During visits with your doctors or other health care providers, do you speak up and ask questions? If the answer is “yes,” congratulations. You’ve taken an important step to getting the most out of your health care visits. You’re also in the minority. Most people have trouble asking their doctors questions. It can be even harder to disagree with your doctor, or make known your preferences for care and even your worries. There are many reasons for poor patient-doctor communication. One is what Timothy J. Judson and colleagues call the asymmetry of power. Medical lingo is another key barrier. The federal Agency for Healthcare Research and Quality’s “Questions to Ask Your Doctor” campaign and the Joint Commission’s “Speak Up Initiatives” offer free information to help people ask the sometimes difficult questions needed for good health care.
We are taught to share at an early age, and sharing is encouraged and praised across the life span. One area in which there has been a lack of sharing is medicine. Doctors have traditionally made decisions for their patients with little or no discussion about the preferences of the person who will ultimately have to live with the decision. That’s changing. More and more, doctors are trying to implement a model known as shared decision making or informed decision making. These terms refer to a process that includes a thoughtful, informed conversation between you and your doctor aimed at making a decision that’s right for you. Shared decision making is gaining acceptance as a medical “best practice.” Many studies suggest that it improves health outcomes, taking medications as directed and following other instructions, and satisfaction with a treatment or course of action.
As wait times to see a doctor for simple problems like sinusitis and urinary tract infection lengthen, more and more Americans are turning to retail health clinics—walk-in medical facilities located in pharmacies, grocery stores, and retailers such as Wal-Mart and Target. The number of visits to such clinics quadrupled from 1.48 million in 2007 to 5.97 million in 2009, according to a study published in the journal Health Affairs, and topped 10 million last year. Convenience is driving this migration to retail health clinics, since you can walk into a retail health clinic without an appointment, and many are open nights and weekends. Although most retail clinics focus on immunizations and common ailments such as strep throat and sinus infections, some are beginning to manage chronic conditions such as high blood pressure, diabetes, high cholesterol, and asthma.
Most reputable companies that provide services tell you what you’ll get for your money. Hospitals are an exception. They haven’t traditionally made public the cost of operations and other procedures. This secrecy has let hospitals set widely different prices for the same procedure. It’s also made it impossible to do any comparison shopping. Yesterday’s release to the public of a once very private database shows just how big the differences can be from hospital to hospital. The database, released by the Centers for Medicare and Medicaid Services, details what 3,300 hospitals charged for the 100 most common treatments and procedures in 2011. It data reinforce the big differences in charges from one part of the U.S. to another. What’s new and surprising are the huge differences sometimes seen between hospitals in the same city, or even the same neighborhood.
Two of every three Americans who reach age 65 will at some point need long-term care for up to three years. Yet the majority of those age 40 and older have done “little or no planning” for how they might pay for long-term care when they get older. That’s a key finding from a new survey of 1,019 Americans over age 40 on the topic of long-term care. The survey was done by the Associated Press and NORC at the University of Chicago. Most people underestimate the cost of nursing home care (it averages $6,700 a month) and overestimate what Medicare will cover. And few people are setting aside money for long-term care even as most worry about key issues of aging such as memory loss or being a burden to family members. Without a crystal ball, it’s tricky to plan for the future. It’s easy to convince yourself that you or a partner won’t need long-term care. But the statistics suggest you should start planning now, even if your plan isn’t perfect.
The toll taken by medical mistakes burst into public attention with a 1999 report called To Err Is Human from the U.S. Institute of Medicine. The report estimated that between 44,000 and 98,000 people die each year as a result of preventable medical errors. Such errors can be headline grabbers, like the death of Boston Globe columnist Betsy Lehman from an overdose during chemotherapy. The safety of hospital stays and encounters with health-care providers got a boost today with the publication of 22 evidence-based “patient safety strategies.” Although most focus on care that takes place in hospitals, they extend to almost all interactions between individuals and their doctors, nurses, and other care providers. Very few of the safety practices are expensive, high-tech interventions. Instead, they are almost old-fashioned efforts that aim to improve communication between health-care providers and their patients, and to improve the practice of medicine rather than the art of medicine. The theme of all of these interventions is to create systems that help caregivers follow every step that is known to improve patient care, and to avoid relying on fallible human memory. To err may be human, but it is also often preventable.
Greater use of generic drugs could save the healthcare system—and American consumers—billions of dollars that would be better spent elsewhere. What’s holding us back? Some consumers are reluctant to use generic medications, thinking they are inferior to “the real thing.” Doctors are also a big part of the problem. Up to half of physicians hold negative perceptions about generic drugs. And a new study to be published in tomorrow’s JAMA Internal Medicine shows that about 4 in 10 doctors sometimes or often prescribe a brand-name drug just because their patients ask for it. Prescribing a brand-name drug when a generic is available is a huge source of wasteful spending that could easily be prevented. People ask for brand-name drugs because they have heard of them through advertising or word of mouth, while their generic alternatives generally aren’t advertised. Doctors could help save billions of dollars by just saying “no.”
Last week, Americans reelected President Obama and returned a Democratic majority to the Senate. How that will affect the economy, foreign policy, and other aspects of government remain to be seen. One thing we can say for certain—it pulls the Affordable Care Act (ACA) out of limbo. The President’s re-election means we can expect to see the ACA implemented. Some popular elements of the law are already in place: allowing children to stay on their parent’s health coverage until age 26, and allowing for cost-free preventive services. Other more complicated aspects of the ACA remain to be realized. These include the establishment of state-run exchanges through which the millions of uninsured Americans covered by the ACE can buy health insurance; extension of eligibility for Medicaid to Americans who earn less than 133% of the poverty level; and innovations to improve the how health care is paid for and delivered while improving care and lowering costs.
In a new essay entitled “Big Med,” physician-author Atul Gawande muses in The New Yorker if The Cheesecake Factory and other successful chain restaurants could serve as a model for improving health care. He wondered how a large restaurant could deliver “a range of services to millions of people at a reasonable cost and with a consistent level of quality,” while hospitals and other parts of the U.S. health care system can’t. The experience prompted Dr. Gawande to meet with managers, cooks, and other workers at a Boston-area Cheesecake Factory to see how it delivers good food and a good dining experience time after time. He then goes on to compare the restaurant’s procedures with what goes on in hospitals.
Today’s ruling by the Supreme Court that largely upholds the Patient Protection and Affordable Care Act should be viewed as a landmark event—whether one agrees with it or not. The Supreme Court’s ruling means that many more people will have health insurance; that health care will continue to be provided largely by the private sector; and that insurance companies won’t be able to deny an individual coverage because he or she has a chronic medical condition, drop coverage if an individual becomes sick, or put limits on the amount of lifetime coverage a person can get. It also means that individuals without health insurance will have to pay for it, and that many employers who do not currently offer health insurance as a benefit will be required to do so, or pay a stiff penalty.