Saturday, June 03, 2006


(Last Part of Stateside Healthcare: Art, Science, and Commerce?)

Even with the professional capabilities, technical considerations, and scientific advances of medical practice in the clinical setting, a US physician cannot dissociate him/herself from the material realities of cost and production in healthcare delivery.

What is important is that no matter how strong the market forces are across all team players in US healthcare, the eons-old goal of healing the patient – the art and science, not commerce – of medicine, should never be forgotten.

Health as Wealth: Managed Care

(Part 7 of Stateside Healthcare: Art, Science, and Commerce?)

Coming from that issue on medical malpractice and physicians practicing defensive medicine, it then becomes important for someone to be able to pay for all services rendered. This is where healthcare insurance comes in, and managed care systems such as the one KSC is practicing takes center stage.

Managed care in the US has a history dating back to 1929 when the first health plan in the country was established for farmers in Oklahoma. Baylor Hospital in Texas followed in the same year, providing care to teachers on a prepaid basis. Health Maintenance Organizations (HMOs) then began operations in the 1940’s. The first Independent Practice Associations (IPAs) followed in 1954, wherein individual physicians would join a group to provide medical care with a health plan.

With the Federal HMO Act legislated in 1973, government then provided financial assistance to start up new HMOs, and federal law pre-empted local State laws that restricted HMOs. Furthermore, employers with over 25 employees were required to offer two federally qualified HMOs (a statute that was rescinded in 1975). Through this concept of “capitation”, the US health industry was shifted from a cost plus environment to that of a market environment, where competition and accountability for cost versus quality control governed.

The years between 1985 to 1997 saw a paradigm shift from traditional methods of care to managed care. A continuum of care was established between inpatient and outpatient facilities. The care of the individual was undertaken to prevent episodes of illness in high-risk populations, a primary prevention practice. The fragmented care system was integrated: from the absence of quality measures, outcomes became monitored. Collegial relationships between healthcare professionals turned into contractual relationships bound in law.

Lately in the US national perspective however, Preferred Provider Organization (PPO) growth has been greater than HMO growth. This may have had an impact on primary care, because PPO members are not required to get referrals from a PCP (acting as gatekeeper) for specialty consultations .

Nongovernmental/private payers in the meantime have been consistently demanding quality medical care for less cost. With healthcare purchasing coalitions forming to achieve more economic leverage and physicians responding in turn by forming alliances to compete for managed care contracts , healthcare has definitely become market forces-driven.

Because they cater towards patients seeking to avoid all the confusing and costly aspects of US medical care as discussed above, health insurance companies themselves have had leverage in the healthcare decisions of individual patients. As may be gleaned in patient interviews parallel with this paper, patients do not care any more on their preference of PCP type – be it an internist, family practitioner, or pediatrician in the case of children – so long as their healthcare insurance will cover the costs and they get well. The same goes with selecting a generalist versus a specialist – whatever the insurance company dictates is followed.

Even the therapeutic aspect of healthcare – pharmacotherapy in particular – is influenced by insurance; certain drugs prescribed may not be covered by insurance plans, and the pharmacist is forced to dispense cheaper drugs that may be generics of the prescription or in some cases, equivalents. Where a brand-name medication is deemed to be medically necessary yet still not covered by insurance, the patient is left with no recourse but to pay for the drugs or have another consultation with his/her physician for alternative therapy options.

It is therefore not surprising that physicians must have a basic grasp of the healthcare insurance system, because patients usually ask outright during the consultation if the treatment plan determined by the physician is covered by their insurance.

This intense interaction of healthcare and economics has even been used as a tagline to the advantage of a US Air Force advertisement recruiting doctors, because military physicians do not deal with insurance. The probable frustration of physicians over this complexity is highlighted by the said tagline: “No one goes through medical school to practice insurance.” The advertisement further states: “Today’s financially driven managed care environments make having a practice difficult. Hurrying patients in and out of the office to make a quota and going into negotiations to prescribe treatments that don’t coincide with a patient’s policy aren’t practicing medicine.”

Next: Synthesis


(Part 6 of Stateside Healthcare: Art, Science, and Commerce?)

