by Rose Rohloff |
| Value is a relative term based upon personal perception, and oftentimes great marketing. True value is based upon insightful knowledge of what entails quality along with the cost of delivering goods and services. Value-based care is the new buzz for basing reimbursement in the healthcare industry. But again, what is value care: personal perception, marketing, cost? |  |
This article was conceived after several conversations regarding what defines quality care, with veteran clinicians (nurses and doctors), insurance brokers, as well as numerous 40-80 year olds who make up the typical population across the country. Using the following encounter as an example, I want to review what determines true value of care delivery compared to the normal perception being marketed.
A surgeon office within a surgical center, (the surgeon with privileges at two leading health systems), has 5-star Healthgrades ratings, including comments: the staff is courteous; appointments start on time; the Physician Assistant (PA) is very intelligent, knowledgeable, articulate and caring; and the surgeon with a benchmark performance staff. There are also one star ratings including a comment the staff is not properly trained and do not know how to maintain a sterile environment.
The primary issue with such score deviations is determining if poor marks are isolated instances (one offs); or, if the variance of only highest and lowest reflect the knowledge of reviewers. Are the high ratings from non-healthcare persons based on perception of the veneer friendliness and scheduling, with one star comments based on specific quality requirements, care competency posted by those with healthcare insight/experience?
As a 35+ year healthcare veteran, an answer was determined accompanying a Medicare patient ‘John’, in his mid-80s who experiences early stage dementia, to the office for a post-op visit for a leg stint placement.
The primary issue with such score deviations is determining if poor marks are isolated instances (one offs); or, if the variance of only highest and lowest reflect the knowledge of reviewers. Are the high ratings from non-healthcare persons based on perception of the veneer friendliness and scheduling, with one star comments based on specific quality requirements, care competency posted by those with healthcare insight/experience?
As a 35+ year healthcare veteran, an answer was determined accompanying a Medicare patient ‘John’, in his mid-80s who experiences early stage dementia, to the office for a post-op visit for a leg stint placement.
| Upon arriving, another elderly patient (80s) was sitting outside, unattended in wheelchair, hot sun, 100 degree weather, no water. When asked why he was there, he stated, “I can’t stand the freezing air conditioning inside while waiting for a ride.” After walking John into the lobby, the gentlemen clearly seen through the glass door was pointed out to the receptionist stating that he was left in hot sun, no water, unattended. The receptionist stated, “It is his choice to stay out there.” I then stated, “Get someone to check on him, give him water, put him in the shade and check when his ride is supposed to arrive and monitor him if it is delayed or bring him inside.” One person escorted us back to exam room. She did not introduce herself or her title. She proceeded to take the blood pressure with no other vital signs (unknown if a secretary, an aide, a nurse or tech). She then asked the patient, “How much do you weigh?” He gave a number. As patient champion I responded, “He doesn’t know, he has not weighed himself. You need to weigh him yourself.” She responded, “We don’t have a scale.” She then left. I followed her witnessing her documenting the incorrect data. | I reiterated he has dementia with no idea how much he weighs. She replied, “It doesn’t matter anyways, we just need to put something in the record.” She was reflecting an 11 pound weight loss from previous recording. It is unclear if they performed the previous weighing, if it was done just prior to surgery to determine proper anesthesia delivery for his surgery.  Another woman in scrubs entered the exam room without introducing herself or her title, asking John to remove his shoes and socks. (The scheduled appointment was with the PA so the patient assumed her identity.) She asked him if his wound was healed and he replied, “Yes.” She documented something in the chart without ever assessing his wound for healing or determining if there was infection. She bent down and felt his feet with her whole hands stating they feel warm, and then asked if he had numbness in his feet. John responded, “Yes.” | Having worked as a registered nurse (RN) in cardiovascular and neuro intensive care units (ICUs), I know she never did pedal (foot) pulse checks x4 comparing both feet. She never assessed location of numbness, or if chronic/intermittent, positional with sitting/, standing, walking, etc. The family had asked if aspirin could be stopped as the patient has experienced nose bleeds in the past. The staff person responded yes and since there was 90% blockage of the previous stint, it was cleaned out and continue Plavix. There was no establishment of lab work as part of care plan determining effectiveness of the medications, especially since the previous stint occluded. "1,750 or so stent patients are also prescribed Plavix to prevent clots from forming around the stent, but of that group, approximately 500 (29%) carry a genetic variation that prevents them from converting Plavix into its active form. This gene-related lack of response stands to be "especially severe" in about 50 (3%) of those patients, who won't derive any benefit from Plavix - 2010 Vanderbilt Medical Center |
She then stated they would be ordering an ultrasound as a standard post-op test to determine the effectiveness of the stint - over three weeks after the procedure.
Why didn't they do the ultrasound during the post-op visit to have results to make sure the stint was effective? No doppler was used to assess extremity blood flow.
She stood up, touched the paperwork, the marker and laminate sheet then touched the door handle leaving – never having washed her hands before assessing the patient, nor after putting her hands on his feet.
Perceived value based on quality versus true value and cost
The office visit was charged to Medicare, with an elderly patient perceiving the staff as nice during the office visit.
The care competency and quality as true value-based care during the visit includes:
- lack of basic cleanliness standards with severe cross contamination practices
- no introduction of name or title of any staff member
- fraudulent documentation in the electronic medical record (EMR)
- no assessment performed during a specific post operative visit (a family member could have taken the BP and said his feet felt warm.)
