May 31, 2013

Finding the Best Doctor-Patient Fit

This is a topic I have been avoiding and I thought I would not do this. However, with the activities of the last few weeks, I decided I should restudy this blog and see what I could determine for myself. Nancy Finn does make some good points. In talking this over with some of our group members, I have made my own discovery. When talking about doctor-patient fit, this is so individual that some ideas can only be generalized.

Because I live in a fairly rural area, many doctors are over 30 miles one-way to see them. And presently, most of mine are at that distance. This is also a determining factor not covered by most writers. I am patiently waiting to discover one that will use telemedicine, but I doubt I will see this in my lifetime. Too many obstacles standing in the way. This will be limited by the state medical board, other local doctors, and the medical insurance providers. I am not the only one that could benefit, as several in our group would consider this. Many people could benefit if the doctors could provide a list of reliable internet sources, especially in the more rural areas of this country.

If you live in a more doctor dense area or a larger city, then what Nancy Finn has to say may be of great assistance. I will list her points (in bold) and give my comments.

#1. What is the doctor’s specialty and does that match your health issues? We are fortunate that the two cities, about 30 miles distant, do have a large variety of specialists. Some are excellent and others are just specialists. We also have an advantage of being about two and one half hours drive from the Mayo Clinic in Rochester, MN. I have not needed to use their services
#2. What is the doctor’s background i.e., what medical school did he/she attend and where did he/she train after medical school? This is interesting as this is something we look at, but for the most part, we have little choice.

#3. Has this physician passed the required medical boards (that information, as well as information on whether the doctor has ever faced any sort of disciplinary action can be found by contacting your state medical board. Again, this is interesting, but not easy to accomplish, as our state medical board is very secretive and hesitant to disclose information like this. We normally know something is wrong when a doctor just disappears and very little has been said about it. It is easier to discover information in local court proceedings.

#4. Does this doctor accept your medical insurance? (Check with your insurer and they should be able to provide you with a list.) In our state, currently the medical insurance company provides us with a list of doctors that have accepted the terms of the company. Also, most doctors post a list of insurance companies they will not accept. For us this is a good thing. On one occasion, I did ask the insurance company who would be a provider and I was told none, but if I went out of state, there were three available.

#5. Is the doctor conveniently located near your home or work? Does he/she have evening or weekend hours? This is not applicable here and a very few have evening or weekend hours. Most work Monday through Friday with a half day off during the week.

#6. How long has this doctor been practicing this medical specialty? Has he/she published any papers? Is he/she involved with any medical organizations? Again, this is interesting, but seldom practical in this area.

#7. Is the doctor in a solo or group practice? Again, you take what is available.

I dislike saying that in many circumstances that you need to take what is available, but this is often the case and if you do not establish a good doctor-patient relationship, you may be required to travel even farther. Therefore, the patient is generally the one that needs to work the hardest to make the doctor-patient relationship work. I will give the majority of doctors credit because they work at the relationship. A few are known for operating on autopilot and some do use the cookbook style of medicine.

Nancy Finn does list many sources that can help find a good doctor if you are in a doctor dense area and not in a largely rural area. So check out her blog for these sources.

In selecting someone with whom you want to have a long-term relationship, it is permissible to request an introductory phone call. A doctor that refuses to do this might not be the right person for you. Some of the personal questions you need answered before making your choice may include:

#1. Are you choosing a primary care physician or a specialist? The criteria are different, but in our area, you take what is available.

#2. Do gender, language, racial differences matter to you? Seldom do you have a choice. I have some of each gender and really feel better with a woman doctor when available for most things.

#3. Will the doctor communicate with you between office visits and about treatment options and choices? Some will, but with most, it will depend on whether they can send you to an emergency room.

#4. What hospital is the doctor affiliated with and is it a place where you would be comfortable if you had to go there? Many are employed by the hospital in the two larger cities. With many local county hospitals eking out an existence and depending on Medicare handouts, it normally is wise to head for the larger hospitals about 30 miles distant. In many cases where using an ambulance is necessary, they are required to take you to the nearest local hospital if Medicare is involved to make sure you are stable enough to be transported to a larger hospital. In some instances, I have known people that have a spouse or relative drive them to the larger hospital to bypass many of the local hospitals.

