Doctors and Gun Control: Get Politics OUT of my Exam Room

 

Let me preface this blog by stating that I write this to stimulate discussion and debate, NOT to sway opinions…..

Today, doctors are required to spend more and more time doing administrative work—including checking off electronic boxes in the Electronic Medical Record (EMR)—the result is less quality time with patients. Now, those that are in Washington, DC think that requiring physicians to ask about guns in the home may somehow reduce gun violence and gun related deaths in the US today. For me, the answer is simply NO. Physicians should focus on the prevention, diagnosis and treatment of disease—we should advocate for our patients BUT we should not be government agents (unless we all collectively become employed by the state. In an article published this week in the Atlantic, author Olga Khazan argues that doctors have a responsibility in preventing gun related deaths. When I read the article, I was simply struck by how much controversy surrounds this issue—How do we protect patient’s privacy rights? How do we preserve our relationships with patients? Certainly, as physicians we may ask many uncomfortable questions of our patients—Sexual history, drug and alcohol use, and other sensitive subjects—BUT should we really be asking about guns? The legal implications alone of these discussions are enough to make even the most steadfast physician a little weak in the knees….

For far too long, the government has attempted to insert itself into the sacred (and privileged “Doctor-Patient” relationship. The bond between doctor and patient is like no other-honesty, confidentiality and trust are paramount to all other concerns. There is already a debate on the role physicians should play in gun control/gun safety. Our own US Surgeon General has proclaimed in the past (prior to his appointment by a Democratic President) that gun control was a top priority for his office. In Florida, there is a law that does not allow Physicians to ask about guns except is certain circumstances. Others want to require physicians to ask and document the patients answers in the EMR. I fear that allowing discussions on guns to enter an exam room may completely undermine a physicians’ relationship with his or her patient. Patients may feel uneasy about answering the questions and may also be suspicious of why they are being asked in the first place. Patients may be less likely to TRUST their physician (for fear of some repercussion) and my also be less likely to discuss other medical issues with honesty. Lack of honest dialogue between doctor and patient can result in a lack of patient engagement and, ultimately, negative clinical outcomes.

Don’t get me wrong, we MUST educate the public about the proper use and storage of firearms. Guns should never be accessible to children and any person who owns a firearm must be trained in its safety and proper use. However, the role of the physician should remain, first and foremost, as healer—We should not be required to become firearm educators, nor should we be required to document firearm possession to the government. While I do concede that there is likely a role for the discussion of guns in a Pediatrician’s office (with the parents) in order to ensure that guns are stored properly in the home, I do not think that there should be any type of discussion in Adult medicine. There has been much research in this area and much controversy remains. This past week in the Annals of Internal Medicine, researchers from Colorado found that there is a vast array of opinions among patients when it comes to physicians asking them about guns. Only 25% of patients surveyed thought that it was ALWAYS appropriate for a physician to have a discussion about guns. 34% of those studied in stated that it was NEVER appropriate for a physician to ask about gun possession or gun use. While study authors spin the data to say that nearly 2/3rds of respondents think that it is SOMETIMES ok to ask about guns, the reality is that many Americans feel that this type of interaction is not appropriate.

Sadly, there are far too many gun related deaths in the US today. We must do more to prevent criminals, those with mental illness, and others who would do us harm to possess guns. This should be the work of the community and the local, state and Federal government—NOT the work of the physician. I fear that if we begin to mandate data collection of this sort by physicians and other healthcare providers we will undermine the trust that our patients place in us every single day.

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Avoiding Burnout in Medicine: Tips For Success

Medicine has become increasingly stressful for all levels of healthcare providers. Every year, nearly 400 physicians commit suicide and in a study published in the Journal of Academic Medicine, it was found that nearly 10% of final year medical students and first year residents (called Interns) reported having suicidal thoughts. Previous studies from the National Institutes of Health found that physicians were twice as likely to kill themselves as non-physicians. The statistics are staggering—suicide accounts for 26% of deaths in physicians ages 25-39 as compared to 11% of deaths in individuals of the same age in the general population. More must be done to both recognize and prevent physician depression—this all starts with working to avoid burnout.

