Inkwell: Authors and Artists

    
Heh! Joe himself slipped and then got accidentally erased. I'll post
again below.

Elizabeth, thank you so much for that kind review! Could you go post a
version of that on Amazon? It does help. The book is just a tool to
spread these ideas. The more people in the industry and outside it
grasp this different way of seeing healthcare, the quicker, more
complete, and easier the change will be for all concerned.
  

    
Jane, very will put. Compassion and self interest are in alignment.

You are sitting down to your nice dinner at that great restaurant you
have heard of. The busboy has arranged the silverware and folded your
napkin and is now pouring your water. Question: Do you know whether he
has access to good healthcare, including vaccinations? What would be
your preference? How about your cab driver, handing you that receipt?
The baggage handlers at the airport? The people passing you on the
street, or near you in your favorite cafe? We are a society, and our
health affects not only us, but those around us.
  

    

> 97% of pharmacies reportedly belong to e-prescribing networks, so my
> scrip pad is soon going to vanish, and not because I misplaced it.  My
> primary and secondary hospital systems are pushing to a system where I
> have to enter all the info electronically which should in theory
> minimize medication errors. 

I caught one of those. The pharmacy misread what the doctor had prescribed
but I noticed the wrong meds and it was fixed. But if I had not noticed
that, I could have been in a world of hurt.
  

    

Another illustration of the problem

Retirement Planner: Some health insurance policies can make you sick
with worry

  My interest in the subject started several years ago when a friend who
  had a multiyear bout with cancer said she routinely spent one full day
  a month doing nothing but sorting through her bills and figuring out
  what she needed to pay. This was a woman who ran a successful business,
  so she had the accounting and negotiating skills that generated positive
  results. At the time she said, "What do normal people do who have no
  financial background?"

<http://www.contracostatimes.com/business/ci_20955264/retirement-planner-some-h
ealth-insurance-policies-can-make>
http://tinyurl.com/7tcqohb
  

    
I had Anthem Blue Cross in California, and they made me jump through
an ever-changing array of hoops in order to get anything paid for. In
fact, even in years when my medical expenses were much higher than my
(high) deductible, they never actually paid for anything, because I
ended up concluding that the amount of effort involved in forcing them
to do so was so great that I was better off simply using that time and
energy on my work. The only advantage -- and it was significant -- in
having the insurance was that I got the negotiated rates.
  

    

Here's an example that shows even Kaiser has problems. The story is
about a colonoscopy for a patient with a high deductableplan. Can you
comment on how this can be fixed?

Action Line: Mystery price: Kaiser patient says she was misinformed
about the cost of a procedure

  ...
  Before I went I called member services and was referred to DHMO
  (deductible health maintenance organization) for information about
  cost to me. I was told there would be no cost to me. (Great -- and I
  am aware that it is a screening test and, according to the current law,
  should not cost because it is a screening procedure.)

  Anyway, when I was two days into the liquid diet, they called to do my
  intake over the phone. At that time I was told I had been misinformed
  and it would cost me $2,000...

  I went in and they made me pay upfront.
  ...
  I started researching and called member services to investigate this
  charge. I was now told that if it were a screening, I would not be
  charged (could get reimbursed), but if it were diagnostic, I was
  responsible for the charge.

  Apparently, this depends on how my doctor worded the request.
  ...

The reporter's note:
  Always complain if you are overcharged for anything. Go up the corporate
  ladder, if needed. I informed Kaiser and this was your report back:
  "Dennis, thank you for your response. I just received an e-mail from
  the head nurse of the GI department saying that my procedure was for
  screening. So, maybe they will just reimburse me. Let me see, and if
  they don't I will contact you again."

<http://www.contracostatimes.com/ci_20972986/action-line-mystery-price-kaiser-p
atient-says-she>
http://tinyurl.com/72t3aml
  

    

Joe, would you like a link to this discussion posted on Amazon as well as 
my review?
  

    
Also, picking up an earlier thread: I'm somewhat less optimistic than
you, Joe, about the ability of an organization like Kaiser to deal with
an illness like chronic fatigue syndrome. A Well member we're both
close with has Kaiser and CFS, and she's gotten terrible care from
them. Evidence-based medicine is lousy when there's no evidence, or
when what evidence there is is based on politically-driven research, as
is the case with CFS. Tighter coordination of care can easily mean
tighter denial of care and tighter enforcement of prejudice.

That's not to say, of course, that tighter coordination of care isn't
nevertheless an overall good thing.
  

    
> Joe, would you like a link to this discussion posted on Amazon as
well as my review?

I think that would be great.
  

    

OK, I'll do it.
  

    
> I'm somewhat less optimistic than you, Joe, about the ability of an
organization like Kaiser to deal with an illness like chronic fatigue
syndrome.

I think you describe that well, Julie. There is no panacea here. The
best answers and biggest savings show up in the great mass of
poorly-handled chronic syndromes for which we actually have good
solutions and good preventive practices. Syndromes that are not well
defined, with clear protocols for prevention, like CFS, are always
going to be more difficult for massive systems to handle well. I would
bet that if a clear set of protocols for CFS arise, Kaiser will move to
institutionalize those across the system.
  

    
> The pharmacy misread what the doctor had prescribed but I noticed
the wrong meds and it was fixed.

Was that a written prescription? One of the major advantages of
digital systems is that most prescriptions are just radio buttons. It
is not possible for the system to mix up Xanax and Zantac. You click on
"omeprazole" and get choices for 5 mg, 10, or 20, but not 50 or 500. 
  