- lack of care planning and evaluation of medication regime
- unnecessary secondary office visit charging for follow up
- another elderly patient left unattended in the hot sun
If the U.S. healthcare system wants to achieve true value-based care, we need an educated population, higher accountability of staff standards with the ability to send evaluations direct to payers based on specific facts and not emotion, and surveys must include care competency reviews versus only veneer questions of politeness, room appearances, and on time scheduling.
The care competency and quality as true value-based care during the visit includes:
- lack of basic cleanliness standards with severe cross contamination practices
- no introduction of name or title of any staff member
- fraudulent documentation in the electronic medical record (EMR)
- no assessment performed during a specific post operative visit (a family member could have taken the BP and said his feet felt warm.)
- lack of care planning and evaluation of medication regime
- unnecessary secondary office visit charging for follow up
- another elderly patient left unattended in the hot sun
If the U.S. healthcare system wants to achieve true value-based care, we need an educated population, higher accountability of staff standards with the ability to send evaluations direct to payers based on specific facts and not emotion, and surveys must include care competency reviews versus only veneer questions of politeness, room appearances, and on time scheduling.
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by Rose Rohloff
The June 29, 2018 BECKER'S Hospital Review article shares the viewpoint "Froedtert CEO Cathy Jacobson: Not every patient needs a primary care physician" (PCP). The article is the perspective from the viewpoint of a health system CEO. The following is a perspective, counterview from patients, the individuals in the population.
The June 29, 2018 BECKER'S Hospital Review article shares the viewpoint "Froedtert CEO Cathy Jacobson: Not every patient needs a primary care physician" (PCP). The article is the perspective from the viewpoint of a health system CEO. The following is a perspective, counterview from patients, the individuals in the population.
In speaking with individuals across the country, spanning several major health systems and states, 100% of the comments and feelings are that health systems are large, top-heavy and more inefficiently run because of their size.
Many people have expressed utter frustration from lack of a good Primary Care Doctor, warranting unnecessary ER visits because a doctor will not call back; the lack of one doctor in charge who would simply LISTEN to them, who knows them - not as personal friends, but with an in-depth professional relationship.
I have been asked several times in various states, "Do you know of any good Primary Care Doctors? I cannot find one." Universally, I am hearing: a gross lack of comprehensive assessments from doctors; clinicians not taking the time to get to know and listen to what is going on, causing the passing through of patients to specialists versus a primary care doctor creating a plan of care and focused tests for getting an actual diagnosis; lack of avoidance for hospital visits with increasing costs that could and should be avoided because conditions allowed to worsen; and doctors simply writing prescriptions for symptoms.
Many people have expressed utter frustration from lack of a good Primary Care Doctor, warranting unnecessary ER visits because a doctor will not call back; the lack of one doctor in charge who would simply LISTEN to them, who knows them - not as personal friends, but with an in-depth professional relationship.
I have been asked several times in various states, "Do you know of any good Primary Care Doctors? I cannot find one." Universally, I am hearing: a gross lack of comprehensive assessments from doctors; clinicians not taking the time to get to know and listen to what is going on, causing the passing through of patients to specialists versus a primary care doctor creating a plan of care and focused tests for getting an actual diagnosis; lack of avoidance for hospital visits with increasing costs that could and should be avoided because conditions allowed to worsen; and doctors simply writing prescriptions for symptoms.
Health systems are relying on data analysis, defining as population health, as Froedtert is quoted, "As we start stratifying our patients into distinct populations based on their health needs." The issue with this premise is that the data is not always clean, and it will never tell the story, the whole story, of the realities going on with the patients. (See I Wish I Had Known stories.)
Her quote continues, "... insight further into consumer driven wants, we are finding that a substantial sector of the population does not want or need a primary care physician relationship. People need primary care but not necessarily a physician relationship." The issue is the primary care physician practices have been acquired by the hospital-health systems, with the biggest complaint from people in the population not being able to find a PCP; and those now under health systems, the doctor only giving 10-15 minutes of time, before passing off to specialists with no plan of care, and/or simply writing another prescription. Many in the public just find it faster, or are being told to just go to the ER. From the perspective of health system CEOs, it would appear primary care is not wanted or needed, which drives up the hospital ER and inpatient business. When actually speaking with individuals across the country, it is the opposite, people complain lack of care coordination, and "the doctor doesn't know me and is not taking the time to listen to me - I want them to actually figure out a diagnosis of what is wrong."
Her quote continues, "... insight further into consumer driven wants, we are finding that a substantial sector of the population does not want or need a primary care physician relationship. People need primary care but not necessarily a physician relationship." The issue is the primary care physician practices have been acquired by the hospital-health systems, with the biggest complaint from people in the population not being able to find a PCP; and those now under health systems, the doctor only giving 10-15 minutes of time, before passing off to specialists with no plan of care, and/or simply writing another prescription. Many in the public just find it faster, or are being told to just go to the ER. From the perspective of health system CEOs, it would appear primary care is not wanted or needed, which drives up the hospital ER and inpatient business. When actually speaking with individuals across the country, it is the opposite, people complain lack of care coordination, and "the doctor doesn't know me and is not taking the time to listen to me - I want them to actually figure out a diagnosis of what is wrong."