Burnout in medicine has been defined as Physician burnout is quite common—A study in the Mayo Clinic Proceedings found that burnout rates continue to rise and most physicians are very unsatisfied with their own work-life balance.

Warning Signs of Burnout

As burnout becomes more prevalent we have been able to identify some early warning signs. Awareness of these signs may lead to early intervention and prevention of more serious burnout resulting in physicians leaving medicine entirely.

Warning signs include:

–Emotional Exhaustion

–Depersonalization and trouble connecting with patients

–Reduced accomplishment/Confidence in skills

Causes of Burnout

In order to make a difference in the lives of physicians and their families-and prevent burnout– a great deal of effort has gone into trying to determine the causes of burnout in hopes of making more of an impact early on and preventing burnout before it occurs. In order to make this happen, we will need the support of lawmakers, regulators and medical societies.

–Too many clerical tasks—Doctors now have to perform more administrative duties and metrics are now putting increasingly daunting non-clinical tasks before physicians. Most doctors go to medical school to care for patients. Patient care provides fufillment where paperwork does not. Physicians are now scribes, coders and schedulers—in addition to healers. Many doctors are left to wonder why they went to medical school—it certainly was not for a data entry job.

–Too little time to effectively work with patients—As physicians most of us went to medical school because we loved science and we cared for patients. Patients provide challenges, opportunities for relationships and a way in which we can improve the world.

–Declining salaries—Medicine takes commitment, time and money for education. Many physicians have taken on a great deal of debt and have made numerous personal sacrifices in order to train for years to provide top-notch care to the patients that they treat. As healthcare reform moves forward, physicians are caught in the middle. Salaries decline, workload and non clinical demands increase and without meaningful tort reform, frivolous malpractice claims continue to propagate. All of these factors work to diminish physician satisfaction and contribute to burnout.

–Longer work hours—With declining reimbursement, physicians are being asked to do more with less time. Documentation requirements and Electronic Medical Records have resulted in more time spent at home completing paperwork. All of this takes away from private time with family and significantly impacts happiness and life-work balance.

Consequences of burnout

–Poor patient care—When Physicians are emotionally and physically depleted as commonly seen in burnout, patient care may suffer. Distraction, lack of attention to detail and poor decision-making can be more common. In order to provide the best care, physicians must engage with their patients and develop a personal connection. If physicians have burnout, often there is no time or energy left for cultivating these important relationships.

–Depression/suicide—A staggeringly high number of physicians, when polled, have clinical signs of depression and many have contemplated suicide. Sadly, every year in the United States, over 400 physicians commit suicide. Depression can adversely affect family life and can impact a doctor’s ability to perform in the clinical setting. Sleep disturbances and fatigue are common.

–Early retirement/MD shortages—For many, the prospect of practicing medicine is no longer tenable. Many physicians are looking for other business opportunities and are leaving medicine entirely. As the pool of insured patients grows, a physician shortage looms—If we continue to lose practicing, experienced physicians due to burnout and early retirement from medicine this shortage will only become more significant. Patient access to skilled physicians is a critical part of patient engagement and improving outcomes. If more physicians leave medicine, the work load will only grow for those who remain.

What we can do about Burnout

Burnout is a real issue in medicine today. We must make efforts to address this problem before more doctors are lost. Here are a few things that I believe will help ward off Burnout:

  1. Schedule Regular time off—extended vacations (2 weeks) While it is not the typical American way to take vacation, I think that extended time away from clinical responsibilities may be important to avoiding burnout. By “unplugging” from the office and clinical demands for more than a week at a time, healthcare professionals are able to recharge and return to clinical practice more refreshed and ready for the challenges of patient care.
  2. Schedule Regular exercise—It is a fact that regular exercise is associated with lower rates of depression and other chronic disease. In general, when we exercise, we are able to turn our thoughts away from work and outside stressors and focus on the moment. Exercise also promotes a more ideal body weight and overall improved health status.
  3. Healthy diet—Along with exercise, healthy eating can help physicians avoid burnout. When we eat good healthy well balanced meals we are able to maintain a more ideal body weight. Avoiding sugars and alcohol can certainly help avoid the depression and other burnout related complications.
  4. Supportive spouse—Having a life partner or spouse who is able to listen and support the stressed physician is very important. A supportive partner can serve as a sounding board and can offer suggestions and facilitate interventions when necessary. In addition, the supportive spouse can also help identify early warning signs for burnout and suggest early intervention..

