Please take a moment to enjoy this recent publication from the Patient Centered Primary Care Collaborative. The success of the Patient Centered Primary Care Care should be spread far and wide!
If you have not joined us please consider membership.
Please take a moment to enjoy this recent publication from the Patient Centered Primary Care Collaborative. The success of the Patient Centered Primary Care Care should be spread far and wide!
If you have not joined us please consider membership.
I fear we will lose the opportunity to re-think the legislative changes required to assure the success of the Affordable Care Act. Instead it might simply die. My reasoning is clear. The original work lost all structural integrity in terms of economic sustainability. This was the outcome of supporters of the legislation sacrificing so many critical features to corporate interests.
I am exhausted and have few words left. Why do we cling to fears, doubts and insecurities that were issues of the Cold War. ”Oh we can’t consider universal coverage as this is a Socialist construct.
If we look round us, all civilized nations figured out a long time ago that universal coverage is mandatory for the economics of health-care to be self-sustaining. Here is my response to a recent petition. I hope my readers will take it seriously.
Sue, I have decided to discontinue any business that UntangledHealth.com has with Staples. Then again, I only purchase two computers per year and will not make a dent in their bottom line. At the same time it is important for all to understand that this has less to do with the legality of the situation than the moral standards we choose to live by in America.We have a wonderful opportunity through a free enterprise system to create huge personal wealth. Personal, now translates to corporations as individuals. Self-Interest stimulates wonderful innovation yet unless closely monitored for “intent” will consume a society in short order.
Plenty of historical examples: eg: other empires. For those active in the E-Patient Movement or Patient, Family, Community Centered Medical Home Movement or E-Health Movement you have a responsibility to weigh-in on the economic issues in health-care. Please add your wisdom, we need you. JFH
My report for today:
Helped one more person register his family for an affordable insurance product using Healthcare.gov
Met friend at 4:00 for dinner prior to our club meeting. Turn’s out he is lost in acronyms and asked for help.
Over the course of the next four hours we improved his ability to self-advocate, submitted an application and lessened his anger and fear of OBAMACARE.
My objective was met by my friends eloquent ability to inform his teacher of the many reasons OBAMACARE should have never been named OBAMACARE and his understanding of healthcare as it differed from earlier in the day when he could only think of it as “the monthly premium “or the cost of a subspecialists co-pay”; or “a communist scam”.
We ended the night with one happy conservative family man receiving a quote for his silver policy for a family of three. The monthly premium is $200 less than last years and his services have increased.
As we concluded the evening he asked if I ever thought of inventing a software program that would track all important health information for patients. He had evidently been responsible for a $4000 co-pay on an $18,000 ER visit for chest-pain. This was mostly due to his inability to articulate a thorough history to the doctors on staff.
I described to him the importance of maintaining a relationship with a primary care physician and then logged on to MyHealthRecord at Duke and MS Health-Vault to demonstrate the rather rough but much better communication I had with my physicians and interoperability of pharmacy and EMR systems. Then I described how these data could be used to empower a person in an emergency with timely and acurate information. His conclusion: Jeesh, I probably would not have needed the expensive work-up if the doctors had access to all these studies!
One more convert.
So little time….
But one more convert.
Tomorrow’s agenda: Meet with ophthalmology practice to organize diabetic eyesight preservation program for non-Medicaid, uninsured folks in NC. So far, I have the cost of a vitrectomy reduced from $12000 at a local hospital to $4800. Not bad for a days work!
Not an insurance company, just an empowered consumer.
Please choose the correct response:
We are all care-givers at some point in our lives.
We will all require care-givers at some point in our lives
It is 3PM on a hot August afternoon in North Carolina. Gathering around my brother Bruce in the spare bedroom of my home are my father, my wife Carol, my brother s children and the occasional visitor.
Bruce is 54- although he stopped smoking fifteen years ago we are now tearfully sharing the last moments of his life. Through his semi-conscious mind, he listens to our conversation.
Leaning over my sweet brother I ask him if he would like some more morphine. He struggles to respond, reaching deep within himself and utters a raspy, lungs filling with fluid “JEFF?”
I respond with yes and again ask him if he needs more pain medication? Looking up he utters the last words I will hear from him “Yes. Please”.
At 8:30 PM, Bruce loses control of his bowels. My father, Carol and I gently roll him on his side to change the bedding. He struggles against us, yet we accomplish the task. We quickly change the bedding, clean the poop from his butt and –like a newborn baby, turn him over on his side.
A small trickle of blood spills forth from his lips and his eyes begin to dilate. “My God He’s Gone” says my wife. Leaning down close to his face I stare into his eyes, tell him he is safe, he is loved and to “go toward the light”. Bruce takes one final breath in my arms; his body jerks and he is gone.
