GeriTech

Infographic: The Cost of Aging in America

March 20, 2015

Excerpt from Cost of Aging in America Infographic

An excerpt from the infographic; be sure to see the whole thing below!

[This is a guest post by Emily Newhook, of the George Washington University School of Public Health. Earlier this year, they published this interesting infographic, titled “The Cost of Aging in America.”

I like that this infographic mentions chronic conditions and multimorbidity, although it would be stronger if it included more information on just how common multimorbidity is (and the association with cost). I also very much like that the infographic mentions long-term care cost and the impact on family caregivers.

Now how to integrate life and care models? That’s literally a trillion dollar question, and hopefully this graphic will spur people to keep thinking about it.

Last but not least, I would say to GW that perhaps we shouldn’t frame the key question as “Can we afford to get older?”

Instead, we should ask ourselves: “How can we effectively and compassionately care for an aging population, at a cost we can all sustain?” This way we put the care before the money.]

The Cost of Aging in America: What’s at Stake?

Americans are living longer, but can we afford to get older?

What Accenture Says Seniors Want re Health & Technology

March 6, 2015

From http://newsroom.accenture.com/news/tech-savvy-seniors-want-online-options-to-access-care-from-home-accenture-survey-shows.htm

This week I almost fell out of my chair when I came across Health Populi’s recap of an Accenture survey on seniors and healthcare technology.

The particular finding that surprised me was this one:

3 in 5 older people are likely to join an online community to check a clinician’s advice before taking it on

Really??

I was surprised since as far as I can tell, it doesn’t cross most people’s mind to look for an online community to check a clinician’s advice, although I do think it’s become quite common for people to look things up on WebMD and at MayoClinic.

Of course, I’d be thrilled if more people would adopt an e-patient approach and do some double-checking before accepting a doctor’s advice. This is a good way to make sure you’ve explored other options, and can help reduce medical errors. But sorting through information online takes skills, as does bringing up what you found to the doctor. (Doctors should be amenable, but many are not.)

Accenture’s press release for the survey is here. I found this finding striking too:

A third of seniors would prefer to work with a patient navigator to manage their healthcare. Last year, $384 million was invested in solutions, like patient navigators, for care navigation.

Interesting, no? Does this represent a failure of primary care for seniors? Shouldn’t the role of a good PCP is to be a navigator for choices and health strategy? (People also often want help managing healthcare logistics, which is something that could be done by a medical home, a care manager, etc.)

Other findings Accenture highlights are:

“More than two-in-three seniors prefer to use self-care technology to independently manage their health”
“More than three-in-five seniors are willing to wear a health-monitoring device to track vital signs, such as heart rate and blood pressure”
“A quarter of seniors regularly use electronic health records for managing their health, such as accessing lab results (57 percent)”

Accenture seems to conclude that the “top five areas for growth” are self-care, wearables, online communities, navigating healthcare, and health record management.

What to make of Accenture’s findings?

Over ten thousand adults aged 65+ were surveyed for this report (in May-June 2014) but only 354 were U.S. Medicare beneficiaries. That’s because this is a survey of seniors in ten countries, assessing “their perceptions of using technology to manage their health.”

The press release didn’t have a link to Accenture’s full report, much less the survey questions they actually asked.

Personally, I found these results intriguing but they also seem a bit tech-optimistic, as does much in the digital health arena.

One could raise endless methodological questions about this press release: How representative were the respondents of other seniors in their country? Were there differences by country? What are the seniors thinking of when they hear “self-care technology” and what does it mean to “independently manage their health”?

And how much does the Accenture team know about the best way to help seniors manage health, and health problems?

Consider this, from the press release:

“The survey showed seniors who place a higher priority on technology are more likely to proactively manage their health. For example, most seniors (75 percent) who value technology are active in tracking their weight digitally, compared to 43 percent of those who do not. Similarly, half of tech-savvy seniors are actively monitoring their cholesterol, compared to 31 percent of those who do not value technology.”

Wow. This is a good example of data that doesn’t help you solve useful problems. (If you’re a clinician that is; I guess this might help businesses figure out who they should market their products to.)

Clinically, I am perplexed by what it means for seniors to “actively monitor their cholesterol.” Unlike monitoring weight and exercise, monitoring cholesterol is something they can’t do without partnering with doctors. Sometimes I think business people act as if managing health is like managing your banking or travel plans: just give me a good website and I’ll conveniently take care of it myself! But once people have active health problems, it’s much more complicated.