What does the future hold?

Burnout is more common that many physicians think. No healthcare provider is immune. It is essential for physicians as well as their coworkers and families to understand the signs and symptoms associated with burnout and intervene early. Burnout can have severe consequences including depression, and in severe cases—physician suicide—are completely avoidable if we begin to better understand what the root causes of burnout are. By understanding the etiology of burnout, we may be able to design a better working environment for today’s physicians. If we do not make these changes, I fear that many physicians will leave the practice of medicine within the next 5 years.

Bringing out the Best in Medicine: How the Tragedy in Orlando Provided An Opportunity for Greatness

Whenever horrific events occur, it is important that we not only take stock in the event itself but we must also look at the good that rises from the ashes. The tragedy in Orlando this week is not without heroes. Volunteers, medical personnel, first responders and blood donors have worked tirelessly to help those in need. In the wee hours of the morning on June 12, 2016 healthcare workers in Orlando received an emergency alert to attend those affected by the worst mass shooting in US history. The quick response and expert training of those at Orlando Regional Medical Center certainly saved numerous lives. Six trauma surgeons and countless other doctors, nurses, technicians and other specialists were mobilized within minutes and were ready to receive the massive number of critically ill patients that arrived all at once.

As a physician, I can only imagine what it was like to arrive at the hospital and begin to care for the large number of wounded. In my experience in dealing with medical emergencies, instinct and training allow doctors and other healthcare providers to jump in and immediately deliver care. Years of training and study allow healthcare workers to react with professionalism, precision and compassion. While all of us are human and are emotionally impacted by such a tragic event, somehow all of those who sprung into action at Orlando Regional Medical Center were able to separate their feelings from the situation and perform their jobs at a very high level. Many hospital workers, physicians, nurses and first responders came in to help—whether they were on call, on duty or on a day off. The selflessness of these medical heroes should not be lost in the tragedy. Many of those involved have been interviewed in the days following the night of trauma and all consistently said that they simply were doing what needed to be done….

While many hospitals have had “Disaster Plans” in place for years, the events of September 11th led to more widespread adoption of these plans. Since that time, hospitals all over the country have put plans in place to deal with mass casualties. Academic societies and organizations of Trauma surgeons have worked to develop best practices and have conducted large scale studies in order to determine the most effective ways to handle these types of disasters. These plans involve extensive, centralized communication systems and a way to quickly alert all essential personnel and mobilize resources.   In addition, these plans involve intensive education and training for all hospital staff. Most hospitals, once plans are in place and staff education is complete, have regular “drills”. Many institutions even have mock disasters with actors posing as critically injured casualties. These drills allow for hospital personnel—Doctors, nurses, techs, first responders and communications specialists to hone their skills and find ways to improve responses in the case of a real disaster.

In my experience at both Duke Medical Center (during my training years) as well as at the University of North Carolina Healthcare system currently, well thought out protocols and training programs are in place and staff are reminded of these plans frequently. As a Cardiology Fellow in the late 1990s at Duke University, I experienced an emergency event first hand. While I was in the Emergency Room caring for a patient with a heart condition in the early morning hours, an alert was sent out that there had been a gang related shooting in Durham and that there was an active shooter potentially inside the ER. We were instructed to get all patients onto the ground and pull everyone into the nearest closed room. I reacted by moving several patients to the floor and pulling them into a supply closet with me. Patients were frightened and understandably anxious. During this time, the ER was locked down and police begin moving through the department in order to clear the area of any threats. Fortunately, there was no active shooter found inside the ER and, after about 30minutes, we were allowed to return to normal operations. After this experience, I remained visibly shaken and it took me a long while to move past the fear I felt that night. I can only imagine what it was like for those medical professionals involved in the Orlando tragedy.