Collapsing on his body I scream out the agony of loss. Making sounds like a little boy I weep “My brudder, Bruce, Oh God”. My father falls on top of me. The man who fought in the Philippines, and buried his wife just one year earlier begins sobbing. We become a grief sandwich; my dead brother, my father, my wife and I: All piled up on the hospital bed. Finally…it was over.
Many do not receive the blessing of being present during the death of a loved one at home. For most, this episode occurs in a clinical environment; for a variety of reasons I suppose. But my career in medicine had given me sufficient insight to understand how ill-prepared our society is to “heal a person into death”.
Bruce and I had a contract. When he received his diagnosis 18 months previously we discussed –in detail- his wishes, the mechanisms to determine what the best treatment approach is; the statistical probability of survival and the financial cost his family in a variety of scenarios. One might think this is all done for us by our physician, or social workers, or ‘for-Gods-Sake” someone else. Unless of course, he or she has spent the last 34 years working as clinician, administrator and chronic disease program manager across all settings of healthcare. A new perspective emerges for folks with this occupational history. An awareness of true cost, profit margins and unending business opportunities that have gathered so much wealth for “value added” service providers in a free market economy. We also understand that in America, we spend twice as much per-capita on health care of any industrialized nation, have lower health outcomes and can be the only Nation to claim health care cost as the leading cause of bankruptcy.
Not so? Well, in 1996 I was flown down to New York City by my employer, a skilled nursing organization. My job at the time: Evaluate five patients who were permanently on life support and losing their financial resources. My company, under contract with NY Hospitals would move these patients to another State establish residency for the individual and collect the Medicaid reimbursement from the State where we were located. This reimbursement for a person on a ventilator was double the New York Rate.
As I deplaned from our corporate Cessna that day, one of the Senior VPS asked “How long do you think that last case you looked at will live Jeff”. You see, buried deep within that – statement was the profit calculation. I remember that night well. Carol and I had just been married. When I arrived home I sobbed in her arms; Fearing for all of us.
What do I know as a caregiver and care recipient who has had diabetes for 47 of 57 years of his life? Well, that if we have any sense of humanity within our value system and we are human: We will both give and receive care before we die.
Our system is not designed to accept death. As a result, where resources are unavailable many Americans are left to care for their dying loved ones with few skills. However, where the administrative processes are burdensome, we should also recognize the beauty and reward of helping a loved one cope with these phases in their life. In actuality I used to send patients home on ventilators having educated the family to care for them. They did just fine and in over ten years, no-one ever lost their life due to a family member’s ignorance or misjudgment. PLEASE: I BEG YOU TO ASK ME ABOUT THE HOSPITAL IN CONTAST TO THE LAST STATEMENT.
I suggest that we include a social contract to educate our children as to the process of acquiring health-care and the personal commitment required for managing our cost-of-care as our system changes. High school would be a great place to start.
I know that we have choices but many of us in America do not believe we have any power when it comes to the treatment we receive, the cost of the treatment, the alternatives and best practices. If we did, we wouldn’t require case managers, patient advocates, Accountable Care Organizations to assure we are treated well. Heck, the new health reform assumes we are unable to do our own research or select the right provider. This is why these job descriptions exist and corporations are contracted to keep watch on the quality of care we receive.
I submit that this may be true for now. But I also submit a challenge to Americans: A challenge for all of us to step away from our televisions and disregard sound-bites. A challenge to become self – educated consumers. It is not as complicated as one might think but you need to understand the shell game.
And by the way, the shell-game is not going away.
As I listened to the Senate hearings today I was very disappointed to hear our elected officials use your time and money to skew your opinion on the ACA. (ObamaCare). Many of these folks now profess to understand the complexity of integrating hundreds, perhaps thousands of separate insurance products with eligibility determination and e-commerce.
Turn off your TV. There is a great deal of good work going on. Stay informed through your own research. and do not rely on the interpretation of single individuals. Ignorance propagates more ignorance and the consumers are always the target of distorted truth.
Man with diabetic retinopathy
September 30, 2013 No health insurance
October 1, 2013 Accepted by NC Blue Cross for $284 per month
I am ecstatic!
I received a call yesterday: A report from an ophthalmologist friend who I am assisting to develop a diabetes eyesight preservation program: “Jeff, we are so excited; our patient y has insurance! Last year we performed his treatment for free. Now, after January 1st we will be able to charge for his laser surgery.”
“Great!” I said; “imagine how many sight years will be gained, now we just need to find them, get then enrolled and treated!”
By the way, this doctor is a dear friend; one of the guys; he and his partners have never denied service to a patient based on their ability to pay. He is slowing down now at age 67, brought on two new partners that are young, accepting of his philosophy and simply thrilled to be practicing their art. There is enough left to earn what they consider a good living and now expand their practice to those patients who have been afraid to approach the office ask for a favor.
This is the first good news I have written about in two years. I hope to continue with this trend!
The invisible North Carolinian waits in line for relief of pain
From Raleigh News and Observer Sunday August 25, 2013
I beg all to share this article on our dental care system in. North Carolina. This is only one example of a crumbling infrastructure as the policy makers in Raleigh decide to not accept solutions.
