Opioids

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Pointing Fingers at Healthcare Problems

I’m only halfway through Elizabeth Rosenthal’s “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back” which means that I haven’t gotten to the “what you can do about the problem” part. It’s a slow read, not because it’s not compelling but because it’s too compelling, and if like the current President, you were surprised at how complicated healthcare is, this book will do nothing to dissuade you. It’s really really complicated.

So far, I have two main takeaways from the book, that are easily illustrated through my recent experience of breaking and dislocating my finger: a simple, non-life-threatening problem, that unearthed a couple of key dysfunctions and unintended consequences.

My first takeaway is that everyone is complicit, and yet seem to manage to finger point at everyone else. Rosenthal spares no punches in unearthing decisions that are not made with the best interest in of the patient at heart. Providers, healthcare organizations, payers, pharma, and employers all are complicit in the mess that is our current healthcare system.

This past fall, I broke and dislocated my finger. It wasn’t a big deal, but because it happened on a Saturday night, my only option for care was at the ER. Last week I received a letter in the mail from my insurance company, that according to the envelope required my urgent reply. In the letter, the insurance company suggested that perhaps someone other than them may be on the hook for my ER bill. While I understand they wanted to make sure this wasn’t a worker’s compensation claim, the form was basically for me to tell them whose fault my injury was so that they could go after another insurance company to pay. This was a sports injury in a game of Ultimate Frisbee, a game so granola-like that there are no referees: players call fouls on themselves. . No one was at fault, and even if they were, I would never have considered suing. However, the form didn’t give me that option: only gave me the option of saying whether I had settled my claim. I created a new box that said “NA” and checked it.

When I received the letter, I couldn’t help but think back to Rosenthal’s book, and also consider the amount of effort and cost that was going into finding someone else to blame and pay. Just imagine what this effort and cost would have been if there were legal action….

The second takeaway is that the original intention of a decision always has much farther reaching implications than anyone who agreed on what seemed like a reasonable decision though. Again with the finger, I was asked a number of times if I wanted a prescription for OxyContin. I did not. As has been well publicized we have an opioid addiction problem in North America. While my finger hurt, aside from morphine during inpatient for an appendectomy, I hadn’t had opioids, and really didn’t think that it was necessary, which I explained to the physician. It wasn’t. Tylenol worked fine—however, it seemed that it was very important that I be the one to make this call, not the physician.

One of the unintended consequences of patient satisfaction scores may be the over prescription of pain medication, as many of the questions on the HCAHPS are about whether the patient’s pain was well managed. In Rosenthal’s book, I was also surprised to learn that a finger fracture where an opioid is prescribed has a different billing code than if it is not prescribed, and that with the fracture plus opioid billing code, hospitals get paid more. Now, if you are wondering how this may be the case, if you think about it, a fracture that requires an opioid must be more severe than one that doesn’t and therefore the billing code reflects the severity. This is exactly where the unintended consequences of billing codes can result in exactly the wrong behavior for patient care and safety.

It’s quite possible that the physicians on duty were not aware of either of these two drivers for prescribing, especially the billing code one. They may have just been told “this is our standard of care” and were following guidelines.

If a simple finger fracture and dislocation can shine a light on two key problems in our healthcare system, just imagine what else is out there. Actually, you don’t have to, just get a copy of Elizabeth’s book yourself, and let’s compare notes when I get to the part about what the fix is. It’s going to take all of us.

Posted in: Health Regulations, Healthcare costs, Healthcare Disruption, Healthcare Legislation, Healthcare Policy, Healthcare transformation, Opioids

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Taking the Fear Out of Total Joint Replacement

I’m not quite ready for a joint replacement but many of our Wellpepper users are, so I found myself spending a recent Saturday morning at a session called “Taking The Fear Out of Total Joint Replacement.” This patient-focused half-day workshop was free to potential patients and sponsored by an organization called SwiftPath that specializes in minimally invasive outpatient total joint procedures. Total joint procedures are feeling the crunch of reimbursement changes in the Affordable Care Act, and one way to lower costs is to perform them in an outpatient facility. However, due to the minimized time an outpatient candidate would spend under the supervision of a doctor, they must be highly engaged in their self-care efforts, including losing weight or quitting smoking if necessary. With people having replacements at younger ages, and often having both knees and hips replaced, the need for engaged patients continues to grow.

I attended the workshop to get an idea of the patient’s perspective on the information and on the procedure. Health systems frequently offer Total Joint Bootcamp but this was intended as an introductory session for people who may be undecided about getting a replacement. The sessions included information about good candidates for minimally invasive total joint replacement, expectations of patients and their caregivers for participation, learning, and recovery, and an overview of the physical therapy involved. The host for the day was Dr. Craig McAllister who is one of the principals of the SwiftPath method. With the exception of the initial opening sequence of surgeons talking about the effictiveness of the methodology, the day was primarily patient focused, starting with risk stratification as a means to determining the best candidates for surgery, through tracking patient reported outcomes, and ensuring patients and caregivers were equal participants in care. There was also a session on determining how a patient pays. Dr. McAllister noted at one point that this entire patient-centered approach was completely different than what he was taught in medical school.

Two of the most powerful sessions were also patient-focused. The first was a patient panel consisting of an OR nurse who had a recent knee replacement and biked to the session, a few people who had experienced both in-patient and outpatient replacements, and one who was not originally a candidate for surgery because he was a smoker. While quitting is a requirement for the surgery, he initially didn’t want to until he realized that he would lose his opportunity to have Dr. McAllister perform the surgery, concluding that he needed the surgeon more than the surgeon needed him: “If I didn’t do what he said, the next patient in line would.” I thought this was a really interesting approach to motivating change: be inspiring and selective, not punitive or even threatening. All of the participants talked about having low pain levels, and some not using the prescribed opiates. As part of the program, Dr. McAllister closely tracked their post-surgical pain, nausea, and opiate usage. One patient disclosed that he drove himself to his first post-surgery physical therapy appointment, and although this was not encouraged, his PT actually gave him the all-clear to drive home.

The final session of the day was possibly the most striking. It featured a police officer and the founder of a drug addiction non-profit, Amber’s Hope talking about opiate addiction. This session was sobering, both from the impact of the drugs but also because measures to control these dangerous substances have actually exacerbated the problem. Since opiates cannot be prescribed by phone, and post-surgery patients are not mobile enough to visit a physician, get a prescription, and take it to a pharmacy, physicians need to prescribe what they believe will be enough pills prior to surgery, which can lead to leftover pills. Most non-prescribed usage of opiates comes from these leftover pills, which means that educating patients on how to dispose of them is key. In Kirkland, Washington where this session took place, for example, the only way to dispose of them is to take them to the local police station. (FDA recommendations for disposal of prescription drugs can be found here.) At Wellpepper, we track the use of both over-the-counter and prescribed painkillers as part of treatment plans. We do this for two reasons: first, it’s a valuable piece of information about a patient’s pain levels and recovery time, and second, too often these pills are prescribed as needed and usage isn’t monitored, leading to a nationwide opiate problem.

I attended this event so I could better understand the people who will eventually use our software. I learned a lot more about changes in care delivery, and got some great ideas for continuing to engage patients that you’ll see in future updates to our products.

Posted in: Behavior Change, Opioids, Outcomes, Patient Advocacy, patient engagement, Patient Satisfaction, Physical Therapy, Seattle

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