While you may not think of the importance of these issues during the time that a disaster occurs, there are a few things that seem to make a difference in the way we as healthcare workers respond. After my experience during my Cardiology Fellowship here are a few things that I believe to be essential–

  1. Centralized Communication—IN a disaster or mass casualty event, communication is critical. Effective communication allows for patients and personnel to be where they need to be at all times in order to provide the most efficient and effective life saving care.
  2. Coordinated Care—Cooperation and coordination between surgeons, nurses, administrators and other personnel is key to the successful treatment of large numbers of patients.
  3. Staff Education—Extensive education and training must take place in order to prepare staff for mass casualty events. When called upon, staff must be able to react in an organized and calm way—all of this comes from preparation over time.
  4. Drills—It is important to practice a response to a mass casualty event. Practice allows for those in charge of the disaster plan to assess response times and identify areas for improvement.

What Are Biggest Challenges in a Mass Casualty Event? What are the Initial Steps?

The heroic efforts of those in Orlando cannot be understated. These men and women should serve as an inspiration to all of us in Medicine. Each person did their job and worked through the night to help as many victims as they could. For many of us, the thought of being faced with such a large number of seriously wounded can be overwhelming.—this is the stuff of War.   However, those first responders in Orlando met the challenge head on—they worked quickly to identify and triage the most critically ill patients. Emergency personnel attempted to quickly stabilize each patient, and then decided who needed the most urgent treatment in the Operating Room. Patients were sequentially moved from the scene, to the Emergency Department, and to the OR very quickly. IN order to triage the large number of victims, , healthcare professionals are trained to use the ABCDE approach:

  1. Airway—Make sure that each patient has stable airway—if not, we must quickly establish an airway
  2. Breathing—We must make sure that every patient is breathing on his or her own. If not, we must provide an external means of providing them with oxygen.
  3. Circulation/Hemorrhage—First responders must quickly assess if the patient has a pulse and if there is major bleeding. If there is no pulse CPR is initiated. If there is an obvious hemorrhage, efforts must be made to apply pressure, field dressings and other interventions designed to stop bleeding prior to definitive treatment. In many cases, blood and fluids must be administered in order to restore blood pressure and adequate circulation.
  4. Disability—First responders must assess each victim’s level of consciousness and if they have suffered any type of neurologic or brain injury. These injuries must be quickly triaged to a neurosurgeon in cases of head trauma.
  5. Environment—In many disaster situations there are environmental exposures (chemicals, spills, etc) that may contribute to the trauma—in the case of the Orlando shooting, this was not the case.

Unfortunately, mass casualty events have become more common in the US in the last decade. Medical personnel and hospital systems are learning to better care for patients in these large-scale emergency situations. Events such as the Orlando tragedy will cause all of us in medicine to review our protocols, plans and readiness procedures so that we will be more equipped to handle emergencies when they occur. Were it not for the heroic efforts of first responders, trauma teams, doctors, nurses and other hospital personnel in Orlando, the number of casualties could have been much greater. In the coming months, those medical heroes that helped treat the massive number of wounded will need time to heal and time to process all that they have seen and experienced. Thankfully, they were prepared and ready to respond with a heroic effort on Sunday morning.

(this piece originally published on FoxNews.com on June 14, 2016)

 

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June 14, 2016: Doctors and medical staff that treated the victims of the Pulse nightclub shooting answer questions at a news conference at the Orlando Regional Medical Center. (AP)

The Sensationalization of Medical Errors—Breaking Down the Data In Order to Improve Patient Care

In the last month, a study conducted by researchers at Johns Hopkins and published in BMJ[1] addressed the rate of fatal medical errors in the United States. By using data from four previously published studies and using mathematical models to extrapolate data to the current year, the authors contend that medical errors are now the third leading cause of death in the US today.

The media has been very quick to pick up on this story and has already sensationalized the findings without carefully analyzing the data and how the study was conducted. While medical errors are a significant concern and result in countless cases of increased morbidity and mortality in the US today, I am not convinced as to the accuracy of the number of deaths that was determined in the study—over 200K deaths annually. Don’t get me wrong, I still believe that this is a very important study. It brings more focused attention to the issue of medical errors—specifically how we can identify them and what systems are needed to prevent them from occurring in the first place. As medical professionals, we need to more carefully exam the study and what we can learn from it rather than sensationalize the findings.