Since election of new state legislature and GOVERNOR MCCRORY
Highest unemployment rate:
Lowest teacher pay
One of the most notable Medicaid Primary Care systems in the country with improvement in health quality and reduction in health cost for many years now.
Reduction in substance abuse detoxification beds
Stipend for food stamps…..nah
Need so many papers to vote; it is as difficult as my Jewish relatives’ attempts to leave Germany in 1943.
Decision to not create a health exchange leaving a 3 company oligopoly to set insurance rates due to lack of competition.
The people standing in line for dental care in this photo are our neighbors. Can you imagine needing a root canal, being unable to eat, experiencing severe pain every time you had a drink of soda? Then being denied care?
Is this how it was in the 30′s Dad?
HELP! The new Director of HHS has hired a 24 year-old with no experience in Public Health to be her policy adviser and his salary is $85,000; more than twice the pay of a teacher with a master’s degree.
Oh yeah, we won’t pay salary differential to teachers who achieve graduate level degree in education!
How we spent our Summer, 2013
On her way to work; my lovely wife Carol was “run off the road” by another hurried North Carolinian. Carol works in the Wake Medical Center Emergency Room. On this day she arrived by ambulance.
Here is a link to the NC Insurance Commission Oligopoly’s plans to inform its consumers of insurance rates.
Essentially, the rates are filed for 60 + plans to be released by three company’s of which Blue Cross is the only with statewide networks.
The citizens of my state are kept in the dark until Oct. 1st. After 34 years in the healthcare industry; with numerous projects and discussions with payers, providers and patient groups I can assure your readers that the decision to not publish rates on what appears to be 67 different health plans (Garner Cleveland-Record, 8/07/2013) is a proverbial ‘punch in the gut’ to the citizens of our State.
First our legislature refuses to accept the federal contributions for Medicaid Expansion, then decides to not participate in the creation of its own competitive exchange and now we are –like mushrooms; left in the dark with regard to critical information necessary for health planning.
In retirement I am working as a community educator with a focus on health services planning throughout one’s life. Most people in the US do not understand healthcare; the complex relationships between business entities; how these relationships inflate cost, an individual’s rights to receive care in accordance with best practice or the historical cost of services and products absorbed by an individual with a chronic illness such as asthma or diabetes: Let alone how to select an insurance company product by carefully evaluating future needs.
We all have the skill to purchase a car. We review the cost of the car and affordability of the monthly payment, we review Consumer Reports or Edmund online or Kelly Blue Book to ascertain future value, cost of repairs and so on. Then we make a rational decision based on the data. Or, like-me we ignore the data and purchase a car with noted mechanical issues and pray for a better outcome. Regardless of the decision we had the data to start with.
So, in October, the legislatures guaranteed oligopoly will release plan descriptions and member fees, then the consumer will need to evaluate their family health situation and make a best guess.
I plan to assist as many as possible, I do not sell any products but have worked in all three sectors of the industry, managed a disease management program and have had diabetes for 47 years along with other co-morbid complications. As the policies changed I managed to stay ahead of the challenges but it has been a struggle. I have never received accurate individualized information from an insurer, physician, or case manager who was employed by an organization fighting for its piece of the pie. The lack of alignment of value proposition alone has driven me crazy. However, when it came time for an insulin pump in 1984 as managed care took hold in America I received the equipment I needed through advocating for myself.
I predict the million or so individuals who are without insurance in North Carolina will begin receiving targeted sales and marketing information in September followed by a call from someone calling themselves a Patient Advocate. The encounter will be posed to educate the consumers when in reality the consumer will be driven like cattle into the sweet spot for the organization that employs the advocate.
It is a real shame…there are a few folks in North Carolina who can help the general public but they are scarce. To my friends in the trenches of population medicine, I ask you to step up and assist your neighbors.
Untangled Health shares revised tools for the uninsured. Enjoy the experience.
Please share with friends seeking information on both individual and corporate healthcare insurance exchange. Hopefully we will all see a more affordable premium: Similar to the rates published recently in other states such as California.
For my friends in NC…Sorry our elected officials are not willing to evolve so those with incomes below 4 times Federal Poverty Level will not qualify for less costly Medicaid insurance.
Anyway, click on the link below.
Patient Centered Care requires patients and families to assume an active role in their health management.Recently, I have fallen victim to daily calls from “National Diabetes Supply Experts” offering free testing equipment. If I accepted each offer I would need to change supply brands through requesting a new prescription from my Medical Home. This process happens thousands of times per week without the inclusion of the physician and patient in a discussion regarding the benefit of supply change. Your data, including diagnostic information (for me Diabetes) is being leaked, purchased or stolen. I have now filed a case for data breach through the OCR mechanism.