So what to make of Accenture’s report? My main take-away is that interest in senior health technology is on the rise. Whether or not Accenture is right, it’s interesting to see how they are framing the digital health needs for the people we care for.

[Many thanks to Carla Berg for bringing this survey to my attention. Do read the Health Populi piece; it includes data from the Utilization Patterns and Out-of-Pocket Expenses for Different Health Care Services Among American Retirees, published in February 2015.]

A Tale of Two Sore Throats: On Retails Clinics & Urgent Care

February 23, 2015

[This post was first published on The Health Care Blog on 1/28/15, and was re-posted to KevinMD on 2/21/15. The comments are worth reading at both sites.]

Six
years ago, just after arriving in Baltimore for a winter conference, I fell
sick with fever and a bad sore throat.

After
a night of feeling awful, I went looking for help. I found it at a Minute
Clinic in a CVS near the hotel. I was seen right away by a friendly NP who did
a rapid strep test, and prescribed me medication. I picked up my medication at
the pharmacy there. The visit cost something like $85, and took maybe 30
minutes. They gave me forms to submit to my California insurance. And I was
well enough to present my research as planned by day 3 of the conference.

Fast
forward to this year. After feeling a bit blah on a Monday evening, I developed
a sore throat, headache, and fever overnight.

I
figured it was a winter viral pharyngitis, rearranged my schedule, and planned
to make it an “easy day.” Usually a low-key day plus a good night’s sleep does
the trick for me.

But
not with this bug. This one gave me chills, a splitting headache, body aches, a
fever of 102, and a sense of serious misery. Plus that awful sore throat. A
dose of ibuprofen 400mg would beat back the symptoms a bit, and allow me to eat
and sleep. But after about four hours, I’d find myself shivering and feeling
horrible again.

And
the following day, Wednesday, I felt even worse. I started wondering if maybe I
had the flu, or could it be strep throat, since I didn’t have a cough?

I
thought about going to the doctor, but I felt so sick and I didn’t want to go
through the hassle unless there was a decent chance of benefit.

Because
in truth, even though I get my care from a large well-regarded health system
that offers online appointment scheduling, a portal to review my outpatient lab
results, telephone advice nurses, and other conveniences, I still don’t like
going in because it’s a big place and the experience never feels…delightful,
shall we say.

I
looked through UpToDate online and tried to figure out the likelihood that a
doctor’s visit would change management (most adult pharyngitis is viral) but my
mind was too fuzzy and so I stayed home in bed.

However,
that night my husband said he was starting to get a sore throat. I also spoke
to a doctor friend on the phone. She thought my symptoms sounded an awful lot like
strep, and urged me to go in and get a rapid strep test. I decided that if I
didn’t feel a lot better by the next morning, I’d go in.

I
was a little better the next morning (day #3 of my illness) but not a lot. The
body aches were better, but I’d developed a killer earache, and it still hurt
too much to eat unless I had recently taken ibuprofen. My temperature off
ibuprofen remained 101-102.

So
I called the phone appointment line, explained my symptoms, and was given an
appointment to see my own assigned doctor. (No urgent care clinic available I
was told; this health system encourages open access to your own doctors.)

As
I had expected, it was a miserable hassle.

The big facility’s big underground
parking lot was full but they kept letting cars in, so I found myself along
with twenty other cars on the bottom floor, with a staffer waving his arms and
telling us to find a way to turn around.

My
doctor’s waiting area was pleasantly uncrowded, and after I’d paid my $20
co-pay I was called by the medical assistant (MA) right away. This, I’ll admit,
was nice. “How’re you doing?” she asked as we walked to the vitals station.

“Sick,”
I replied. “That’s why I’m here. I haven’t felt this bad in years.”

The
MA made a sympathetic noise, checked my vitals, and then put me in an exam
room. She asked me to tell her about my symptoms, which I did.

And
then she proceeded to quiz me about my lifestyle habits. Did I exercise
regularly? Just what type of exercise do I do? How many times a week? And for
how many minutes? What about drinking? How many times a week? How many drinks
in an evening?

Now,
I have always found it intrusive and annoying when clinic staff ask me these
types of questions. I know why they do it and why it’s overall important, but
as a patient I’ve always disliked it.