Controversial Study Methods and Design Leads to Debate

When interpreting this latest study we must carefully analyze the methodology and only then can we comment on the robustness of the data. While the media has focused on the numbers of deaths that have been noted in the study (nearly 250K deaths attributed to medical errors), much of the academic medical community has been debating the validity of the data as presented. In order to effect real change and address medical errors, we must first better understand the problem—this all begins with examining exactly how the researchers in the BMJ paper reached their shocking conclusions. For starters, the authors have used 4 separate studies to gather their data. Some of the studies that were used do not even make it clear what percentage of deaths due to errors were “preventable” and the Hopkins researchers simply assumed a rate of 100% in their analysis– which could have led to a gross overestimation of medical error related deaths. Moreover, some of the events classified as medical error related deaths are actually related more to understaffing issues and lack of resources due to actual errors in the treatment of patients. Critics of the study have recalculated the death rate from these data and have determined the numbers to be nearly 30% lower than those presented in the results of the original paper[2]. In addition, it is important to note that in each study, the diagnostic codes that are used are most often assigned by non medical personnel known as “coders”. Many coders have less than 6 months experience and do not fully understand the medical information that is documented in the chart. IN many cases where a study is based on coder-generated data, it is “garbage in, garbage out”. However, no matter how you evaluate the study and its methodology, it is clear that medical errors are a significant problem that must be addressed.

What exactly are the issues and why are the errors occurring?

The issues with medical errors are quite complex. Errors occur for several common reasons. Certainly, when poor clinical decisions are made by healthcare providers negative outcomes can occur. In addition, handoffs of patients between physicians, nurses and other hospital clinical workers can be haphazard and incomplete. Transitions of care are a major source of medical errors. When busy clinicians receive either incomplete or inaccurate “sign outs” important patient details can be lost. Labs may not be followed up, tests may not be ordered and care plans may not be followed. These types of errors can result in delays in treatment, wasted days in the hospital and incomplete follow up of results. Transitions between units can be even more problematic. When a patient is transferred between departments—such as between the Emergency Room and the Intensive Care Unit—mediations can be forgotten, and missed doses (or duplicated doses) of drugs are quite common. In addition, communication between caregivers can be rushed and important details can be left out. The advent of the electronic medical record (EMR) has given many healthcare professionals a false sense of security in that a patient’s story will be archived digitally for all to see. However, many EMRs are rather incomplete and the data required during documentation of a patient care event is inconsistent and often clinically irrelevant in the acute setting. System errors are the most common type of errors—these occur when the care systems and algorithms that are created within and between institutions are non-standardized and based on regional preferences. These inconsistencies can result in gaps in care. Safety measures and protocols are often inadequate to prevent error.

What needs to be done going forward?….

It is clear that there are far too many medical errors that occur in medicine in the US today. While I firmly believe that the current article far overestimates the total numbers of errors, the problem is still quite substantial. As physicians we must work together to create better ways to protect patients. We must do a better job communicating directly with one another about patients rather than rely too heavily on the EMR. Within hospital systems, we must put more checks and balances in place and make transitions between caregivers and units seamless. In addition, we must determine a more standardize way to define and measure medical errors—the creation of a national database may lead to important discoveries and allow us to provide safer, more efficient care for all of our patients in the future.

[1] Medical error—the third leading cause of death in the US BMJ 2016; 353 doi: http://dx.doi.org/10.1136/bmj.i2139 (Published 03 May 2016)

Cite this as: BMJ 2016;353:i2139

[2] BMJ Rapid Response published online 21 May 2016 DanielBaldorMD/MPHStudent (MS3)Adam Kravietz MD/MPH Student (MS3)University of Miami Miller School of Medicine Miami Fl 33130

Imagine that?….It doesn’t work and costs more…..More Bad News for Obamacare

Recently the Blue Cross Blue Shield Association published a report detailing the effects of the Affordable Care Act legislation on consumers and insurance companies. Now granted, the BCBSA is a conglomeration of independent BCBS insurers so we must read the document with a pinch of skepticism. In the analysis, the BCBSA collected data of every individual market health insurance carrier and product sold in the US.