The priorities of Health Reform include improving access to services, medicines and supplies to all who are in need. One special population: Those with chronic illness; require recurrent refills for home monitoring and therapeutic supplies. For example: As a diabetic I require home glucose monitoring supplies and much more. The photo above shows my kitchen table while preparing for a business trip. You will observe that I have an insulin pump, a continuous glucose monitoring instrument, the associated catheters and an impressive array of prescription medications.
The cost of supplies to me personally exceed $5000 per year in addition to my current $800 per month insurance premium. The cost of my supplies to my insurance company also exceed $8,000 per year over the past two decades.
Now! Another purpose EQUALLY IMPORTANT of the Affordable Care Act is to make health care AFFORDABLE!
Because we decided to maintain a multiple payer system we continue to have a dichotomy between public and private funding sources e.g. Medicare and Blue Cross. As a result many entities are competing for your business as a healthcare product consumer.
Where we have free market, we have human entrepreneurial ingenuity. As I have said in the past, folks like me have always managed to figure out a way to maintain our cash flow during times of legislative change. So, lately: through the lens of a patient and former healthcare entrepreneur I have witnessed the following behavior:
Somewhere, somehow a bunch of mail order diabetes supply services have been calling my home. Over the past three weeks, the calls occurred daily from three different telephone numbers. Each call represented a different company and each agent had the same script:
“Hello Mr. Harris; I represent “Acme Diabetes Excellence” we have been chosen by your insurance company to provide you with a new technology for blood sugar monitoring. I need to collect some basic information to fulfill this order and your free supplies will be mailed shortly.”
No agent has been able to inform me of how they obtained my protected health information and not one agent has allowed me to speak with their supervisor. I have filed a HIPAA data breach complaint with the Office of Civil Rights but suspect nothing will happen.
Most insured diabetics today have multiple blood sugar monitors that have been given to them by their physicians, drug stores and other vendors to try the technology and conclude which device has the most appropriate for their life style. The meters are free because the profit is in the resale of test-strips which have retail prices between $10.00 and $50.00 per package of 50. Each b.rand will only work when coupled to the monitor given away through such wonderful corporate generosity!!
What these companies are doing is taking advantage of some database products that have evidently become available. I find this infuriating as the intrusion on my self-care plan which is negotiated between my medical home personnel, my insurance company and myself will serve no purpose other than inflating individual and aggregate healthcare costs. THIS IS A PROBLEM! IT CAN UNDERMINE THE EFFECTIVENESS OF THE ACA AND I AM ASKING FEDERAL CONSUMER PROTECTION AGENCIES TO RESEARCH THE ISSUE.
I support free market economies. However I suggest human behavior arising from free-market opportunity might be the largest determinant of uncontrolled health care cost escalation.
So, as we work toward building a comprehensive, coordinated team approach to chronic disease, let’s not forget the impact of our decisions when we select self-care technologies.
I have little hope. After 34 years as a healthcare executive, therapist, HIT visionary and above all: Advocate for fair and proper service access to all US Citizens; I doubt I will have my needs met as a patient:
I also doubt I will ever see harmony between payers, providers, patients and the media. It is far too easy to become distracted by the numerous disparities and factors giving rise to our overall US population cost and the rage between stakeholders. The distractions allow all who work in the industry to define a spot for themselves where they are comfortable: Comfortable with regard to salary, comfortable with regard to business processes, comfortable when they create a new service industry within the market under the argument of cost savings and quality improvement; comfortable, comfortable, comfortable. It is far too easy to reinvent ‘value added’ services and industrial segments. No ONE is in charge. No ONE is willing to step-up and claim they are the Great Oz.
I began my career as a paramedic and then received credentials in respiratory therapy, cardio-vascular technology and pulmonary physiology. My work unfolded as I was promoted to department director and then division director in the first five years; as DRG’s were settling in and hospitals began finding new ways to make money in ancillary services. Healthcare –because of its capacity to rename, re-market, leverage known waste into ‘new savings’ and offer new technologies without utilization controls and proof of social value has been very good to me. My upper middle class salary increased every three years and when it became apparent that HMOS would begin purchasing business logic to approve and deny procedures, define lengths of stay and pummel physicians with outcome data I learned enough about each sector to add consulting value on both ends. Because of the dynamic legislation across both commercial and socialized sectors any entrepreneur could make an excellent living as long as he or she was personable and able to rationalize their behavior in terms of improving quality adjusted life-years for the 85 year-old golfing buddy who needs a second CABG.
Then…in 1989 I began a ten-year period where I retreated to offering disease management programs for folks with moderate to end-stage lung disease. We accomplished a great deal of good for many people in the last years (or months) of their lives.