    
Yes, I agree. The awkward thing is that there *are* some pretty clear
best practices for the treatment of CFS that just haven't made their
way into the general understanding of doctors. For example, every GP
should know to test CFS patients for orthostatic intolerance, which
they can do with no special equipment beyond a blood pressure cuff and
a timer. There are standard methods of treating OI that can make a real
difference in the lives of CFS patients. There are other things that
are more tentative or experimental, but that one is absolutely
unequivocal, and the problem is simply doctor ignorance (and
prejudice). Even with all that's unknown with CFS, an organization like
Kaiser could (but isn't) do a lot to codify the best practices that
exist.
  

    

Rats, only one review allowed per customer. I thought about it as I was
writing mine, but wanted to ask permission first.

Can someone who hasn't reviewed the book on Amazon include the Inkwell.vue
url? It is:
<http://www.well.com/conf/inkwell.vue/topics/445/Joe-Flower-Healthcare-
Beyond-Ref-page01.html>
  

    
> screening v. diagnostic

Boy, that's the pits! Kaiser needs to have a lot more clarity and
transparency about these things. I'm a fan of Kaiser generally, but
they are still capable of screw-ups. At least you don't get the feeling
that it is corporate policy to screw you.
  

    
>Always complain if you are overcharged for anything.

I've always found Kaiser to be very responsive to squeaky-wheel
behavior.
  

    
> The awkward thing is that there *are* some pretty clear best
practices for the treatment of CFS ... the problem is simply doctor
ignorance

The subject here is not really Kaiser, it's how do we help doctors
keep up on the latest information. A Duke University study (didn't
mention it in the book because I couldn't find the cite) estimated that
the amount of information that the average doctor needed that was of
real clinical usefulness (like this bit about testing for orthostatic
intolerance) doubles every four years.

It would not be possible for doctors to keep up with that, even if the
knowledge sluiceways were not clogged by pharmaceutical companies
pimping their latest blockbuster drug for their latest favorite
"condition marketing" target. There are other ways of getting
information to doctors in the clinical situation that would help a lot.
One example (poorly marketed, little known, just bought by Dr. Oz's
company Sharecare) is the "Problem-Knowledge Coupler" at pkc.com. The
practitioner (or even the patient) starts from the problem, answers a
series of basic questions, and is led through a decision-tree to
possible diagnoses and the tests that would differentiate them or rule
them out. Such software, for instance, would lead your average GP who
had not followed the literature to the orthostatic intolerance test,
and what that would tell him or her. It's all based on evidence-based
medicine, and the doc using it can drill down to find the actual
studies on which the recommendation is based.

Using such software as a backup, a help, a prompt, right in the
clinical situation, is a little far-out for docs even today. I would
imagine as we move to systems that are more at financial risk for
producing real results, we will see its use adopted in a much broader
way.
  

    
Fascinating, bbear.
  

    <scribbled by wickett Mon 2 Jul 12 13:09>
  

    
The closest thing like that (an expert decision support program)
provided by my workplace now is something called isabel, which requires
a hefty subscription fee to use (paid by one of the medical centers I
work at).  I can enter a set of symptoms, abnormal labs or other
findings from exam and imaging, put in the age and sex of the patient,
ethnicity if that seems pertinent, and it gives me back a list of
possible diagnoses.  But the diagnoses are based on matches between the
symptoms I enter and words associated with the diagnoses it returns,
and there is no prioritizing for the relative importance of the
different connections or possible diagnoses.  I go to it once or twice
a month with difficult cases, to be sure I've considered as many
possibilities as I can, so I don't miss the correct answer.  
  

    
> no prioritizing for the relative importance

As I understand it, PKC is a human-engineered and tweaked system, and
it gives probabilities for everything.
  

    

>> The pharmacy misread what the doctor had prescribed but I noticed
>> the wrong meds and it was fixed.
>  Was that a written prescription?

Yes, sorry, I thought I had been clear in context. These days it's all
electronic. But I still look at what was prescribed just in case a wrong
key was tapped.
  

    
What is your take on this thought Joe;

I wonder if ACA and the easier ability to get health insurance will
encourage some older workers to retire -- freeing up jobs and
promotions for all of us early Gen X folks who have been in a holding
pattern.
  

    
> I wonder if ACA and the easier ability to get health insurance will
encourage some older workers to retire

Might. More broadly, it's long been recognized that the accessibility
of group healthcare insurance through your employer has caused a great
deal of "job lock," with many people staying in jobs, locations, and
even marriages that they would otherwise cheerfully abandon, just to
make sure they stay covered. This is especially true of people with
"pre-existing conditions," and especially true of people in their 50s
and early 60s, just pre-Medicare. This puts a damper on the fluidity of
the whole job market. It not only slows people from premature
retirement (and thereby freezing out a lot of younger people), it also
makes it difficult for lower-paying businesses that don't give health
insurance to hire and keep good people. It also greatly inhibits
entrepreneurship: Many people who would be willing to take the risk to
start a new business (open a cafe or a store, go big on the Internet
with some idea) and be true "job creators" are unwilling to quit their
jobs, for fear they will not be able to find new affordable health
insurance for them and their families.

I believe that if we actually move to an environment in which it is no
more difficult (and not too much more expensive) to get healthcare
insurance through your employer than as a self-employed person or small
startup business, that in itself will act as a major stimulus to the
economy, free up many jobs, and create many more.
  

    
I have often thought that very thing, Joe, and I wonder if we will see
big changes on this front in the next several years.