This
time, having come for an acute care visit after feeling miserably sick for
days, I was seriously annoyed. I have a low BMI, low blood pressure, and a
beautiful lipid profile. (I credit genetics/epigenetics.) In other words, I am
not in dire need of lifestyle interventions. But I gave the MA some brief
answers and in truth I inflated my exercise levels a bit, because I didn’t want
them to get on my case, or get distracted from my top priority, which was
getting my illness evaluated.

A
few minutes later, my doctor arrived. I had to repeat the story of my symptoms.
She listened to my lungs and peered in my throat. And then she announced she
would do a throat culture.

What?
What about a rapid strep test, I wanted to know.

“This
is a rapid test. It’s a rapid throat culture which gives us results in 6-8
hours. We don’t have any other strep tests.”

I
looked at my watch. It was 11:40am. “Let’s get your culture in to the lab,”
said my doctor. “If they start running it soon, we might have a result by
evening. You can check online and if it comes back positive, call the advice
nurse and they’ll have a doctor order your prescription, which you could pick
up tonight.”

I
sat there, sick, spaced out, and very disappointed that there wasn’t a rapid
strep test available.

My
doctor handed me a paper bag. “Take this to the lab on your way out.”

It
took me a little while to process this last bit. Not only did they not have a
rapid strep test, but they were now telling me to go deliver my sample to the
lab. Helpfully, the doctor gave me a “After Visit Instructions” handout, on
which she had checked “Specimen drop off: Please take a number and the next
available receptionist will help you.”

I
went to the lab. The waiting area was overflowing with people. I took a number
(361) and then discovered they were now serving number 329; there were at least
30 people ahead of me. There was no bin or spot to drop off my specimen, so I
sat huddled in a chair as my ibuprofen started wearing off and my fever
returned.

It
took them twenty-five minutes to call my number. I had to tell them my name and
address, and give them my ID again. “No co-pay required today!” the
receptionist announced brightly. I told her I’d been waiting quite a while just
to drop off a specimen and why didn’t they have a bin? She apologized and said
they used to have something like that, but then the space was rearranged and
they took it away. I consoled myself thinking that since I’d dropped off my
specimen at 12:25pm, hopefully I’d have a result by 8:30pm.

I
went home to my bed and my ibuprofen. That evening I started checking the
portal online. No result. No result. No result. I took more ibuprofen and spent
another restless night with fever, sore throat, and earache.

The
next morning, I checked again. Hallelujah! A positive strep culture! Which, I
noticed, had been reported at 9:45pm after the specimen was “collected” at
1:57pm.

I called the advice
nurse, she arranged for the phone doc to call in my prescription, and then I
had to schlep back to the health center to get my penicillin. And finally that
afternoon, I started to really feel better.

Should I go to a retail clinic next time?

I
don’t like being sick but it’s always instructive to be on the patient side of
things.

Because
my PCP didn’t offer a rapid strep test, my treatment was delayed by almost 24
hours. I lost an additional day of work and some income. My beleaguered spouse
took care of our two little kids on his own for an extra day. Plus it’s not fun
to have fever and a splitting earache.

All
of these problems are a big deal to me. But they are an externality for the big
organization that manages my healthcare. Rapid-strep tests can be expensive for
a provider; only 5-15% of adult pharyngitis is strep so unless you are
selective about who gets tested, you end up with a lot of negative rapid tests
that often get followed by a throat culture.

As
for making your patients drop off their specimens at an over-crowded lab,
well…it’s quite easy to see how that happens in a big organization. (Presumably
it’s cheaper or easier than having staff do it.) I didn’t like it but I’m not
going to leave the provider over that.

I
will, on the other hand, probably go look for a retail clinic next time I’m
acutely ill and think I might have a treatable infection. I haven’t yet decided
just how much a day of health is worth to me, but it’s surely more than the
cost of a retail clinic visit minus my $20 copay.

Now,
you may be scoffing and thinking that since I’m a doctor of course I can afford
a retail visit. But if you have low socio-economic status, a day not working
can be an even bigger deal than it was for me. When I worked a salaried doctor
job I had paid sick days, but that’s not true for
many workers.

However,
I would be worried if many older adults with chronic health problems started
going to retail clinics. That’s mainly because I’m skeptical that retail
clinics can provide the right care – whether acute or chronic – to people who
are medically complex and getting care from other providers.

I
also worry that retail clinics will over-prescribe antibiotics and other
medications, in part because patients often want these things.