Many of the decisions can be yours in a doctor dense area, but in many rural areas, you will not have a large choice unless you are able to travel many miles round trip.

May 30, 2013

Insurance Co-pay Elimination Equals Adherence?

Improving care coordination is a cornerstone of health reform. That's why this is a watershed paper. This is a claim by the Editor-in-Chief David B. Nash. This article describes a strategy known as value-based insurance design (VBID) that supposedly reduces financial barriers to medication access. The major fault I find with the study is that it is from self-reports from the patients. Therefore, I will disagree with the editor and say it is very interesting, but far from a watershed paper.

If, as the study reports, it can improve medication adherence and diabetes management, then this could be more valuable when it is in turn supported by a proper study with more controls. This study compared self-reports from before co-payments were eliminated for diabetes-related medications and supplies. Another self-report one year after reported improved adherence. The statement that there was a significant decrease in out-of-pocket costs associated with non-adherence should be self-evident and therefore not a major surprise.

The lack of specifics about the financial status of the study participants is also a weakness, but maybe that fact that nearly 90% felt elimination of co-payments helped in better self-management indicates a lower financial status. Another weakness is the lack of information about what medications the study participants were taking. Co-payments for insulin and the more expensive oral medications would be a huge factor compared to generic forms of metformin.

The last factor not mentioned in the study is a big one to me. Were the study participants allowed only one test strip per day, or did they have access to “as needed” test strips for more effective blood glucose management. We they given any education about self-monitoring of blood glucose. This could also have created better adherence. Too many pieces of essential information are missing from this study to make the claim the Editor-in-Chief makes. At best, this is something that does need more studies, but also the control of more variables.

This study did raise a great issue and challenge to Medicare and the insurance industry about where viable assistance could play an important role.  Don't expect the insurance industry to rise to this challenge as it could decrease their profits.  Unless, it can be shown in more studies that there is a large future cost savings proved by future studies.  That is the real value of studies like this.

May 29, 2013

Are People Really Self-Tracking?

Even this topic brings out a lot of disagreement. Some think it should be more, others don't think it is growing fast enough, and others feel it should not be increasing. My blog here near the bottom may indicate why as people are encountering insurance problems. This is not addressed in the study and may explain why the growth rate is not growing faster.

In 2012, the Pew research people found that only 11% of adults track their health using mobile apps when only 9% were in 2011. The questions now being asked are relevant and more discussion needs to be sought. Pew is also saying cell phone usage is increasing about 20% a year, but mobile app usage is not.

Since this topic is gaining momentum in the blog world, I thought I would do a little unscientific research on my own. I stopped by a Radio Shack in a town about 30 miles distant and asked the manager of the franchise store about cell phone purchases and he said that mobile phone sales were increasing; however, cell phone app purchases were declining. He said that until recently, he had wondered why. Then one day a regular customer brought by an article showing that medical insurance companies were using data that they could collect from medical apps to help set individual insurance rates. He said this is why he is being requested to deactivate many medical apps and some other applications that could have medical uses. He estimated that for every medical app that he sells, he deactivates seven others.

He went on to state that some cell phones brands are not selling because of an article in an out-of-state Sunday paper showing a list of medical apps that were included on the cell phones and insurance companies were capturing this data.

In talking with another cell service company, they deactivate all medical apps and medical related apps now and only activate the ones that a customer wants. In talking to two different doctor practices, they said they are not equipped to receive medical data from any device currently, so they advise all their patients not to use cell and other mobile devices to collect data when they don't know where the data goes.

So it is rather obvious to me that we need to be cautious about our medical data and who has access to it. While my information is not scientific, it does convince me to be extremely careful if I ever upgrade my cell phone.

May 28, 2013

Deadly Physical Examination Requirements (PER)

When I wrote this blog back in July 2012, I thought I would never see it again. Then on March 12, it reappeared in two places, here, and here. This time I found an email for one of the authors and have a copy of the study. It is very interesting and with the articles and study, I will try to emphasize what the medical profession is doing to prevent telemedicine from happening.