Major Points to consider from the report:

Choice of carriers declined in all markets

United Healthcare (UHC) has confirmed that it will be dropping out of a majority of ACA exchanges in 2017. While posting a predicted loss of $650 million dollars in 2016 (after a loss of $475 million in 2015), United executives are concerned that more losses are on the way if they continue to insure the Obamacare pool of patients. With the departure of UHC, many worry that choice will decline even further—some areas may only have as few as two choices. Ultimately, this move will drive prices even higher for exchange participants. Fewer choices almost always result in less competition –less competition can lead to lower quality products and care. According to a study conducted by Kaiser, the impact of shrinking choices in the marketplaces can be very significant—particularly in southern states and rural areas. United accounts for nearly 71% of all enrollees currently and 29% of counties that are currently served by Untied would only have ONE choice of carrier if UHC pulls out. Overall, 1.8 million enrollees will be left with 2 choices of carrier and 1.2 million will have only ONE choice.

-New enrollees received significantly more care and those insured by the exchanges had costs nearly 25% higher as opposed to those insured via employers

Not surprisingly, those enrolled in the exchanges accounted for more emergency room visits, more inpatient admissions, more prescription drug costs and inpatient admissions than those that were insured in traditional employer based systems. Many Obamacare enrollees have waited until a major illness occurs before signing up and gaining access to care. Once treatments are completed, many of these same patients simply drop out—thus skewing the insured pool to those with higher costs–with fewer “young and healthy” patients on board to help fund the more expensive treatments required by many of the newly insured.

New enrollees are much sicker—More Diabetes, heart disease, HIV and Hepatitis C

Over the last three years, it has become apparent that new enrollees in the exchanges tend to have more medical problems. Many have gone without treatment for a long time prior to acquiring insurance. These patients often have very advanced disease (along with multiple disease related complications) and by the time they gain access to care and most require expensive, intensive treatments. Newer drugs for diseases such as hepatitis C are priced exorbitantly and costs for a 12-week course of therapy can reach $80 thousand dollars or more. Obesity and obesity related illnesses are epidemic in the US today. Obesity places patients at risk for diabetes, heart disease and other potentially debilitating and costly chronic diseases—accounting for 150 billion dollars of healthcare expenditures in the US annually. Until we focus on preventative efforts and individual accountability these costs will continue to rise.

What is to be done to save healthcare in the US?

We must revamp the system. This job will require Congressional action and actual bipartisan cooperation and support. Moreover, both the legislative and executive branches of government will have to come together and actually compromise in order to stop the implosion of the best healthcare system in the world. While providing expanded access to healthcare for all Americans is an important goal, we must develop a system that rewards good health choices and focuses more on disease prevention. We cannot expect, nor rely on, young healthy Americans to completely fund healthcare those who do not even attempt to modify risk and engage in their own healthcare.   We must set up a system of individual accountability where premiums are tiered based on health choices—lower premiums for those who DO NOT smoke, those who exercise and those who avoid other high risk behaviors for example. At best, healthcare in the US is headed for disaster. Unless we can address the rising costs, diminishing choice and pending physician shortages we will soon become a single-payer system—just ask the Canadians how well that has worked out north of the border….

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Making Progress in Social Media and Medicine: Engagement at ACC

This week at the American College of Cardiology meetings I was amazed by the uptick in Social media engagement. While 75% of all fortune 500 companies are represented and active on twitter, doctors have been quite slow to enter into the social media space. Many of us have who have pioneered social media in medicine have often felt like Dr. Sisyphus as we push the “Social Boulder” up the hill in order to show our colleagues the value of digital engagement. However, it appears that finally the tide is turning…..

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From the very outset of the meeting the hashtag #ACC16 began trending. Just in time for the annual sessions, the American College of Cardiology recently created and published a Cardiology Hastag Ontology reference guide in order to bring together the broad topics within cardiovascular disease so that common subjects of discussion can be easily identified, searched and catalogued.

Analytics from #ACC16 demonstrated that by meetings’ end, there were nearly 3600 individual tweets, 35 million individual impressions with roughly 1500 members participating via social media platforms such as twitter. During the meeting, there was an average of 155 tweets per hour and many participants “live tweeted” during important presentations such as the late breaking clinical trials sessions on each day. Leadership in digital engagement was spread among individual attendees, twitter feeds from the college itself as well as feeds from institutions such as the Mayo and Cleveland Clinics. Interestingly, the “Top 10 Influencers” by impressions were not the same as the Top 10 by tweets—suggesting that WHAT you say may be more influential that HOW MUCH you say in the digital space.