But in the end I found myself arguing for my ashen patients who had lost their oxygen prescriptions when they rolled off of Massachusetts Medicaid because of a $1.00 per hour bump in salary. I found new ways to ‘work the system for payment for their oxygen’. The oxygen they received through a small machine which cost $750.00 retail was billed to payers at $299.00 per month in 1989 dollars. In 1997 I flew to NYC and other areas of the North East to review individuals who were dependent on ventilators in acute care facilities. The call for help came from the hospitals as they accrued huge losses due to the prospective payment on these cases that were depending on their life support. One day as I was stepping off of the company Cessna the senior VP asked to review my list of cases from the day. Taking interest in an 80 year old woman on the list he asked “how long do you think this one will live Jeff?”; “Is the family willing to transfer her and liquidate her assets?” His self-justification for asking the question was a simple knowledge that he owned an excellent group of rehabilitation hospitals. He was not the type of fella to consider the pain associated with separating a grandmother from her grandchildren.
I left this venture to work in the design of web-based continuous care plans for persons with Chronic Disease. However, even separating myself from the ugliness of clinical care that we all see in our lives I found similar behaviors wherever I went. For example: I had an IT start-up CEO fly us out to the 1999 Managed Care Conference. We had just released a very cool integrated transfer management system the previous month. The founder asked me to place a sign in our booth stating MEDICAL LOSS RATIOs 69%!!!! In essence, he asked me to repeat the MLR of the one brand new client that had purchased our new system the previous month. I felt ashamed and refused. (ref. MLR is amount spent on medical care / member fees)
Eventually I found myself in NC as I declared I wanted to learn about policy. I was hired to work with what I envisioned to be a leader in Medicaid community care management and care coordination. The years I spent in the public sector with special programs under Medicaid only revealed the same type of rationalization for ‘stretching the truth’ or creating political and financial pressure for physicians. The eternal mind-set; we know this is the right thing so we need to keep the program alive.
I found NC Medicaid to have a wonderful program. But, as in many situations in the past I felt boxed in to “the –insert corporate name- WAY”. I have found that questions as to data integrity or suggestions to reduce cost by deploying new technology that will remove a necessary contract with a friendly vendor to always be un-welcome. Many healthcare workers are content with status quo; some are not. So I became a consultant.
My last few years were spent listening to boards of directors who shared numerous conflicts of interest shift charity funding between duplicative projects. I thought the ARRA, HITECH and perhaps parts of the PPACA might make work more enjoyable. Unfortunately, I found myself asking an FQHC who had received $1M in stimulus funding to delay their deployment of telemedicine since they had no plan. I said this just as the checks were being written to purchase high resolution flat panels for the clinics and a local vendor was installing a new VLAN. This was my first day on the contract. After fifteen months they never did succeed with getting their VLAN up and running. I was however able to launch their desired remote-psychiatry service for children with ADDH. How…well I conferred with some geek friends, researched the legal security standards; drove to Best-Buy and installed a three clinic encrypted Skype service. My submitted expense report for the work was $250.00. The cost of the ARRA never implemented tele-medicine service across a new VLAN? $144,000
As a diabetic who is now retired after 44 year’s dancing with the disease and receiving SSDI at the age of 56 I feel as though I waited my entire career. My income is $2400 per month, I have some savings, little debt and many fond memories of the days with my patients. My insurance cost through my wife along with the ‘cost sharing’ pieces of my “cost of care”; roughly $1200 per month.
What I see happening is ONE MORE TIME…new products and services. Last week I was told my physician was to charge me an additional $1500 per year through the local university’s Integrative Health Program. The money evidently is to pay for better access and (I am not kidding) an interest in my LIFE GOALS.
The issue of the cost of health care in the USA has nothing to do with Physicians, Hospitals, HMOs, TPAs, Pharma, Therapists, Insurance Companies or any other entity. The problem is far greater than the sum of the parts.
A society has gone askew with its values when it treats “Well Being” and “Well Fare” as a commodity in a free market system. The value of “Well Being” varies for every person, or culture and when intertwined with the largest factor in “Well Being” in early life (Employment) the calculus becomes complicated enough to manipulate and confuse the masses.
Jeffrey Harris (BS, RCVT,RPFT,LRCP) All exams inflated salary beyond reasonable value for just one more Bozo on the Bus.
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Last month my father called and complained of being ‘dumped by his primary care physician of 25 years unless he was able to pay an additional $2000.00 per year for concierge services. He said: “Jeff, Dr. Xxx’s nurse called and said that this new program would assure 30 minute follow-up appointments and 60 minute annual evaluations along with a 24 hour, 7 day per week personal communication with the primary care physicians in the practice. I told dad to pay the fee since he could afford it. With disgust, my 84 year-old father and former career NASA aerospace engineer told his Dr. to stick it where the sun doesn’t shine.
