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Saturday, September 24, 2016

My week in ultrasound

After 5 years of doing bedside ultrasound, I'm still excited about it. Bedside, or Point-of-Care ultrasound is using an ultrasound machine during the physical examination of a patient in order to make a diagnosis. I use a pretty tiny machine that fits in my pocket. As an internist who works in the hospital and in rural clinic outpatient settings, I get to use my ultrasound all the time, and it's still lots of fun. (For more on adventures in ultrasound see this or this or this.) Those of you who have read this blog for awhile can skip the intro and go to the cool cases.

When I talk about it, most people who haven't already heard me wax eloquent say, "you mean you look at babies?" Ultrasound has been used as a bedside tool for looking at pregnant wombs for a very long time. It is extremely useful for that, since you can see if the baby is alive, about how old it is, whether their are two, what position it is in and a number of other useful things. I would never give up the chance to look at a baby if my patient were pregnant and willing, because they are so cute, but since I am not an obstetrician, I look mostly at other things. I can see whether the heart is failing, whether there is extra fluid in the lungs or belly, whether the kidneys are blocked, whether the bladder empties. I can see pneumonia and broken bones, tell whether a swelling is full of fluid and whether a lump is solid or a cyst. I can see disease in blood vessels and stones in gallbladders. Combined with talking to a patient and doing my usual physical exam, I can determine whether a patient is dehydrated or the opposite and can often be more accurate about diagnosing blood clots or sepsis. It's cool. Yes indeedy it is.

This week I worked as an outpatient doctor in clinic and also in the hospital, admitting and taking care of sick patients. I use the ultrasound nearly every time I examine a patient and it always helps, but there were some cases in which it was more spectacularly useful than in others.
  1. A patient in clinic had pain in her head and cheek and teeth on the right side 3 weeks after getting a cold. She had a long history of allergies and sometimes used a nose spray or an antihistamine, but this was worse than usual. On exam there were polyps in the nose and maybe a little bit of tenderness in the right side of her face. It is possible to use the ultrasound on the sinus bones behind the cheek to see if there is fluid, because fluid transmits ultrasound and you can see the back wall of the sinus only if there is fluid in it. I could see the back wall on the right, the side with symptoms and not on the left. I diagnosed a sinus infection. She will try nasal steroid spray and washes to see if things can open up and drain, and if that doesn't work, she has a "pocket prescription" for an antibiotic which she can fill and take. I also looked at the teeth on the right with the ultrasound and found no evidence of an abscess, which was reassuring.
  2. Another patient in clinic had stubbed his toe pretty hard. It had swollen and then swollen some more and he was concerned about an infection. The clinic does not have an x-ray machine and is a pretty long drive to the closest one. Beside the cost, it takes an hour of a patient's time to wait, fill out papers and then have an x-ray done, plus I will usually then wait another hour for results and the patient will then be difficult to contact. I was able to ultrasound the toe, find a non-displaced fracture at the point where he was tender and give an explanation plus an appropriate set of recommendations.
  3. At the hospital I had a patient who had been admitted with low blood pressure and likely pneumonia along with blood enzyme tests suggesting a possible heart attack. He responded well to antibiotics and fluids and, due to having lots of chronic medical problems, wanted to avoid being transferred to a larger hospital to see a cardiologist. I knew from previous visits what his heart looked like with ultrasound and could tell him that it looked no worse, which meant that an emergent visit to the cardiologist was not necessary. I was able to use the ultrasound of the heart at the time of our conversation to help guide our shared decision-making about whether to get in a helicopter and head far away from family and friends.
  4. Another patient had severe pancreatitis, an inflammation of one of the nastiest and most caustic organs in the digestive system. He was 80 years old and drank too much whiskey on a daily basis, which caused the pancreas to become angry. After a day or so he developed an acute alcohol withdrawal syndrome, trying to crawl out of bed, anxious and with an elevated heart rate. We treated him for the alcohol withdrawal, but his heart rate remained elevated. Was he dehydrated? None of the other labs gave me the information I needed, but ultrasound of the inferior vena cava showed that he had been adequately hydrated and that, as expected in severe pancreatitis, there was some fluid in the belly and at the base of the lungs, so more fluid would make things worse rather than better. I was able to repeat the ultrasound daily to determine how much intravenous fluid to give.
  5. A young man, with a history of longstanding intestinal inflammation and several operations in the past, presented with abdominal pain. X-ray was pretty normal, but can be hugely misleading. A CT scan would have been helpful, but is associated with a high radiation dose. He had undergone many CT scans in his life and the possibility of his developing cancer on the basis of his radiation exposure was already significant. I was able to look for fluid in the belly or fluid filled loops of bowel which would suggest obstruction and feel pretty confident that a non-surgical approach to his problem was safe. 
It was a good week. Nobody died. I felt competent. Patients were happy. Bedside ultrasound was terrific.

