0 The Non Surprise of Increased Physician Referrals

Big deal!

News flash! 

In the last century, American derrieres have grown by 5%! 

In the last 20 years, rates of professional athlete misbehavior have skyrocketed! 

And in the last 10 years, theres been a near doubling of physician errals!  

If these trends surprise and amaze you, you may want to check out the up-to-the-minute news outlets like The New York Times "Prescriptions Blog."  On the other hand, regular readers of the Disease Management Care Blog may not need to go to such extremes. They are astute observers of backsides, know how to access ESPN and can confidently predict trends in health care utilization.

That being said, the DMCB thinks a recently published article on physician errals may be worth a look.

Michale Barnett and colleagues extracted physician survey data on a sample of clinic visits from 1999 to 2009 that had been collected by the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey.  Physicians were asked about their type of practice setting (employed vs. physician owned), their patients demographic variables, reasons for the visit, diagnosis, treatment and disposition, including whether or not there was a erral to another physician.

The study found that the rate of errals increased from 4.5% of visits in 1999 to 9.3% in 2009.  This increase included Medicare patients, who went from 4.2% to 9.7%.  Physicians who owned their practices were less likely to er (from 4.2% to 7.5%) and physicians with more than 50% managed care experienced an increase from 5.5% to 8.7%.

In the Discussion section of the manuscript, the authors point out that two possible explanations for the increase in errals include 1) the increasing complexity of health care and 2) the benefit of off-loading some of the work of patient care onto another colleague.

The DMCB agrees and would add two more explanations:

1. The increase in "PPO" vs. "HMO" style managed care during the period of study, and

2. An increase in patient consumerism.

Can recent health care orms, like ACOs, reverse this erral trend?  While the DMCB awaits the answer to that question, it looks forward to the continuing roominess of its movie theater seats and the next juicy sports scandal.

Stay tuned!

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0 The 3 Legged Stool of Telemonitoring The Device A Non Physician Professional and the Patient

Just when the Disease Management Care Blog has barely learned to control itself when its in the company of clueless electronic health record (EHR) techno-weenies, enter the equally intolerable "telemonitoring" enthusiasts. Their jargon-laced claims of pan-medical and cost efficacy is enough to give the DMCB a migraine.

Their bombast is easy to spot.  According to this new class of leprechauns, small wearable telemonitoring devices for blood pressure, temperature, breathing, heart rate, weight, calories, blood sugar, cholesterol, brain waves, nail length, eye-blinks and minutes spent in the bathroom upload the data to the doctor who, thusly armed with critical insights of well-being, can do more of their... doctor stuff like... give out some prevention and stomp out disease.

For the best example of how that is simply not true, the DMCB is reminded of this negative December 2010 heart failure symptom telemonitoring study that alerted the patients physicians about "variances."  The DMCB readership already knows that physicians are already busy and just dont have the time to fit one more task into their busy days.  Thats doubly true if the data is unfiltered and without any context.

Yet, while the DMCB is unwilling to hop aboard the telemonitoring train, that doesnt mean that this has nothing to offer.  In the DMCBs estimation, itll increase quality and probably lower costs if it is combined with two other key ingredients:

1) a non-physician professional being in the loop, who can a) monitor the information and b) contact the patient with significant variances and c) use a combination of clinical judgement and standing orders/protocols to guide a patient response (which, by the way, doesnt have to include seeing the physician).  An example is here.  Theyre usually nurses and they can be part of the Patient Centered Medical Home or as part of a population health management program (or both).

2) an empowered, engaged, enabled and educated patient who understands the "output" of the device and can respond autonomously, confidently and collaboratively.  While some readers may pooh-pooh the DMCBs unrealistic idealism, the DMCB has found that most patients are smarter than they are given credit for.  As far as the DMCB is concerned, if a patient can manage a telemonitoring device, they can usually deal with the non-physician professional and also have some insight about what the device is "saying."
   
The DMCB thinks of it as a three legged stool.  Having telemonitoring patients be 1) passive and 2) unsupported bystanders while their data uploads scramble their overburdened physicians workflows isnt health reform, it isnt cost saving and it isnt quality. 

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