Then; on a personal level: I started visiting the Duke Integrative Primary Care program. They have made wonderful changes to my treatment after uncovering several unknown nutritional and biochemical deficiencies. Unfortunately, they tell me today that they will be pleased to accept my commercial insurance but no Medicaid and no Medicare. They also now require that I pay $1500 per year in addition as a membership to the practice as they are limiting the practice size to 600 patients. The administrative RN tells me that this is the only way I can get the services one would expect from a ‘medical home’ such as appointments of sufficient length to “ADDRESS MY LIFE GOALS”. With a smile, the RN says: “Well, with your background Jeff, you know that it is impossible to do without additional funding”. My response was to illuminate (with colorful words) the purpose and methodology of practice re-design when implementing Medical Homes. I find it hysterical that Duke itself claims to be a leader in their own primary care system in the evolution of Medical Home concepts and adherence to Meaningful Use Criteria. I find it disgusting that their ‘offering’ of this concierge service is really nothing more than what over 3000 physicians have been providing through NC Medicaid’s Community Care of North Carolina contract for a decade. I find it nauseating that we are continuing to squeeze profit from a dwindling consumer base and refusing services which are noted to be ‘best practice’ to the poor. People are people I suppose…and subject to greed.
I am writing this as I leave the Duke Integrative Primary Care clinic today, probably for the last time. These folks diagnosed my metabolic issues and low testosterone: I feel better. If I did not ask for the appointment with my “10 minute visit primary care doctor” she would have never referred me to the clinic. I will now return to her and when I am able to afford it I will return for further investigation and treatment of the many factors that decrease my health related quality of life.
Note: I returned to my PCP yesterday March 15th, 2013:
She was angry that I had been placed on testosterone since she had worked me up last year for prostatitis. Had she read the notes in the wonderful e-HR that inter-operates with only duke physicians she would have noted that prostatitis is now ruled out, neurogenic bladder is the new dx and that Dukes own specialty physicians had started testosterone replacement with the intention of having primary care pick up the prescription writing responsibility.
She stated she would not write the prescription.
My next move was to walk her through the notes of the physicians she had referred my case to. I then told her that the Duke Integrative Medical practice would charge me $1500 per year if I needed to return to them for the prescription and that I would leave Duke and her primary care practice if she couldn’t address this with the other doctors on my health team.
My doctor says: “Well why would you leave, what is it that you expect?”
I followed with: “Dr. XXX; I would expect that you would have read the consulting notes prior to entering the exam room so we would not wind up in this tense situation where you are asking me to run all over the locality to describe your directions to my specialists as far as who prescribes what” ”Beyond that, I find your employer ‘Duke Primary Care’ attempting to drive my SSDI money as a private payment to their concierge doctors by not allowing the consulting physician to prescribe medications. In other words, he finds the chronic disease which is treatable with integrative techniques and then refers the patient to the front desk to get them enrolled with the two new primary care physicians in the concierge program.” “Furthermore, not only has this new system of care created a barrier to me getting the medications I need but it has done this by not addressing the educational issues that are clearly needed among their own medical staff.” “Oh yeah, one more thing I realize this is not your fault with the exception that you neglected to read the consult results. I believe this is due to the fact that you carry a case load of 2500 patients and become overwhelmed at times.” “Actually Duke has insulted both you and I. You call me whenever I need you and that is why I choose to be treated by your practice. In my view you have a nice start with your Medical Home right here. But your employer is selling a package wherein they differentiate the offering by noting that the concierge physicians are 1) more available and 2) interested in my ‘life goals’. I realize nothing will happen as a result of this discussion today because it relates to Duke Politics. However, if you think about it we have just touched on: Cost of Care, Quality of Care, Patient Satisfaction, Provider Satisfaction and reputation.”
She nodded, said nothing else; spent ten minutes reading my chart and looked up at me with a sad expression. She apologized for “not getting it right”: I responded with “You did not have enough information, you were not educated as to the changes in program marketing and none of this is your fault.” “I promise you that I will only take medications that are prescribed by you for chronic conditions once I return from the specialty consults. I count on you to interact with my other doctors and resolve conflicts on my medication list; but I need to trust the system of care.”
Dr. XXX of Duke and me are still together, we have agreed to how we will relate in the future and how we will survive in a patient-primary care relationship within the context of the Duke System. I think that what transpired over this last month models patient participation in medical decision making, cost control and providing feedback. I hope that my doctor stays with Duke, it seems their turn-over is quite high. Perhaps they should look at those data!
Dear Brother and Sister Patients,
You will find many physicians not agreeing with me when I state that all should have access to 100% of my health record, care plans and prescriptions. They might further disagree (for legal issues) with owning the responsibility of taking into consideration 100% of available information so may be less supportive of data exchange between electronic medical records.
Please understand: We, that is you and I paid for a seamless ‘inter-operative healths record through ARRA-HITECH funding. Our purpose in asking for this feature was to make sure we did not fall victim to therapeutic misadventure e.g. a physician prescribing a medication that could interfere with your ‘well-being’. YOU NEED THIS as it is one issue, which we call poly-pharmacy that is responsible for well over 100,000 errors in medical practice per year.
When your doctor gives you your visit summary which should include a problem list and medication list make sure that it correlates with other doctors in your treating team. You might just save your own life!