While the Filipino patient’s legal rights may be similar or have equivalents to his/her US counterpart, there still are medical issues bordering with law that should be explored, and the most prominent of this (with a great effect on how US physicians practice) is medical malpractice.

Given the available knowledge and skills of practitioners, with patients highly aware of their disease and probably its management, the constant apprehension on being sued for medical malpractice has physicians practicing defensive medicine. A common example is a patient with abdominal pain which, given a thorough history and physical examination, could be easily diagnosed as having appendicitis. While the impression of appendicitis might as well be written down by the keen physician, he/she would probably order imaging studies all the same in order to “properly document” the case for future reference. It would not be surprising that some US physicians would proceed to order CT imaging of the abdomen for what could as well be a straightforward surgical problem.

This defensive behavior has led to a higher cost of healthcare in comparison with the Philippines’ own, with defensive medicine estimated to account for up to 20% of medical costs (total medical costs in 1995 were estimated to be at US$ 900B) . Several diagnostics are ordered with the intention of preparing in advance for the possibility of being sued.

Next: Health as Wealth: Managed Care

Medical Informatics: Streamlined Efficiency or Rigid Technology?

(Part 5 of Stateside Healthcare: Art, Science, and Commerce?)

Perhaps the most striking of all aspects of US healthcare is the heavy use of information technology. Thus is posed this question: is medical informatics a boon or a bane in clinical practice?

As part of the elective rotation, shadowing with a KSC hospitalist-internist was undertaken at the Methodist Willowbrook Hospital , a part of The Methodist Hospital System. This would perhaps best illustrate the extensive use of medical informatics, which is also the case in the KSC Copperfield Clinic. The following were seen:

About a half hour before going on call, the hospitalist receives via electronic mail “check-out information” from the physician on call immediately prior to his/her shift. This would serve as virtual endorsement rounds, bearing clinical abstracts of patients on the service. On arrival at the hospital, the triage nurse would key in the physician’s schedule at a computer terminal, and a patient census would then be printed.

Barcodes bearing patient-identifiable numbers are used everywhere – sheets in the charts, medication containers, lab specimens collected, etc. Medical records/charts, while still on paper and filled-in by hand, are scanned (digitized) into electronic images within a short time, which can be digitally signed from anywhere an attending physician is physically located by simply logging onto the internet and using the appropriate security codes.

Each nurse at the nurse station has a computer terminal assigned to him/her. Nursing flowcharts bearing the vital signs and nursing notes of a patient are electronic. Telemetry can be easily availed of if indicated, and a centralized console at the nurse station provides a continuous monitor of vital signs including electrocardiogram traces if necessary. Laboratory and imaging results are typically accessed by the nurse and printed onto paper only for the physical convenience of having a hard copy, but the records are primarily electronic.

Radiology is a technological advance on its own. Radiological transparencies are no longer the norm – entire plates/films are digitized the moment a patient undergoes imaging, and the same are instantly made available for the attending physician who might want to make a preliminary impression by accessing the system anywhere there is high-speed internet access. The films are also transmitted electronically to the radiologists who would then make interpretations at a different location via dictation, the transcriptions of which would be available within the same day or the morning after the examination. It goes without saying that given the technology, physicians viewing films online can alter the brightness, contrast, and magnification of the radiological images. Details not previously seen on traditional x-ray transparencies can be studied in detail, allowing for a more accurate interpretation.

This connective nature of information flow is also the case for other diagnostic examinations. Electrocardiogram traces, while still printed on strips for rapid bedside or outpatient interpretation, are also sent to another location where cardiologists interpret them and return the results to the attending physician in the same way that the radiologist returns reports.

Patients themselves can have access to their own diagnostic information. In cases wherein imaging or laboratory results are normal, KSC has a system called “TeleVox” wherein two days after an examination (some special tests taking perhaps a week at most), the results can be obtained by the patient through a convenient website on the internet or via phone call. Otherwise, if the results may indicate an ongoing disease process, the physician himself makes the call to inform the patient and suggest further treatment plans such as follow-up consultations.

Since records can be transferred with ease, continuity of care is maintained. This is the case when a patient admitted into the hospital is discharged for follow-up at a KSC branch with a PCP. The PCP simply asks that the patient sign a release waiver authorizing the transmittal of confidential medical information, and the same is sent via fax to KSC’s medical records section. The same is true when a new patient previously cared for by another physician outside of the KSC system comes for consultation – the prior physician, upon request, promptly transmits the patient’s medical record to the new KSC doctor.

