
Some patients become very bitter, angry and unhappy as a result of the failure. Others, who are more resilient, become kinder, nicer human beings - more empathetic and understanding, because they have been through the fire of adversity. This is one of the reasons I like treating entrepreneurs - because they are used to dealing with failure - and bouncing back ! They response is - " Fine, what did we learn from this ? And what do we do differently the next time ?"
The life lesson a failed IVF cycle often teaches is that it forces you to confront your own mortality - that life can be fickle and uncertain. This can be a major life changing event - and if you enjoy the learning , you will learn the truth behind the saying - What does not kill you, makes you stronger !
Unfortunately, very few are willing to think through the " real-life problems" associated with surrogacy. Even a busy IVF clinic like ours which performs over 400 IVF cycles every year will only see 1-2 patients every month who actually need surrogacy.
Not only is surrogacy extremely expensive, it's also full of and emotional and ethical minefields which most doctors do not want to discuss. Infertile patients can be so desperate, that they are happy to try anything new - and clutching at the surrogacy straw seems to be a logical thing to do when you have failed 5 IVF cycles.
However , it's often not medically needed. Not only do these patients end up wasting a lot of time , money and energy - they also expose themselves to potential legal battles and emotional blackmail. Moreover, since they are operating in a legal grey zone, they leave themselves open to exploitation - both by the doctor ( who can charge a bomb for the treatment) ; the surrogate; and the agency which organises the surrogate.
The key question you should ask yourself is - do you really need it in the first place ? While there is no disputing that surrogacy is a valid treatment option for women without a uterus, the real tragedy is that it is being overused and misused to treat women with repeated IVF failures - an especially vulnerable group, which is extremely easy to exploit !
Most women who fail repeated IVF cycles for unexplained reasons usually do so because of a genetic abnormality in the embryo. This is Nature's defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because the eggs of older women have more genetically abnormalities, because they have "aged" and have genetic defects, which cannot be screened for.
It's extremely rare that the reason for failed implantation is a damaged uterus. However, after failing repeated IVF cycles, these women have extremely poor self-esteem, nd it's easy for unscrupulous doctors to exploit them . Since the literature is so confusing ( and confused) about IVF failure ( because we really don't have the tools to pinpoint the causes in women), they come to the conclusion that their uterus is "defective"; or that they have "immunologic issues" which is causing them to "reject" their embryos.
Because many of them have reached the end of their emotional tether , they do not want to take any more medications or suffer from the crippling blow of another failed IVF cycle. They are more than happy to allow the surrogate to go through the IVF process, so they don't have to deal with the physical and emotional pain of another failure. And when there is a demand for this extremely lucrative option, it's hardly surprising that agencies and doctors will be more than happy to supply this option for well-heeled patients - even though they may not actually need this at all, and would be better served by considering alternatives such as donor eggs or donor embryos.
treatment ? IVF can be extremely expensive , and since there is so much riding on this decision, it is critically important that you make it correctly ! So, how do you decide ?
Most couples will not apply their mind and simply go to the local IVF clinic - or where their GP or gynecologist sends them. The vast majority of patients are very passive. They rarely do any homework, and are happy to follow their doctor's advise. While this may be a good idea for some patients ( since it's so easy to just do what the doctor says), this is often not the best option. Smarter patients will explore their options, so that they can select the clinic which is right for them. After all, not every sportcar driver is going to be as good as Schumacher - and it's a good idea to try to maximise your chances of success !
Many will ask friends or relatives as to which the "best IVF clinic" is - and then follow this recommendation. They shop around by soliciting opinions , and while this can be effective occasionally, it is not a very reliable technique . Bad doctors may get a good reputation for spurious reasons, so this is not a method I would recommend.
Others will use the internet to research their options. This is a good idea - but you need to be fairly sophisticated in order to separate the wheat from the chaff in order to be able to use this correctly. There are lots of bad clinic with very good websites out there !
The best way is to shortlist 3 IVF clinics - and then interview them. You can do this by visiting them ( if you stay in a large city, for example, there are likely to be many clinics in the city itself , so you maybe spoiled for choice !) and asking for a guided tour. The others you can explore by emailing them or phoning them. You become a better and more discerning patient each time you get a second opinion, so this is a valuable exercise - don't take shortcuts which you might regret later !
Making the final decision is always a very personal matter. Some patients prefer large clinics with an international reputation. Others prefer those with the best rankings on the success-rate league tables. Other want a smaller clinic which offers a personal touch and more individualised care. There are many intangibles, such as the chemistry between you and your doctor, so it's hard to generalise what's going to be right for you - you will need to explore to find out what works best for you. The good news is that there are now many choices. You are no longer forced to settle for the nearest clinic, so you should take off your blinkers and be willing to do your homework.