Human Motivation: Our legislature no longer needs to play cards close to chest; this is a Power-Grab
To the multitude of people and organizations interested in the cost burden of health-care services on the average Constituent. Please pay attention as you attempt to change the course of a system rooted in 100 years of free-market philosophy: Where human ‘well-being’ is exchanged as a commodity for common currency. In other words: “nothing personal, this is just business”.
On any given day, at least 50% of North Carolina’s existing Medicaid beneficiaries are working persons without access to affordable health insurance. Many…work more than one job to make ends meet.
This statistic glares in the recent event of Governor McCrory’s decision to give his cabinet a salary increase of 8% (average = $108,000 per year). His logic…”They must have a livable wage”. No other State employees saw such increases.
Ironically, on Wednesday February 27th, 2013 Governor Pat McCrory of North Carolina signed into law legislation which prohibits NC from participating in the Federally Funded expansion to Medicaid. This single act will prevent one half million North Carolinians from becoming eligible for Medicaid Benefits. It appears he judges those without access to healthcare services to already have a livable wage?
So here are some facts:
My wife and I moved here in 2001 to participate in what was quickly becoming known as one of the best low-income chronic disease management programs in the United States: NC Medicaid’s Community Care of North Carolina. Working for Community Care of North Carolina, I participated as a team leader in implementing the first statewide care coordination and patient risk management systems in the US. Today, if you are in NC and on Medicaid’s CCNC program you probably have access to chronic disease management programs that are more organized and successful than ANY commercial service. This truth is illustrated by the externally validated reduction in emergency room reliance and improvements in chronic disease management indicators. The external validation has been provided by nationally recognized actuarial firms and schools of public health. In-fact, in North Carolina, one of only a few National Beacon Communities is a Community Care Network.
I enjoyed being part of this effort. Unfortunately I NOW SCREAM OUT TO MY FRIENDS: GET ME THE HELL OUT OF THIS STATE!
I am an example of many of those people in NC who were counting on Medicaid. One of the 60% who have been or are employed and cannot afford health-insurance: a 56-year-old male who within the last year was disabled from his diabetes; a disease diagnosed at age 10, a history of excellent self-mastery of illness. I received my first SSDI check in November. It will be two years before I qualify for Medicare and the $1200 per month premium simply does not fit a net monthly income of $2400.00. I would like to ask Governor McCrory, John Boehner and others of the same philosophy just what they consider affordable when it comes to healthcare cost as a percentage of annual wage?
Their answer unfortunately is either predicated on ignorance or selfishness. I judge that they are not ignorant in the least; although Governor McCrory of late seems to be believing some very questionable information which I have plenty of data to disprove.
How a boy from New England winds up in North Carolina:
I came to North Carolina to assist the Community Care Program with the data architecture and clinical decision support data model for their Web-resident care coordination application CMIS. This model was a variant of one I had used previously while at Active Health Management the provider of the Care Engine Decision Support System to Aetna. Aetna purchased Active Health for $465 M in 2002. The system employed by North Carolina used similar data objects identified as Problems, Interventions, Goals and Tasks which were generated by Care Coordinators to create shared Care Plans for all Medicaid recipients who were high-risk and high-cost. Essentially, before most were familiar with the importance of Continuity of Care and Comprehensive Care Management: The Community Care of North Carolina Networks were leading the charge with over 600,000 people enrolled in their CMIS software. I feel blessed to have been a part of their success.
So where are we eleven years later?
I left CCNC in 2006 to work on several national implementation projects utilizing components of what would become the standards for today’s Electronic Health Record. In 2009 I worked for my wife who was an assistance field coordinator for the Obama Campaign. Spending hour’s daily crunching data we were able to redirect or feet on the street to move over 4000 voters who were necessary to make NC a “Blue State” for the first time in many years. We did not do so will this last elections season.
Since 2009 it was obvious that I would need many of the health reform changes to have a satisfactory fall and winter in my life. The neuropathy accelerating, February 2011 was the last month in my career where I was able to work a full-time schedule.
I never worried about getting my needs met. Believing in my country I did not see how in the world Americans could decide to turn their backs on their brothers and sisters. I am quite naïve and I must admit my failure in ratcheting down a secure financial future with the knowledge that my chronic disease would take me out before the age of 60. I honestly was stupid enough to believe that healthcare would become affordable. I know better now…watching as we behave like toddlers in DC and seeing the disapproving looks on the face of men and women in my community when they speak of those ‘people’ who live on entitlements. Well, I guess they can include me in the group. I hope the next time I kneel to perform CPR on one of them (done this three times in my life); they ask me if I receive any entitlements before I start compression.
NORTH CAROLINA! Who will you blame as it all falls apart?
Three days into office our new Governor, Pat McCrory introduced his new executive leadership team. I admire all of them. At the same time Governor McCrory adjusted each the salary for each position on the leadership team upwards by 8%.This occurred at a time when NC State Employees have seen no salary increase in several years. With no plans to alter the basic wage of a North Carolina State Employee, Governor McCrory justified the increase as follows: “Well, they all need a living wage”. The average salary of his staff exceeds $108,000!