First a little background about what started the rush to require the physician examination requirement (PER) before a prescription could be issued. Our internet pharmacies let their greed create much of this, but only those that did not follow the laws of the state in which they had facilities. There are three core models of the Internet pharmacy to consider. The first model is either part of or partnered with existing brick and mortar pharmacies. This means they adopted the procedures of traditional pharmacies including accepting prescriptions only from patients' physicians.

The second model of online pharmacies permitted patients to complete online health status questionnaires that were evaluated by physicians under contract with the pharmacy. After a favorable review, the prescription was written, filled, and shipped. The third model of online pharmacies is all located outside of the USA. They do not follow any rules other than to make the sale happen. The second and third model is what generated the rush to PER. I have no problem with this because of the problems these pharmacies have caused. The first model was not supposed to have been caught is this, but has when lawyers thought they could make some money.

The first PER restriction was implemented by the medical board of the District of Columbia in 1998. Between 1999 and 2006, 32 more states have put regulations in effect. The last state in 2006 to do this was Idaho. Only 17 states have not adopted PER.

Although PER was not specifically directed at telemedicine, the imposition of PER certainly had the potential to adversely affect key aspects of it. The practice of medicine at a distance, what we now call telemedicine, had its roots in 1960s. However, telemedicine expanded dramatically in the 1990s, as improvements in technology made it more useful and reliable. Telemedicine should generate significant savings in time costs rather than the monetary cost of telemedicine. This is the reason that the study calls for more studies to separately investigate the effect of telemedicine on those groups that experience the largest savings; people located in predominately rural areas and those living in areas of low physician densities.

From the intent to prevent access to a variety of non-beneficial drugs, the regulation has had the effect of raising the implicit cost of telemedicine. This created a trade-off of reducing access to medical care for some and giving some patients a higher quality of medical care. PER adoption has its greatest impact by elevating mortality in rural areas and areas of low physician density.

In 2008, the federal government implemented a nationwide PER, prompted by concerns over non-therapeutic access to drugs from foreign-based Internet pharmacies. Although some of the circumstances leading up to the federal legislation differ from those observed earlier at the state level, the methods we used may be of value in subsequent examination of the effects of this federal law. The findings are also relevant to policy discussions of the appropriate regulation of telemedicine. It seems that even if (as suggested by others) telemedicine offers somewhat lower quality care, its effect on access to care in rural and physician–deprived locales may be important in improving overall health outcomes. Finally, the results help illuminate some of the key margins to consider in the broader discussion over the regulation and provision of medical care, emphasizing the importance of identifying the relevant trade-offs between access and quality of care.

In my personal opinion, all PER laws need a careful review to eliminate the burden on telemedicine and allow telemedicine to proceed in rural and sparse physician areas. Yes, we still need laws to stop the two models of pharmacy sales that do not follow state or federal laws, but we do need to make allowance for legitimate telemedicine in largely rural areas where travel can be a real burden.

May 27, 2013

Current Format for Our Group

After our meeting where we added new members, Tim's email created some concern and several emails among the six of us. Finally, we agreed to get together by ourselves and see if we could agree. We did agree that maybe some formality would be good, but we wanted to think about it. Tim did suggest not having officers of a standard type, but a leader, a program chairperson, and maybe one other that could fill-in when one of these could not participate. We all agreed these would be acceptable, as we did not want a lot of formality.

For snacks, we agreed that these should be eliminated or if someone wanted something, they should bring their own. We knew this may be over ruled, but this is where we wanted to start. We all agreed that we would like to have a regular meeting place and Tim updated the current status of none yet. We were concerned that we had grown too fast and that some changes were needed, but we all admitted that we may have grown too comfortable in the way things were and that some of us were doing all the work.

We all agreed to an email Tim had composed while we were talking, but after discussion agreed to one change. With that, Tim sent the letter to all members outlining what we had been approached about and some suggestions which we thought should be considered. Tim sent it out under his name and we suggested that anyone having other ideas should send emails to Tim. This would be the topic of our next meeting and that everyone would be called upon for input.