The professional sharing of medical information, seldom seen in the Philippines wherein patients have to narrate their entire medical history almost always when seeing a new physician, allows for the avoidance of duplicate or unnecessary diagnostic examinations or treatments. It also has a bearing on the PCP’s role – who, as the gatekeeper, has to see the patient in his/her entire context.

As posed earlier, this raises a few doubts however as to the reliability of the entire system. Power outages pose a threat to the information stored, and the dependency on computers may be a downside. The risks associated with technology and power supply fluctuations are minimized, however, by the proper infrastructure that involves back-up systems. That translates to an improved quality of care for the patient and efficiency on the part of the physician.

Next: Legalities

To Choose, not just to Consent

(Part 4 of Stateside Healthcare: Art, Science, or Commerce?)

Patient awareness of diseases is high in the US. The typical source of information is the internet. This poses an interesting scenario to the physician: on one hand, his/her patient is highly aware of what to report and may later on have a higher compliance rate; at the same time however, the physician must keep abreast of the latest information in medicine. The physician’s role however cannot be replaced by the amateur research performed by the patient because it is usually the case that the patient becomes biased towards reporting symptoms found in a disease’s information sheet. Furthermore, diagnostics and therapeutics are still best interpreted and recommended, respectively, by the trained clinician.

In the event however that the patient has not accessed information on his/her symptoms before the encounter with the physician, the role of patient educator then becomes that of the physician him/herself with the aid of take-home instructional materials using lay language. There also again is the nurse who can further educate the patient immediately after the encounter with the physician or at a later date, as earlier mentioned via a centralized call center staffed by registered nurses.

Next: Medical Informatics: Streamlined Efficiency or Rigid Technology?

Allied Forces

(Part 3 of Stateside Healthcare: Art, Science, and Commerce?)

During observation duty, it was noted that the healthcare system in the US maximizes staff members by getting them to work to the “top of their license”, as was described in an American College of Physicians publication . It is asserted there that “all office staff members should be ‘working to the top of their license,’ doing what they are qualified to do, no more and no less. That means doctors, the most skilled and highly compensated members of the team, should stick to those tasks they are uniquely qualified to do and delegate the rest.”

Nurses observed in particular have shown that they help significantly in patient care, not just in clerical aspects but also in certain medical decisions. To illustrate, a KSC patient typically calls a centralized number which would have him/her connected to the Customer Contact Center. This call center is actually manned 24 hours by registered nurses who are capable of eliciting a concise medical history over the phone and, in their professional judgment, advising the caller one of several options from immediately going to the nearest emergency room for urgent cases to scheduling an appointment with the appropriate physician in outpatient cases. In calls wherein home interventions can be performed by laypersons, the nurse goes ahead and instructs the caller what to do.

The above concept of telephone triage saves time and resources, allowing the physician to see those who need professional care more than those who can be instructed the appropriate treatment. This has been a principle of KSC, wherein its manuals for managed care state that “when a consultant will not need to interview or examine the patient, a telephone consultation may save time and serve the patient better.”

Apart from triage, nurses are also maximized in that they perform several tasks otherwise delegated to other paramedical personnel in the Philippines. It was observed that nurses also do extensive patient education (e.g. diabetes education, wherein nurses can be certified by the American Diabetes Association to be a “Diabetes Educator”) in addition to explaining therapeutic regimens to patients and calling-in routine prescription refills to the pharmacy, on behalf of the physician.

Pharmacies in the US are also active members of the patient’s healthcare team. A registered pharmacist, while not part of the KSC system (in the Copperfield Clinic’s case because it doesn’t have an on-site Pharmacy), would see to it that the physician’s prescription is explained through counseling to patients making a purchase. Drugs are dispensed securely and with great care. Prescriptions are documented and kept on record, and physicians or their nurses are routinely called in cases of doubt. While this may seem routine, it is of sad notice that the Philippine Pharmaceutical Industry, at this point in time, may benefit from adopting some of the practices noted here in the US (because currently, for instance, antibiotics and certain restricted drugs can still be easily acquired without a prescription from Philippine pharmacies).