This is a crucially important decision, and if you approach it intelligently, and invest the time and energy needed to perform your "due diligence", you will have peace of mind you did your best !
What else can you ask for ?
Saturday, September 29, 2007
In the past, housecalls were an integral part of the practice of medicine, and no nineteenth century doctor would even dream of practicing medicine without making housecealls. However, the fact that they are now practically unheard of means we should be taking a hard look at the present traditional ways of practicing medicine so e can come up with newer models of providing healthcare more efficiently and effectively.
The major bottleneck today in providing healthcare is the doctor. Doctors are expensive and scarce resources and the question we need to ask ourselves is simple – are we using this scarce commodity wisely ? The heart of modern medicine is based on the doctor-patient visit in the clinic – but is this really necessary ? Many problems are self-limited and could be better handled without involving a doctor. Many clinical transactions do not require a face-to-face discussion, and can be better done by email or through the web. Also, patients with chronic illnesses can be taught how to manage their own illness better. How can we create an alternative model, which offers a better option ?
Many attempts have been made in the past – and all of these have revolved around using a substitute for the doctor – for example, a village health worker in India, or a “barefoot doctor” in China. The modern “ retail clinic” in the US which is located in a mall is a variant on this model, since they allow a nurse ( who is much less expensive) to offer care for simple medical problems. However , none of these are very effective solutions, because they still keep the patient dependent on an outsider.
How can we create a more patient-friendly model ? I think we can learn from the education sector. In the past, education meant that children were sent to schools, where the experts ( teachers ) “taught” the children what they needed to know to pass their examinations. Today, we understand that teaching is not just the passive transfer of knowledge from teachers to students. Good teaching involves the active participation of students so they learn to learn for themselves. In fact, this is the major reason why the US has been so much more successful than other countries in the past few decades. In most countries, students were taught using traditional rote learning methods, which means they made great clerks or professionals, but they never learnt to take risks or think for themselves . In sharp contrast, thanks to the national network of free public libraries set up by Carnegie in the US, students here were forced to go to public libraries to do their own research for themselves, so they learnt to ask questions and find their own answers.
I think the health-sector can learn from this model by setting up networks of Patient education libraries to help patients get better healthcare. I agree this is an unusual proposal, but it’s worth examining closely.
- This is quite inexpensive to do. For the cost of one new MRI scanner, one could setup over 100 libraries , each equipped with about 100 books and 10 PCs with internet terminals !
- Librarians are much less expensive than doctors. They are also far better teachers , because they are used to helping and guiding patrons so they can find the information they need
- Patients in a library are likely to be much more empowered . They will not feel scared or intimidated, as they do by their doctor. They will treat the librarian as a guide or peer , which means they are much more likely to craft their own answers and make their own decisions . They will formulate their own treatment plans and stick with these, ensuring a higher degree of compliance.
- This is a much more enlightened, participatory and democratic model, which puts patients at the center of the healthcare universe. This is where they belong, but in order to reclaim this place, they need to become well-informed, so they can be treated as equals by their doctors
Much more importantly, this model represents a completely different philosophy – one which respects patients, and teaches them to ask questions and find their own answers. This means patients will take much more responsibility for their own health , and this is especially important for patients with chronic illnesses , who can become “expert patients” and help guide others with the same illness !
How is this different from the traditional “patient education model” where the doctor educates the patient by giving them brochures or showing them videos ?
For one thing, the information is likely to be much more reliable ! Since the librarian has no vested interest in pushing surgery or promoting a particular drug, patients will get objective vetted information about cost effective, tried and tested treatments, rather than the newest , most fashionable ( and most
expensive !) drug which is being actively promoted by the drug companies.
Librarians are good at applying evidence-based medicine because they are information specialists. However, since they do not provide the actual care, they are objective and will act as guides or coaches. This allows a two-tier approach , so that armed with this information the patient goes to the doctor and discusses his options more intelligently . This makes better use of the doctor’s time as well – and helps to keep the doctor honest too !
I need to emphasise that my concept of a library is not just a collection of books in four walls. While it is important that each hospital have a patient education library to which patients can go and to which doctors can refer their patients, a lot of this will be done online as well . Information could be delivered through the web and the mobile and queries could be answered by email; or through a call-center. As clinical decision support software becomes more mature, this could also be used by librarians to help patients think through possible diagnostic alternatives.
Patient education libraries represent a great return on investment, as patients will no longer undergo unnecessary ( and expensive !) surgery; or be pressurized into popping the newest ( and costliest ) version of a drug . Since the information is being provided by someone other than the actual clinician, the information is likely to be much more objective and reliable ! These libraries could also form the nucleus of patient communities ; where patients could get together and support each other with a little help from a librarian.