Two days later, Tim said we had answers from everyone and they were not the same, with each one different. They ranged from keeping the current informal setup to a full set of officers and dues for everyone. With this, Tim selected the meeting for Saturday and suggested everyone be present. Sue had requested having it at her home. I knew things were not going to be easy, but decided to wait and see.

Glen set the tone and wanted a full set of officers, dues, and formal selected meeting dates. This was defeated and we were sorry to see several people leave, but we had suspected this might happen. At that point, Sue's husband commented that we had been doing very well with our informal operations, but he did like the idea of having a leader and a program chairperson. He felt that that anymore was not productive for the way we had been operating. Jason said that using emails when certain studies came out that raised concern for quite a few members had handled the situation very well and that Barry's program had been very appreciated.

Max said that he liked the idea of not having snacks and thought this would prevent putting a burden on anyone. Allen agreed and asked that we put the ideas to a vote. Tim suggested we talk about the program chairperson first. I explained that this would be a person that would coordinate the programs. People that had ideas they would like to discuss would be in charge of the program, but would let the chairperson know so that we did not have meetings without programs unless we had something important, as today that needed our attention. I said we needed to bring back the hospice and the county health people and that the date was coming up. Allen asked if he and Barry could coordinate this and possibly one other group.

I asked if Barry would consider being the program chairperson. Barry hesitated, and then asked if this meant he would have the program if no one else had a topic. Tim said not necessarily, unless he had something. Tim said that we have had meetings with no programs and they still were interesting. Brenda said that if we added more members a regular program might be necessary. She commented that she had appreciated Barry's program and the way Tim and I had assisted. She said we did not need images like that, but under the circumstances, they were necessary to make a point.

At that point, Jason nominated Tim for our leader and Barry for program chairperson. Max seconded and the vote was unanimous. Tim accepted and thanked everyone that had stayed with the group. Barry said he would work with everyone and asked that people consider topics after we had finished with the ones scheduled and what Allen was working on.

A.J. asked if we could consider a record keeper of sorts, not a secretary keeper of minutes, but more of an historian. He said he was not aware who had started the group and others of the members and when they had joined. Brenda thought this would be good. Tim asked if A.J. would do this. A.J. said he would and that he would rely on the rest of us to provide the information.

Tim updated us in his search for a meeting place and that presently he had not found one. Everyone had indicated that since we were an informal group with no dues, they would not consider letting us use their facilities. He said that he did not feel that dues were necessary and because we had more houses available now, maybe we could get by without being concerned. He stated that unless he was told otherwise, that he and I were the only two that could not hold a meeting unless if was only four of us.

At that point, Sue asked me what my feelings were since the members that had left were ones that I had introduced. I said I was hurt by their actions, but not surprised in a way, considering their background. Had they accepted a lack of formal organization I would have been happier. I said that their background was such that snacks and dues was the accepted norm, but that we may need dues someday, but for the present, I was not upset to see them leave, as we seemed to function better as a group this way. I said I am happy that we have Tim as a leader and Barry as the program chairperson. No, I was not unhappy about anything else as I have my blog which serves as an informal history. A.J. asked if he could copy my blogs relating to the group and I said yes. I also said that I would like to see a membership committee for the future. Tim thanked me for bringing this up and asked if there was any discussion. Since there was no discussion, Tim said that he had some ideas for a committee and would put them in writing for approval at the next meeting.

The next day Tim called and asked to stop by.  We talked about the membership committee and he wanted to know why I wanted one. I said that I had brought in members that fit and others that did not fit the group and I felt this was something that maybe should have a committee to evaluate each on established criteria before offering a membership. I stated that the prospect of having the group completely torn apart still bothered me. While I was happy that most felt the need to do something, but had wanted to stay together was great, I did not trust my judgment after the last meeting. Tim agreed with me that we needed a committee and he had some ideas for criteria.

Tim did state that he was happy that the remaining members were not anxious to have dues or snacks as he felt this could be an added expense some could not handle, and others really did not need as people with diabetes. Most had indicated that they carried their own snacks as it was, because they knew the carb count this way. He also stated that most had glucose tablets and were glad they did not need to refuse snacks.

I suggested asking the Library for use of their large room and then another room in another building. Tim said that was a great idea and unless I had objections, he would approach those responsible and see what developed.