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Screenshot via Symplur at #ACC16

Furthering the importance of social media and mobile health in medicine at ACC, a novel study evaluating the use of digital tools for engaging patients on outcomes was presented at the meeting as well. Researchers from Mayo clinic investigated whether or not patients undergoing cardiac rehabilitation would benefit from using specially designed health tools on their smartphones. In the study, 80 patients were randomized to a group having access to a smartphone mobile health tool with cardiac rehabilitation versus rehabilitation alone. Primary endpoint was total weight loss in the 12-week time period. The mobile tool group lost four times as much weight compared with those undergoing 12 weeks of cardiac rehabilitation alone. This randomized controlled trial is the first in the U.S. to look at how adding the use of mobile and wireless devices concurrently with cardiac rehab might improve health outcomes—and clearly demonstrates the power of patient engagement via digital platforms.

Once again, social media sessions were included as part of the Annual Scientific Meetings academic programming. I was honored to chair and participate in the session alongside many distinguished colleagues. The session was well attended and each talk was delivered in a TED talk style format—emphasizing audience engagement, interaction and story-telling. Slides contained images rather than charts and each speaker shared real world experiences and examples of social media and digital successes. Topics included the use of social media for connectivity, engagement and innovation.   The expanding use of mobile tools for the advancement of clinical trials was explored as well as issues surrounding direct patient engagement.

It is clear that the American College of Cardiology has embraced the digital space. As cardiologists we are innovators and social media and digital engagement should be no exception. The future of social media in medicine is limitless—it is my hope that in 2017, we add to the numbers of active healthcare providers on social media.   Ultimately, engagement can only help the people that we are pledged to serve—our patients. Through embracing our digital future in medicine, we can improve outcomes, improve disease awareness and access to care and provide new tools for disease management. Lets all be part of the leading edge of the bell curve—As Rogers shows us in Diffusion of Innovations, we must be the early adopters…not the laggards, in order to maximize success.

 

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Rogers, EM Diffusion of Innovations, 2003

Are We Really Better Off With Obamacare? Examining The Blue Cross Blue Shield of North Carolina Debacle

The snowball effect has begun. Earlier this year, United Healthcare announced that they were unlikely to continue to participate in the Affordable Care Act (ACA) exchanges in 2017. As the largest Obamacare insurer, United’s announcement may be the harbinger of things to come—I predicted that others would follow. Many patients will likely will be left with even less choice and may be left with no insurance at all.  Many of the insurers that remain in the Exchanges are not able to provide the services that they promise to their patients.  Case in point–Blue Cross/Blue Shield of North Carolina.

This past month, Blue Cross/Blue Shield of North Carolina announced that they may leave the Affordable Care Act exchanges. BCBS is the state’s largest insurer and is the only company that has provided health insurance policies through the ACA in all 100 counties in North Carolina. The insurer has reported a second consecutive financial loss in spite of raising rates more than 35%. Rumor has it that BCBS may no longer provide insurance through the ACA exchanges unless it is granted yet another rate hike by the State’s insurance commissioner. IN addition to reporting financial losses, BCBS has struggled to provide basic services to its customers in North Carolina. Software “snafus” and a lack of staffing in call centers has resulted in many insured patients reporting to hospitals and physician offices and finding that they have either no insurance (via a computer database) or not the same insurance they signed up for. Some patients report that they have been charged twice for coverage and others have been charged incorrect amounts. When customers have turned to BCBS for answers, they have been unable to speak with customer service representatives without extended wait times lasting hours at a time. IN response, BCBS of North Carolina’s CEO made several public apologies via television and print media and promised to “get it right” in the future. However, lapses in service continue to plague North Carolina customers. For example, since January the customers have experienced the following issues:

-Nearly 7% of 25K customers were put into the wrong plans

-3200 customers had their bank accounts drafted for the wrong amounts (most were over-drafted)

-Many customers never received their insurance cards or received them late

-The company’s phone lines backed up. They have the capacity to deal with 20K calls a day, but received nearly 100K on certain days in January, 2016

Why is this Happening? Why Can’t BCBS Do more?