Friday, September 28, 2007
Thursday, September 27, 2007
Amazon.com: Who Killed HealthCare?: America's $2 Trillion Medical Problem - and the Consumer-Driven Cure: Books: Regina Herzlinger
What to do? Herzlinger's convincing, indeed compelling and eloquent response to that question is best revealed within her narrative. However, for present purposes, here are a few key recommendations:
1. Consumers must take back the money their employers and government now take from their salaries and taxes to buy health insurance on their behalf so they can make their own purchase decisions.
2. Physicians must be empowered to design better, cheaper health care.
3. The destitute must be subsidized by 'the rest of us' so that can purchase health insurance 'like everybody else.'
4. The federal government must help subsidize the destitute, provide transparency (a key factor for all consumers, actually), and prosecute fraud and abuse."
* P–Purpose and name of the medication
* I– Instructions for use and dosage: o How many times a day? o Time of day? o With food or without food? o How long to take it? o What if I miss a dose? o Should I avoid alcohol, sunlight, certain foods, etc.?
* E–Effect of the drug, both positive and negative "
Plain Language: A Promising Strategy for Clearly Communicating Health Information and Improving Health Literacy
* You do not want your patients to view the Teach Back task as a test, but rather of how well you explained the concept. You can place the responsibility on yourself by using this suggested language:
* “I want to be sure that I did a good job explaining your blood pressure medications, because this can be confusing. Can you tell me what changes we decided to make and how you will now take the medications?”
* If your patient is not able to repeat back the information accurately, you should try to re-phrase the information, rather than just repeat it. Then, ask the patient to repeat back the instructions again until you feel comfortable that the patient really understands the information."
who have learned to rely upon oral forms of communication, written information sources are of little or no use. For such audiences, health educators and communicators need alternative
approaches with appropriate visuals and activities that stimulate learning, are interesting and fun, and motivate the intended audience to experience new behaviors.
The AMC Cancer Research Center, with collaboration and support of the Centers for Disease Control and Prevention (CDC), Division of Cancer Prevention and Control, has developed Beyond the Brochure to assist health educators and health communicators in conceiving and producing educational materials and activities that do not rely solely on the printed word. The intent is to present innovative intervention ideas and strategies that can be used to reach audiences who are not benefitting from current health communication efforts.
Great idea. Just like we have classes to teach people how to invest, we need to have classes to teach people how to take care of their health and how to talk to their doctor. A mini-med school for patients !
Imagine how much worse the situation is in India !
HELP is now working to develop original graphic-based solutions to educate low-literacy patients about their health problems.
Clever marriage of private resources to accomplish public good ! We need more win-win partnerships like this.
Wednesday, September 26, 2007
1. Using PHRs for medical record keeping is only the tip of the iceberg.
As the Project HealthDesign teams design and test their prototypes, they are learning that using PHRs to record observations of daily living – such as sleep, diet, mood, medications taken, etc. — may provide helpful clues to patients and doctors about how to better manage their care.
2. The need to make day-to-day observations about mood, pain, etc. is consistent across all patient groups and lends itself to common approaches to record, store and analyze this data
As PHRs are further developed, technology designers could create personal health applications that respond to trends in daily information to empower patients to make minor lifestyle and health adjustments, thereby improving how they feel.
3. Successful PHRs and their applications need to mesh with the tools that consumers rely on in their everyday routines. For example, patients aren’t likely to use a separate calendar that highlights timing for breast cancer treatments; they want information about their breast cancer treatments to sync with the electronic calendar they already use to organize the rest of their lives.
Specialization and Global Reach Characterize the IT Services Landscape — Digital Healthcare and Productivity
Tuesday, September 25, 2007
As the cost of medical care goes up, medical insurance coverage is going to become increasingly important for
Many studies have proven that a dollar spent on patient education ends up saving the insurance companies over 10 dollars ( for example, by preventing unnecessary surgery).
Patient education is a powerful tool to promote health, manage chronic disease, prevent medical mistakes, achieve patient-centered care, improve health care system efficiencies, and improve the overall quality and experience of patient care.
Can't the Health Insurance companies see the forest for the trees ?
Monday, September 24, 2007
Lavasa Corp, Apollo to develop healthcare centre - Healthcare - Healthcare / Biotech - News By Industry - News - The Economic Times
Bluewater plans healthcare foray; to invest Rs 500 cr - Healthcare - Healthcare / Biotech - News By Industry - News - The Economic Times
Medical tourism is a major growth area - and custom built hospitals are a clever way of attracting international patients.