Of
course, more conventional primary care urgent care clinics suffer from the same
problems. Over-prescribing
of antibiotics
is common in outpatient care, and medically complex people often get
sub-optimal care during acute and chronic visits. So perhaps it’s not fair to
bash retail clinics excessively, until our primary care clinics get much better
at what they do.

What constitutes good urgent care?

No
matter what one’s age or medical history, one should be able to access a good
urgent care experience when acutely ill. By good, I mean that:

·
The encounter
involves a minimum amount of friction and burden. I put off my
own doctor’s visit because I was reluctant to face the hassles while feeling
sick. Imagine if I were employed and had cancelled an additional day of clinic,
in part because I was sick and avoiding the hassle of my doctor’s office. My
employer and patients would’ve been upset, and rightly so.

·
Delays in
diagnosis and treatment are minimized. Even when delays in treatment aren’t
medically dangerous, they impose a serious burden on patients when the delays
affect ability to work or care for others.

·
Diagnosis and
treatment are in accordance with recommended practices. It can be hard to agree on the finer
points of what is recommended practice, but in general, care should be similar
to what is recommended in UpToDate, for instance. Avoiding over-prescribing of
antibiotics is an issue in all urgent care settings.

Should
patients be quizzed about healthy lifestyle habits during an urgent care visit?
This would be an interesting topic to debate, as it requires weighing
population health benefits with patient satisfaction.

Will
I go back to my PCP next time I need urgent care? Maybe, but if I think it’s
strep again, I’ll probably look for a reliable urgent care provider who offers
rapid strep tests. For working adults who aren’t medically complex, convenience
and minimum delays in treatment are key.

7 Types of Help People Want from Healthcare

February 6, 2015

What do people want from their health care, and their medical care?

In my last post I shared a rough taxonomy of patient types, based on stage of life and type of chronic health problems.

Similarly, I think it’s useful to sketch out the types of help that people seek from the healthcare system. So far I’ve come up with seven.

But before I share them, let’s step back and consider the big picture of health care.

What’s the point of health care and our healthcare system?

The overarching purpose of health care, and the overall thing people want from healthcare, is:

To optimize the ability to participate in life, today and in the future.

This is the underlying reason that people want help with their health.

(What is health? See my practical definition here, and yes I’m still hoping for feedback on it!)

Just what it takes help optimize a person’s abilities depends on the details of their health situation. For instance, for a person who has recently suffered a stroke, it might be things like speech therapy and physical therapy to optimize function, adaptive equipment and home modifications to facilitate getting around safely, treatment of post-stroke depression, and medical management to reduce the risk of a future stroke.

7 ways the healthcare system helps people with their health

Flipping the Clinic: On Brainstorming Innovation by Patient Type

January 23, 2015

Last week I attended the Flip the Clinic Lab event in San Francisco, which was co-hosted by the UCSF Center for Excellence in Primary Care, and sponsored by RWJF. (See my Storify of related tweets here.)

It was a fun and engaging day, but it left me thinking something that I often find myself mulling over at health innovation conferences:

Is it possible to constructively brainstorm about healthcare when thinking about everyone’s health needs at the same time?

In other words, are we likely to come up with good ideas when we’re striving for ideas that work for all patients? Are we likely to come up with really useful ideas when a pediatrician and a geriatrician and a 30 year old Type 1 diabetic get together and envision a better patient-clinician experience?

The difficulty, of course, is that different types of people need different types of help from the healthcare system.

A generalist pediatrician presumably has many patients who are overall fairly healthy. They do need monitoring, and health education, and also help when a new health problem comes up. Many of them might be struggling with weight and healthy eating, and some are at risk due to their social determinants of health. Some of these patients will develop a chronic disease like asthma, and will need ongoing help with their chronic illnesses. And a minority of pediatric patients have the kinds of health problems that require frequent hospitalizations.

A geriatrician like me, on the other hand, cares for older adults who tend to have multiple “mundane” chronic illnesses. Many of them have chronic impairments of the brain or body. Many of them have caregivers assisting them with life tasks, including “self-healthcare” such as symptom monitoring. Many of them experience hospitalizations, and life-threatening health crises.

The truth is that when we brainstorm flips for our clinic, or any other kind of improvement to healthcare, we generally aren’t thinking of everyone at once.

Instead, we are either thinking of our own needs as patients and families. Or if we’re a healthcare provider, we’re thinking of the needs of those patients that we spend the most time with, or are most interested in.