Sunday, September 18, 2016

What's wrong with socialized medicine? The Economist calls the National Health Service "a mess"

The British National Health Service (NHS) was born in 1948, based on legislation passed that year mandating free high quality healthcare for all paid by taxes. In contrast, the US started Medicare in 1966 to provide healthcare to the elderly and the State Children's Insurance Program (SCHIP) in 1993 to fund healthcare for children whose parents were unable to afford it. Healthcare in the UK is still almost entirely funded by the government (through taxes, of course), which it is not in the USA.

Britain is proud of the NHS, and rightly so. They have it figured out. Or so it would seem. Everyone can get care and nobody goes bankrupt because of huge medical bills. Brits do have to pay for prescriptions but everything costs the same, the equivalent of $11 per month.

So why would the Economist, the global news magazine based in London, call it a mess? This article says that the NHS is in trouble, and needs to learn some new tricks in order to stay effective. It turns out that Britain only spends 7.3% of its gross domestic product on healthcare which is significantly below average for its peers in the Organization for Economic Cooperation and Development (OECD) countries, and plans to cut that expenditure to 6.6% in the next year. Because their population, like ours, is aging, costs of care are actually rising so already pinched services are being further curtailed. Because of the high costs of caring for patients with complications, some local health commissions will not provide routine surgery to patients who are obese or smoke cigarettes. General practitioners are overworked and can't provide the kind of preventive services that keep patients out of the hospital and nursing homes are unable to house all of the patients who need their beds so those patients stay in the hospital, limiting the beds available for sick people or people needing surgery.

The US, in comparison, spends over 17% of its GDP on healthcare, at least 5% more than the next highest OECD country. Most of our problems are not due to stinginess of payers, but rather to distribution of healthcare dollars, with some people having no access to affordable medical services and others receiving care that is very expensive which they may not need or want. Many of us long for a fully government funded healthcare system like the NHS.

So what has gone wrong with the NHS, then? I'm not entirely sure, but I have some ideas. Since the government is the payer for services, they have the ability to limit funding. Because of the inevitable waste that goes on with the provision of medical services, it could well be that 6.6% of GDP is plenty to provide good healthcare. It is not enough right now with the system they have. Because the government pays for services regardless of whether the consumers find them to be of good quality, there is no direct incentive to please the patient. Because doctors don't know how much things cost, they are less able to be good stewards of resources. Their healthcare delivery is therefore inefficient, and reducing funding has not made it better.

We do have similar problems in the US, with both lack of knowledge about what things cost and lack of incentive to do things better or more efficiently. Because the government is not the only payer and so cannot put a cap on payment for healthcare, our system is much more expensive. Our hospitals are prettier and our technology is more snazzy and we probably do more miracle cures per capita.  But citizens of the UK have universal access to medical care and nobody goes bankrupt because of medical bills.

Since healthcare per the NHS is not what we want, but we do want universal access with good quality and lower costs, how shall we do it? Americans have enough mistrust of government, and fiscal conservatives are absolutely allergic to the federal government being the sole provider of health insurance, so we will not get "socialized medicine" anytime soon. The Affordable Care Act (ACA, also known as Obamacare) has improved our situation considerably. Expanding Medicaid to cover Americans whose income is at or below 138% of the federal poverty line has helped in the 31 states that have adopted that (my state, alas, is not one of them.) It is now easier and cheaper for the rest of us to get insurance, which helps avoid catastrophic and crushing medical bills. But even people with health insurance go bankrupt due to their share of healthcare costs, combined with inability to work. Footing part of our medical costs is supposed to help us make more frugal decisions, which is one of the reasons most healthcare proposals have included some kind of a deductible ("cost sharing.") Unfortunately most patients don't have the information they need to make frugal decisions and their doctors don't know enough about costs or other options in many cases to help them do this.

In the JAMA (Journal of the American Medical Association) an article reported that an intervention to give doctors information on costs of the various aspects of their patients' care as well as a look at their outcomes significantly reduced costs while improving hospitalized patients' health. This seems obvious. Of course knowing what things cost and how a patient fares will make us do a better job and not cost so much. The strange thing is that this is not standard practice. We don't know what the tests and procedures we order actually cost. And most of us don't get a longitudinal view of how a patients illness or surgery actually turned out.

