Using Shared Decision Making as a Tool

Shared decision-making is an approach where clinicians and patients communicate together using the best available evidence when faced with the task of making decisions.  This is ne of the new trends allowing patients to directly participate in their care.  The goal is to give the patient sufficient data to make an informed decision with the clinician to determine the curse of their medical care.

In the article, What is Shared Decision Making?, the author defines as a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values and preferences.

Traditionally medical care was 100% paternalistic, where Dr. Welby knew what was best in all situations.  With the tremendous growth of information available the consumer can google all the information they may or may not understand.  Even if they understand, they do not necessarily have the context to make appropriate decisions.

The provider is the person who adds the context, but it is easy for the provider to bias the process.

There are certain situations in medicine where shared decision making is inappropriate.  A patient who needs life-saving surgery or immediate cardiac care should not create an excessive dialogue.  Other not so urgent problems with multiple treatment options is another story.

There is one place where shared decision making can be used as a tool to eliminate medical-legal testing, CYA procedure, unnecessary hospitalizations, and the overuse of our extension and expensive pharmacopeia.  This will also appeal to practitioners who believe in the motto, "Trust Me" and/or "In My Experience".

Keep in mind that any action has risks.  While one might wish that the benefits of an action outweigh the risks, we all know this not to be consistently the case.  Thus any decision on which an action or the act of inaction is based has risks, and a risk/benefit ratio can be surmised.  Actualized risks have costs, the most central of which are risks to the patient and the patient's health, the secondary, and tertiary, tiers of actualized risks are litigation, blame, and social or interpersonal dispute regarding responsibility for the decision.  In traditional care models, the physician bears the secondary levels of risk; indeed in Marcus' time there was little litigation, and the risk of a questionable decision was small.  But in our current dominant medical model, there is considerable risk to the care of patients, and to shouldering the decision making process.  Hence, medical care is expensive.  Broad shoulders require huge payouts and large premiums.

In a share decision model, who would bear the risk?  Would it too be shared?  Or perhaps when the patient is a decision maker, he/she agrees to assume all the risk of the decision.  How would the elements of a negligence claim be parsed?  Duty, Breach of Duty, Proximate Cause, Damages.  Shared decision-making may be an advance, but some pieces have to be in place.  For example, standard forms upon which a doctor checks off the options, risk, recommendations, and the patient perhaps on the other side of the sheet notes his acceptance, decisions, and signature.  More forms, that's for sure.  Lots more forms.

Take advantage of the consumers' willingness to participate in their care by having informed discussion with them.  Talk with them like a family member, and give them the same advice.  The monetary savings will be astronomical and your public relation scores will sky-rocket.

A Technique for "Road Rage"

Road Rage an aggressive or angry behavior by a driver of an automobile or other road vehicle.  These behaviors could include rude gestures, verbal insults, deliberately driving in an unsafe or threatening manner or making threats.  Road rage can lead to altercations, assaults, and collisions that result in injury or even death.

A simple technique to combat road rage or any stress is Pranayama breathing.  Pranayama is a Sanskrit word meaning extension of the prana or breath- extension of the life force.  It is a yogic discipline with origins in ancient India.

A simple form of this breathing is a long 3 second inhale through the nose followed by a long 3 second exhale through the nose.  Easier said than done.

One of my yoga instructors stated that in 12 seconds- 2 complete breath cycles- one can eliminate stress and hostility.

The next time somebody cuts you off in your car, try 1 breath I, 1 breath out, 1 breath in, and 1 breath out.  You will be surprised by the power of the breath!

Is It Time to Start Downsizing?

The author of 12 Changes That Will Affect Doctors' income in 2015 lists major changes that should have a net negative effect on providers’ incomes due to the Affordable Care Act. I suggest you read this article.

 

1.      High deductibles is the new self-pay in disguise with many patients not aware of this serious issue.

2.      Decrease in malpractice premiums which will probably be a transient benefit. Caps are being overturned or litigated in most states.

3.      ICD-10 will begin in October and the true cost is not yet known. Most experts think practices should have a 90 day reserve fund to make payroll.

4.      Practices involved in Medicare Accountable Care Organizations will be losing their guaranteed contracts to avoid losing money. There is a bill in congress to keep the contracts viable for 3 more years. Not sure what will happen in new congress.

5.      The emergence of Telemedicine is affecting the growth of certain practices. The reimbursement for these services are still be battled over. The legal liability is also in flux.