As we moved into the New Year one of the first agenda items for the NC legislature was the consideration of how NC will participate in the PPACA program. As my friends in the ‘biz’ know, our health reform law allows each State to expand Medicaid by creating new classes for eligibility. Medicaid is the federally supplemented health insurance program for the disadvantaged. Usually the State receives somewhere in the range of 60%-70% of Medicaid Healthcare Costs from the Feds while making up for the rest through State taxes. The expansion will be covered by 100% by federal dollars and then be reduced to 90% after a few years. In addition, the States are allowed to establish their own competitive market basket for insurance plans called a Health Insurance Exchange or share a joint system with the Feds.
For detail on health-reform I suggest you all start at Wikipedia (http://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act).
So far this year our newly elected legislature and governor have worked the press nicely by illustrating how expensive Medicaid is and then describing it as a management failure since many aspects of the system regarding clinical care are shared by several divisions (Public Health, Mental Health and The Division of Medical Assistance). These folks actually believe that partnerships are dysfunctional. I guess I agree with regard to administrative costs but certainly not clinical and regulatory expenses since the majority of the covered individuals have co-morbid physical and behavioral health problems along with social environments falling far short of adequate when it comes to primary and secondary prevention due to critical access and affordability barriers. This is not my judgment just a parroted agreement that I hear from the experts in public health. If you want honest expert data and opinion look at the North Carolina Institute of Medicine Website.
As of this week, a final vote has passed through the legislature to prevent expansion and the creation of a competitive insurance market. Instead, the governor and legislature will consolidate and use an insurance eligibility system titled NC Fast or North Carolina Families Accessing Service and Technology.
I was working for NC when NCFAST was funded. It is far passed its original implementation deadlines and I have heard nothing but complaints from the numerous users I speak to at conferences during the year. By the way, unlike smart business people like our new governor purports to be, the NC teams have built much of their own technology, guaranteeing the job security of the staff at the DHHS Division of Information Resource Management (DIRM). Most of my mentors taught me to keep an eye on the work occurring in large commercial sectors and evaluate their offering prior to deciding to build something on my own. I guess there was nothing out there ?
So…no Medicaid expansion AND no Insurance Exchange!!!!
I moved to NC to learn about policy and community organization. Why? Well, in 2001 this was one of the best environments to nurture my growth…as a citizen and as a person. About 4500 physicians collaborate on best practices, assessment of the overall needs of our population as well as the independent needs of their own geographic region. During my tenure (2002-2006) our teams assembled and implemented a fully operational ‘single sign on’ web-native care coordination portal for Medicaid. When we started it served nine networks and contained 250,000 patients. Today, it contains 14 networks and 2 million individual patient records of which around 200,000 are actively managed by one of the 14 networks. You can see why I wanted to move here (grin).
The time spent here has been wonderful regarding my initial purpose and mission. That said, I have learned that our species is threatened and there is no one or no THING to blame. It appears to be a genetic mutation and it is not recessive. In well over 2000 years we have learned that we are a social species in need of a safe container to live: Supported by a community of others; We have learned that we are responsible not only for our-selves but also for our neighbors and children. We have learned that we struggle with a self-obsessive demon that tends to reinforce the opposite axiom: “Only a society of self-interested, competitive individuals will thrive”. Yet in the end, we are all interdependent unless you have figured out how to bury your own remains.
I moved here because of the cool progressive patient centered care-system being created. I had a blast and observed the success. Eleven years later I am disabled, on SSDI from my disability and living on $2400 per month. I think I deserve it since I worked 34 years and paid my taxes. I have a problem though: My diabetes and other co-morbid conditions cost me $500 per month in cost sharing. My wife’s insurance plan costs an additional $500 per month for me to be added to the membership. I had counted on becoming eligible for an affordable plan through an Exchange as it would include benefits for folks like me. Now, North Carolina has decided to keep me out of their pool. The Affordable Care Act is designed to subsidize folks with decreasing stipends up to 400% of the poverty level. Trust me there are a lot of us in this category. It will cost me a bit to have the legislation as my medical equipment will have a surtax and I will pay additional tax if I want a Cadillac plan that covers removal of tattoos placed on my body sometime thirty years ago in some place that I can’t quite remember (just kidding).
Guess I will leave the blog for the night, please drop by on occasion. I am now documenting how I use the Duke Information Portals to manage my care. This week I taught two physicians on my five member team who are not in the Duke System how to access my data. When we reviewed my clinical notes; Medications, labs and tests a major shift occurred in my plan of care. I now have one less physician and am on a new medication that is improving my quality of life by 40% of so. I will create a separate post for this experience as I expect to add the material to the collective education material arising from the e-Patient movement.
This photo was taken as I prepared for a three-day trip. This is just my medical stuff!