So if we could have any system at all, what would be best for us here in the USA? I'm not sure it actually matters, as long as we get what we need and so long as there is enough shared knowledge about what things cost, how well they work and what are the alternatives. The direction we have gone, with private and government funded insurance has lead to our present situation. But if the insurance companies paid physicians to take care of patients, and how much we actually made depended on providing the most appropriate care that caused the least unpleasant impact on patients' lives, costs would go down and care would improve. This would require that patients' voices be heard. It would require that doctors knew what was good value and the healthcare industry was encouraged to create options with better value. A single government payer could do this, but not without built in systems to feedback what patients value and what actually works and innovate actively to improve quality.

Thursday, September 8, 2016

T-mobile and medical billing nightmares--a rant

A few months ago I had a clever idea about how my husband could use my cell phone in England, because getting cell phone service across the Atlantic can be expensive and inconvenient.  

So I had this bright idea. I have an unlocked smartphone that I use in Africa or Haiti with a sim card that I can buy there cheaply and with no difficulty. T-mobile, the cellular phone provider that began as a German company and has provided competitive service in the US, advertised that their service would also work in the UK and Europe and that it would include unlimited data. Or something like that. It sounded great. I would just buy the T-mobile sim card in the drugstore here, get the service and be good to go. But not so fast. T-mobile does have the no fuss pre-paid option, but to get the international service requires a different plan, with a monthly fee. After attempting to do this online, then converting to the monthly service, nearly losing the money I had mistakenly spent on prepaid minutes, speaking to operators working out of many non-English speaking countries, whining and finally prevailing, I signed up. Unfortunately T-mobile didn't work in most of the places my husband traveled and didn't work at all in my community. No big deal, live and learn, and I never received a bill. Cool. It didn't work and I didn't have to pay. Eventually they notified me that my service had been discontinued. All good.

Then I got a notice that my account had been sent to collections. $185.00 I owed. I called, spoke to people from many countries, raised my voice, heard vile hold music, spent an hour predominantly on hold, closed my account, and assured the poor folks at the call center that I didn't intend to pay for a service that had never worked and for which I had never been billed. As I delved more deeply into what had happened, I found that they had notified me of billing, via the cell phone that had no service where I was. When I tried to log in to my account at their website to look at an itemized bill, I no longer had access due to having closed my account. I fumed and felt myself to be ill used. At last I paid the bill in order to never have to speak to them again or listen to their hideously distorted hold music. Probably worth it. I will think of it as a fine for making a poor choice. I did research other customer complaints regarding T-mobile and found that mine paled in comparison. It could have been so much worse.

But the whole experience did make me much more viscerally aware of how my industry treats people who owe money. I consider T-mobile to be a bunch of amoral and powerful extortionists. But the same kind of thing happens to thousands of unsuspecting medical consumers when they unwittingly spend huge amounts of money on medical care. Take, for instance, a person hit by a car. Insured or not, they will be billed for some portion of their medical care in emergency rooms, surgery, intensive care and for their general medical hospitalization. As they lie helpless in the hospital the bills will likely arrive at a mailbox that is being emptied and put in a shoebox by a neighbor, possibly under a utilities bill that is more important or likely lost amid catalogs, and certainly confusing as heck once they are opened. Hospitals and doctors are not shy at all about sending unpaid bills to collections. When the unfortunate car accident victim finally gets home after rehab, the collections agency will likely have reduced the information in the bill to a single heart-stopping number without any itemization or information about how to dispute it (such was my T-mobile experience.) The Consumer Financial Protection Bureau documented in a December 2014 report that just this sort of thing happens frequently due to the complexity of medical billing and insurance payments. People sent to collections for medical bills often have completely clean credit histories and didn’t pay those bills because it was never quite clear who owed what and to whom. (For more info on medical billing, read this blog.)

I can choose never to deal with T-mobile again if I want. Also my bill was only $185, which is a lot for nothing, but will not bankrupt me. Medical debt is the major cause of personal bankruptcy and a decision to never receive medical care again can have devastating consequences. Sometimes, as a person who is supported by healthcare dollars obtained in part from heinous billing practices, I wonder if I'm really one of the good guys.
(I would like to see a system in which medical care cannot destroy a person financially. This will involve reducing what we spend on it by getting rid of wasteful practices that do nobody any good, simplifying the payment system and assuring universal access to what we can agree are necessary medical services. But that is a story for another day…)