Helios & Matheson eyes $100-m buy in Europe - Healthcare - Healthcare / Biotech - News By Industry - News - The Economic Times
The healthcare BPO and RCM sector is booming - and India is going to get a large slice of the pie !
Sunday, September 23, 2007
Technology in the NHS is to give healthcare professionals access to patient information safely,
securely and easily, whenever and wherever it is needed. The National Programme for IT is an essential element in delivering The NHS Plan. It is creating a multi-billion pound infrastructure, which will improve patient care by enabling clinicians and other NHS staff to increase their efficiency and effectiveness.
The key 'customer-centered' principles she identifies have been adapted and paraphrased below for healthcare and patients specifically:
1. Create a compelling 'brand personality.'
2. Deliver a seamless experience to patients across channels and touch points
3. Care about patients and their goals
4. Measure what matters most – to patients
5. Value patients’ time
6. Place patient “DNA” [information] at the core of the system
7. Refine operational excellence
8. Design any new system or process with the expectation that it will need to evolve
9. Provide self-service access to services if possible, when and where the patient wishes"
Patient Relationship Management: Streamlined Approaches for Defragmenting Healthcare — NHS Connecting for Health
The PCM acronym I like is : FIFE.
F = FEELINGS related to the illness, especially fears What are you most concerned about? Do you have any specific fears or worries right now? I imagine you have had many different feelings as you have coped with this illness. Sometimes people have fears that they keep to themselves and don't tell their doctor.
I = IDEAS and explanations of the cause What do you think might be going on? What do you think this pain means? Do you have ideas about what might have caused this illness?
F = FUNCTIONING, the illness' impact on daily life How has your illness affected you day to day? What have you had to give up because of your illness? What goals do you have now in your life? How has your illness affected your goals? How does this illness affect important people in your life?
E = EXPECTATIONS of the doctor & the illness What do you expect or hope I can do for you today? Do you have expectations about how doctors can help? What do"
Saturday, September 22, 2007
Friday, September 21, 2007
Thursday, September 20, 2007
Wednesday, September 19, 2007
"P&G's 'Healthy Living brand' is built on the following principles:
* Partnership--working with employees and their families to maintain or improve their health and wellness
* Quality--supporting initiatives that promote health care quality and help to identify the best health care providers for employees
* Prevention--decreasing barriers to preventive health care in order to reduce the burdens and costs of illness
To help implement the brand, in 2006 alone, P&G began to offer the following preventive benefits and incentives:
* A $40 incentive for employees who complete an online health risk appraisal
* An $80 incentive for completion of weight loss and smoking cessation programs
* A $160 incentive for completion of a one-to-one personalized condition management program (for conditions such as diabetes, congestive heart failure, coronary heart disease, and depression)
Some of the early program successes that P&G can report now include:
* 40 percent of eligible employees have completed wellness assessments
* 78 percent of those eligible for condition management have enrolled in a program
* More employees have become compliant with taking prescriptions for their conditions (such as diabetes) while overall medical costs have dropped."
health care costs and the impact that their actions have on these costs must be unrelenting and ongoing. "I partnered with them and they partnered right back," she explains."
Comparing patient power with other decision mechanisms.
by John C. Goodman
ABSTRACT: To control health care costs, someone must choose between health care and
other uses of money. The value of most health care is experienced subjectively, as is the
value of other goods and services. No one is in a better position to make these subjective
trade-offs than patients themselves. The current system not only systematically denies patients
the opportunity to make such choices, it distorts the incentives of providers in the
process. Chronic patients in particular would be much better off if they could manage more
of their own health care dollars and if providers were free to compete to meet their needs.
This is a great idea ! It's such a simple tool, which can be used to help doctors across the world.
* Consumerism in health care is based on the idea that individuals should have greater control over decisions affecting their health care.
* A number of innovative products and plans are advancing the consumerism trend. Health Savings Accounts (HSAs) and Health Reimbursement Arrangements (HRAs) are savings vehicles generally paired with High-Deductible Health Plans (HDHPs).
* Consumer-directed health care is a common-sense approach for addressing two of the most vexing challenges in our health care system: controlling costs and improving access to affordable, high-quality care."
It's good to see that official bodies and the government have started using Web 2.0 technology to help doctors to talk to each other !
In general, effective patient communication involves:
Presenting detailed information about how you are feeling.
Asking questions if desired information is not provided.
Checking your understanding of information that is given to you.
Expressing any concerns about the recommended treatment.
These four communication skills make up the PACE system for communicating with you doctor. You can get the most out of this web site if you take notes as you work through the pages. There will be points where you will want to write down information to tell"