The simple answer:  Follow the Money. BCBS–and others  like it–are designed as a for-profit entity. It probably does not surprise anyone that these insurers are NOT providing insurance services in order to make the world a better place.  Rather, insurers are taking a calculated actuarial risk on a patient population that they insure in order to “play the odds” and make a profit.  Ideally, insurers want to insure large populations and provide few costly services.

I spend a great deal of my time arguing with BCBS and other insurers as to the appropriateness of medications, tests or procedures that my patients may need. Even though I have trained for nearly a decade and have multiple board certifications, awards and honors, insurers have their own way of looking at prescribed treatments–often it involves cost rather than efficacy as a bottom line for decision making.  Every single week I must deal with insurance “denials” and even though I am the expert in cardiovascular disease, I must speak with a “physician representative” on the phone in order to argue that an indicated medical test be approved. Many of the insurance “physician representatives” have no training in cardiovascular disease and are simply reading a script or checklist in order to determine an approval or disapproval status for a particular patient. They do not routinely examine the individual case–unless a clinician, like myself, appeals the denial and takes the time to argue the case specifics. In my opinion, insurers today are looking for higher premiums and work diligently to avoid as many “payouts” as possible. Unfortunately, it is our patients who suffer the most. It is hard to both prevent chronic disease and treat acute events when patients are afraid to come to the doctor for evaluation due to high costs passed on by insurers.

The “Buck” does NOT stop here….

As you might imagine, the “buck” is quickly passed when BCBS of North Carolina is asked about the reasons for the recent avalanche of errors and poor customer service. CEO Brad Wilson is quick to place the blame firmly on everyone BUT his own organization—the Affordable Care Act, software companies from other states, billing errors by third party companies—you name it.  BCBS claims that they recently implemented a new customer service record system and that a third party company (hired by BCBS to handle billing) is responsible for the errors in billing that many patients have experienced. In addition, a whistleblower claims that BCBS leadership knew about the potential for errors when implementing the new systems but declined to address these concerns prior to the roll out.  BCBS vehemently denies the whistleblower’s claims.

While Mr Wilson has issued multiple public apologies on behalf of his organization, little has been done at this point to correct the problems.

And the problems continue…

More recently, BCBS released privileged health information from one customer and their family to another customer by mistake. Last month, a family went online to check their information on the “secure” BCBS patient/customer website and found another family’s names, medical histories, social security numbers and other sensitive information listed on their account in addition to their own. When the customer tried to contact BCBS to report the error and data breach, she was placed on hold for hours—ultimately she was told that it was due to an error made by another third party vendor from Utah. When she contacted the company in Utah, they blamed BCBS of North Carolina. Bottom line…no accountability….AND these folks want to raise your rates? Really?

What is Next?

While there are no easy answers, we must hold insurers accountable for their actions. They must accept responsibility for lapses in coverage, breaches of sensitive data and they MUST provide the services for which they are contracted. Insurers must be held to the same high standards that all healthcare professionals are held to when it comes to working with customers and patients.  While cost controls are a reality of modern healthcare, we must put patients first. Insurers must be forced to approve tests, medications and procedures that are deemed appropriate by the preponderance of the data—less focus on cost, more focus on quality.

These changes in insurance will not come without legislative action. The ACA has provided for significant regulations on physicians, hospitals and other healthcare providers. However, nothing is being done to ensure that insurers provide affordable, quality healthcare and allow patients Access to the institutions and therapies that they deserve. While the ACA was designed to provide access and affordable quality healthcare for all Americans, it has fallen far short of this lofty goal. It is my hope that the next administration will focus on the patient—and require insurers to become more accountable.  As voters and as medical professional, we must reach out to our representatives in Congress and demand action.

As for North Carolina BCBS, the story is not yet over.   The State Attorney General is now involved and has sent a formal letter to BCBS leadership. I fear that BCBS will likely follow the lead of United Healthcare and withdraw from the exchanges in 2017. If this happens, hundreds of thousands of North Carolinians will be without viable healthcare. In a state with a high prevalence of heart disease, obesity, diabetes and other chronic diseases, patients will suffer and I fear that preventable deaths from treatable illnesses will only increase.

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