6.      Retail clinic pharmacy driven practices are direct competition to the standard practitioner.

7.      Primary Care Physicians will lose their enhanced Medicaid payments. These payments will lower back to approximately 40 cents on the dollar.

8.      Meaningful use become more “mean” and will now penalize rather than reward the practitioner.  The government wants its money back.

9.      PQRS will no longer give maintenance of certification monies for meeting quality measures. Penalties will ensue.

10.   Medicare payments to specific providers are now available without context on new websites.  Bad publicity is the net effect.

11.   Medicare will start paying for chronic care outreach to providers who deal with patients with 2 or more chronic conditions. The downside is the necessary documentation to avoid future audit.

12.   New CPT modifiers to replace the 59 modifier for procedures. Make sure your billing team is ready to change. Failure to act will lead to another excuse to deny or delay
CLAIMS MADE.

 

Welcome to the electronic age to save Medicare money. These trends are just the beginning to try to save Medicare. Cost shifting to the provider is an easy route because they are all “rich doctors” anyway.

Fighting the Most Common Chronic Financial Illness

Chronic illness is a long-lasting condition that can be controlled but not cured. As described by the Centers for Disease Control, chronic disease is the leading cause of death and disability in the United States.

In financial terms the most common chronic illness is the “Disease of Fixed Expenses”. This affects all demographics and incomes. It is the never ending list of payments and obligations that one accrues through ordinary life. It becomes an acute illness when the “patient” gets ill, fired, laid-off, and or retires where the monthly income is significantly reduced or eliminated.

This can be controlled through conscientious budgeting, but this is not in the nature of 95% of the population. The advice is always the same- Save, spend less, avoid immediate gratification, have a plan, etc., etc.

This advice is always in a vacuum that doesn’t take into account the pressures to spend by family and friends is endless. The most organized and frugal person may not control their dependent group leading to a feeling of hopelessness or just “going with the flow”.

Some easy suggestions to ameliorate the problems.

1.      Anticipate that house payments, car payments, insurance payments, and tax payments never go away.  Realize that the most expensive house and or car is not necessary and these possessions are only tools. After a couple of years, the $25-40,000 car gets you to the same location as the $60,000 vehicle. The more expensive car with insurance, maintenance et al costs over $1,000 per month for 5 years.

2.     Discuss money with your family/dependents and carefully explain “how much a broom” costs and come up with a reasonable spending approach. Let them make compromises to get what they want.

3.     Realize you are getting older, and basing your “happiness” on things is misguided and driven by television and movies.

4.     Avoid being jealous of another’s success.

5.     Stay healthy and avoid medical costs.

6.     Anticipate unanticipated disasters – things are going to happen; face it. These characteristically require significant expenditure, often all at once, and often without time to develop a less costly strategy. Thus, planning for, and having an account with, say, $100-$150K, set aside only for emergency purposes, is wise.  If you do, there are several principles: don’t touch it for anything but an emergency; never borrow from it thinking you will repay (shortly) in the future. You won’t. Are you wise?

 

These may sound preachy but I am guilty of all these sins and now realize the shortsighted of my lifestyle decisions.

Making more money does not improve the condition, it only changes the paradigm. More money=More expenses=More Fixed expenses.

 

"Melting" Your Aches and Pains Away

My spouse recently started a new program called the "Melt Method" to achieve flexibility, relaxation and pain relief.

The self-treatment system claims to restore the supportiveness of the body's connective tissue to eliminate chronic pain, improve performance, and decrease the accumulated stress caused by repetitive postures and movement of everyday living.

Benefits include:

Improves

• flexibility & mobility
• posture
• results of exercise
• range of motion
• sleep & digestion
• overall well-being

Reduces:

• aches & pains
• wrinkles & cellulite
• tension
• headaches
• risk of injury

Does it work in real-life?  It essentially functions a directed self-massage techniques that involves using soft rollers, acupressure-type balls for hands and feet, and stress reduction attempting to improve one's general well-being.

My wife and friends claim they are 1-2 inches taller and stand up straight after a standard class.  Wanting to take a peaceful nap after the sessions is a side effect.

As one ages; stiffness pain, loss of flexibility, balance, and loss of range of motion become the reality instead of the exception.

At present my wife is involved in Yoga, TRX and the Melt Method and the combined results are pretty outstanding.  My suggestion is you might add this to your regimen.  It is a great substitute to using medications to treat chronic pain.