On the matter of drugs, it can be viewed either positively or with disdain that the US healthcare system is heavily influenced by marketing. Whether it be the general tendency of physicians to use brand names in prescribing drugs or the aggressive strategies employed by pharmaceutical representatives in getting physicians to write out prescriptions for advertised drugs, marketing dominates. It was explained however that sometimes it is better to tell patients about drugs using brand names, because using both the brand and the generic name may cause confusion. It must be remembered however that later on, when healthcare insurance is called upon to answer for the expenses of the prescribed medications, there is a tendency for the generic brand of less cost to be filled by the Pharmacist.

Next: To Choose, not just to Consent

Family Practice

(Part 3 of Stateside Healthcare: Art, Science, and Commerce?)

As one of the primary care fields, Family Practice (FP) has an important place in the healthcare delivery system. Its versatility of being able to diagnose and treat conditions classifiable under various specialties (seen during the elective rotation were cases falling under orthopedics, psychiatry, gynecology, internal medicine, pediatrics, ophthalmology, and minor surgery) gives it a role that allows patients to receive immediate care and not wait long for a specialist. In the event however that a condition proves to be beyond the training of the family practitioner, an educated referral is made, with the FP physician ordering preliminary diagnostics and administering basic treatment – easing the illness of the patient and the work that the specialist has to do.

There is of course the question of what differentiates a family practitioner from a general practitioner (GP). While a GP in essence has the same scope of patient age (from womb to tomb) with that of FP, the latter lays claim to post-graduate residency training of three years. Typically, the first year includes rotations in major medical disciplines with time for outpatient services; while the second and third years involve rotations in major specialty and subspecialty services and increased outpatient time . This gives FP practitioners familiarity with and experience on management of commonly encountered diseases, equipping them with the knowledge and skills to do primary care to patients of virtually any age. In underserved areas wherein certain specialties cannot be found, FP provides diagnosis and treatment (e.g. emergency appendectomy).

Alternative practices also abound for FP physicians. A 2001 essay in the American Academy of Family Physician (AAFP)’s publication Family Practice Management lists fourteen alternatives to the often construed outpatient practice style of the FP Physician: resort doctor, prison doctor, free-range physician , medical director, locum tenens , legislator, urgent care and emergency medicine, hospitalist , administrator, focused practices , public health and epidemiology, research, private business , and education. Considering individual practitioner variations, FP income on the average ranges from approximately US$ 140,000 to 163,000 (PHP 7.23 to 8.42 million, at US$1 = PHP51.65) per annum.

Next: Allied Forces

Kelsey-Seybold: the McDonald's of Medicine

(Part 2 of Stateside Healthcare: Art, Science, and Commerce?)

With apologies to the food magnate, the Kelsey-Seybold Clinic (KSC) in Houston, Texas is comparable in accessibility and convenience to the McDonald’s fast food chain. It has been, for more than half a century now, a pioneer and key player in managed care in the city of Houston. It is the largest, community-based physician group caring for more than 300,000 patients, with active service to the US National Aeronautics and Space Administration (NASA) since 1966. It also has a research arm, the Kelsey Research Foundation. Currently it is under the supervision of the St. Luke’s Episcopal Health System.

KSC founders Drs. Mavis P. Kelsey, William D. Seybold, and William V. Leary established the group practice in 1949. The clinic’s mission includes highlights on 1) improvement on community healthcare quality and value, 2) provision of comprehensive medical care for patients through a multi-specialty group practice, and 3) provision of exceptional opportunities for personal and professional growth. It currently has twenty locations all over the city of Houston, allowing for convenience to patients who would prefer locations close to home or work .

KSC Specialties and Sub-specialties include fields from Aerospace Medicine to Vascular Surgery.

Central to the theme of KSC is the founder’s original goal to “combine the expertise of physicians in a variety of medical specialties, with the close personal care of the general practitioner, or family doctor. ” This is attributed to an original Mayo Clinic concept, an idea of primary care in the named institution where KSC’s founders originally came from in the 1950’s. KSC is thus a pioneer in the sense that it first brought the concept of primary care into the state of Texas.

Next: Family Practice