I recently went to a James Taylor concert and the crowd looked like (myself included) an AARP convention.  The majority could have used a physical and mental health program to walk up on down those steep stairs.

Screen Savers as a Communication Tool

Almost every medical facility has multiple computers at multiple work stations. Each computer has a screen saver that is usually a name, advertisement, and or picture.

With the recent confusion at the Texas hospital about Ebola, it is a simple tool to enhance communications throughout the institution. Some hospitals have already posted announcements and schedules of meetings on them.

The next step would be to use the screen as a notification tool to all the staff.

1.      Infectious disease updates:

a.      Fever, Travel, and/or exposure to traveler to West Africa: Contact Physician and Nurse Supervisor Immediately.

                        b.      Children with shortness of breath may have serious Enterovirus.

                        c.      Influenza season starting: Get your flu shot, please:

                        d.      CDC warnings

2.      Meeting or Activity notices:

a.      Joint Commission here Mon-Fri

                        b.      Blood Bank drive Friday.

                        c.      Hospital wide meeting with Leadership on Tuesday.

3.      Drug shortages:

a.      The list is endless

                        b.      Substitutes available

The utility is endless and can be easily programmed. Different computers with specific target audience can get different messages.  Add the screen saver as part of your system to ensure that everyone hopefully knows what is going on.

Instead of being reactive, this is a proactive step.

Tyranny of the 24 Hour News Cycle

It does not take a university level course on marketing to see that news sources are more truthfully in the business of entertainment than in the business of accurate information dissemination.  If a “story” excites, titillates, captures the mind, it is successful, despite its truth.  To observers, the current mode of public information distribution seems more like onscreen supermarket tabloids than the down-to-earth news given by respectful predecessors like Walter Cronkite, Jules Bergman, Chet Huntley, and David Brinkley.  These days, entertainment trumps accurate reporting.

            The problems inherent within an insatiable need for more information at breakneck speed include lack of verification, HYPE!, misinformation, professional “talking heads,” speculation without sufficient data, and the race to be “First”.  After all first-and-foremost means top entertainer.  The list of such inaccuracy generating issues could go on and on.

            In the 24/7 cycle, people or perhaps institutions are blamed or praised at the outset, according to the political bent of the station. Then, political correctness (either right-wing or left-wing) is added to the mix; now we have an attention-getting story that can be repeated every 15 minutes for 24-72 hours or until some new disaster pops up.  Advertising is sold hand-over-fist according to the ratings that any news show gathers through it’s stage show.

            The Texas Hospital Ebola exposure presents a good example of how the blame game feeds the fire of the news-show/entertainment industry. Here, the hospital, nurses, physicians, Emergency Department, Electronic Health Record, Homeland Security,  and the TSA were all good candidates to blame, and each was hit sequentially according to the texture of the moment. Rather than taking a systematic review of the entire process, a tangible scapegoat was needed, and someone, some individual, had to have failed, rather than the system as an interconnected entity. However, this was instead, a system failure. When you blame an individual for a system problem, finger pointing immediately occurs. “It was not my fault, but was a result of someone else’s incompetence (certainly not mine!).”  That generates interest, attention from the masses, and channel habits, being psychologically less boring than saying “Hey, look, the system just failed.” There is nothing more dull or tedious for the human psyche than to have no one to blame.
            Gun control, abortion, immigrations, health care, race, and welfare stories always lead to an immediate pro or con response without analyzing the individual merits of the case. For the sake of the modesty of this blog, nothing further will be said regarding the visual appeal of the female news anchors that always seem to appear.  In real life, there just are not that many scantily dressed beautiful women in one place. Seriously? There must be an average looking female journalist somewhere.  But, after all, entertainment is entertainment.  Just saying.

            As one watches Fox, CNN, MSNBC, PBS, and any number of other news stations, their political viewpoint is easily ascertained. Depending on the channel, the CDC was either on top of the situation or “hiding the truth”. Even with talk radio, expected to be along partisan lines, it is easy to hear an underlying “chronic agenda” that is hardly impartial.
            In conclusion, the massive appetite of the 24 hours news cycle does not reflect an overall common sense collective approach to solving problems. Information, provided in this way, and blanketing the media, is thus a major contributing factor toward the endless divisiveness in our society. Would it not be healthier to allow the average person to sit on different sides of an issue, even retaining a bit of ambivalence, without the inherent name calling that derides an absence of political correctness from one or the other perspectives. Occasionally, a reasonable compromise can be a good thing.