Wednesday, September 26, 2012
Many experts have expressed concerns that antibiotics are being overprescribed and overused, leading to unnecessary spending on prescription medicines as well as more widespread bacterial resistance to the drugs. In the elderly, who are more likely to suffer adverse side effects and reactions from antibiotics, the health consequences can be amplified.
Despite this vulnerability, antibiotic use among seniors has not been as closely studied as it has been among younger Americans. So a team of researchers looked at prescribing patterns among men and women over 65 across the country, comparing rates over a period of several years and doing breakdowns quarterly. Their research, published in Archives of Internal Medicine, showed that during a typical three-month period, about 21.4 percent of older Americans in the South used an antibiotic, compared with about 17.4 percent in the West. The rate in the Midwest was 19.2 percent, and in the Northeast it was 18.2 percent.
The researchers adjusted their findings for health status, demographics, insurance coverage and other differences that could have influenced the findings. Even after controlling for these variables, the rate in the South remained higher. The study was not designed to determine specifically whether antibiotics in the South are overprescribed, but the data point to overuse as a likely explanation, said Dr. Yuting Zhang, an author of the study and assistant professor of health economics at the University of Pittsburgh.
"We don't know the exact reason," she said, "but what we can say is that antibiotic use is higher in the South, and this is consistent with previous research that shows the quality of prescribing is poorer in the South compared to other regions."
Dr. Zhang and her colleagues found that there were also seasonal variations in antibiotic use. Regardless of region, antibiotic prescription rates tended to peak in the first quarter of the year, from January through March, and then drop to a nadir during the third quarter, from July through September. The seasonal peak is probably related to the rise in respiratory infections during the winter months, Dr. Zhang said. But since many people are infected by cold and flu in the winter months and these viral infections are not susceptible to antibiotics, the seasonal trends may reflect further evidence of poor prescribing patterns.
The findings were based on Medicare data collected from the beginning of 2007 through the end of 2009. The data was based on about one million patients per year.
Though antibiotic overuse remains common in all areas, one lesson from the findings is that it may be worthwhile to target the South with programs aimed at reducing unnecessary antibiotic use, Dr. Zhang and her colleagues noted, using rates in low-prescribing areas like the West as a goal.
An accompanying editorial from public health experts went further, calling the persistence of antibiotic overprescribing "a failure to translate national public health priorities and evidence into local practice and policies."
"We need to find better ways to compel individuals and organizations to address the significance of the problem of antibiotic overuse," they wrote. "Strategies to achieve transformation at these levels may need to differ substantially from the current educational approaches that have been in use among patients and clinicians thus far."
There are many reasons a soldier will take his own life, but one major factor is post-traumatic stress.
Anyone who undergoes trauma can experience post-traumatic stress disorder — victims of rape and other crimes, family violence, a car accident. It is epidemic, however, among soldiers, especially those who see combat. People with PTSD re-experience their trauma over and over, with nightmares or flashbacks. They are hyperaroused: the slam of a car door at home can suddenly send their minds back to Iraq. And they limit their lives by avoiding things that can bring on the anxiety — driving, for instance, or being in a crowd.
PTSD has affected soldiers since war began, but the Vietnam War was the first in which the American military started to see it as a brain injury rather than a sign of cowardice or shirking. A study of Vietnam vets 20 years after the conflict found that a quarter of vets who served in Vietnam still had full or partial PTSD.
America's current wars may create even more suffering for those who fought them. In the Afghanistan and Iraq conflicts soldiers have been returned to these wars again and again, and they face a deadly new weapon — improvised explosive devices, or I.E.D.'s — which cause brain injuries that, terrible in themselves, also seem to intensify PTSD. "We surmise PTSD will be worse," said Dr. James Kelly, the director of the National Intrepid Center of Excellence, which studies and treats the intersection of PTSD and traumatic brain injury. "Some people are on their 10th deployment. Previously, people didn't have those doses. And there are multiple blast exposures and other blunt blows to the head. This kind of thing is new to us."
When we think about treating PTSD, we usually picture a single patient and a psychotherapist. The two treatments in widest use are, in fact, just that: cognitive processing therapy, where patients learn to think about their experiences in a different way, and prolonged exposure, in which the therapist guides the patient through re-experiencing his trauma again and again, to teach the brain to process it differently.
These therapies help a lot of veterans — about 40 percent of those who go through treatment are cured. But there are many, many more suffering veterans who are not helped. It's not just that these treatments don't work for everyone — no therapy does. More important, they are not broad enough. PTSD is often accompanied by and entwined with other serious problems — depression, sleep disorders, chronic pain and substance abuse. Sometimes these resolve if the PTSD does, but often they require specific attention — which the standard PTSD therapies don't provide.
There is another way these treatments need broadening — they need to reach more people. The military and Veterans Affairs hospitals do not have enough psychotherapists to offer them on the necessary scale. And many soldiers are wary of psychotherapy and afraid of the stigma it carries.
Today, the military is fighting that stigma. The V.A. is trying to integrate mental health care into primary health care; soldiers are now routinely screened for issues like PTSD, depression or substance abuse. A public awareness campaign called AboutFace features dozens of vets talking about their PTSD and how they got better — the point is: they are people just like you. A new program calledComprehensive Soldier and Family Fitness builds in resilience training for all soldiers at every phase — pre-deployment, in theater, upon return. It seeks to make regular mental health exercises as routine for soldiers as physical training.
According to a recent report by the National Academy of Sciences' Institute of Medicine, since 2005, the Pentagon and the V.A. have greatly increased funding for PTSD research. The V.A. has added 7,500 full-time mental health staff members and trained 6,600 clinicians to do cognitive processing and prolonged exposure therapies. Starting in 2008, all large V.A. clinics were required to have mental health providers onsite. The V.A. also added more centers that offer free, confidential counseling. Mobile centers bring counselors (themselves combat vets) to rural areas where other counseling is scarce.
All this effort however, is falling short. Only about 10 percent of those getting mental health care in the V.A. system are veterans of Iraq or Afghanistan — a vast majority of those treated are still Vietnam veterans. But some 2.4 million soldiers have been through Iraq and Afghanistan. The RAND Corporation's Center for Military Health Policy Research did a telephone survey of vets from these conflicts and found that one-third were currently affected by PTSD or depression or report exposure to a traumatic brain injury — and about 5 percent had all three. RAND also found that only half of those who reported symptoms of major depression or PTSD had sought any treatment in the past year.
Individual therapy is not the only way to treat PTSD. In January, a young man with the nickname of Trin (he asked that his real name not be published) sat down in a small, drab, room at a Veterans Affairs clinic in New Orleans with nine other men. All were veterans — of Iraq, Afghanistan, Operation Desert Storm or Vietnam; Trin had served in Iraq. All had PTSD. The men took chairs facing each other around tables pushed into a square, along with two women, who were running the group.
The facilitators asked everyone to do three drawings: of how they felt, where they were and where they wanted to be. Trin drew himself with no facial features. The next week, the facilitators put on some music and everyone stood up, faced a wall, and bounced to it. At other sessions they took large sheets of paper and colored in their family trees, with different colors for divorces, early deaths, conflicted relationships. And at almost every meeting over 10 weeks, they practiced conscious breathing and mindfulness.
"When they asked us to draw and color, people were rolling their eyes," Trin said. "We had older gentlemen, and some people might have thought this is kind of soft — not my lane."
Trin was anxious, cold and short-tempered. He was drinking a lot. Before starting this group, Trin had tried individual therapy, with no success. "My psychiatrist would ask a question and I would answer it," he said. "It was like talking to a wall. He didn't understand what I had gone through." He gave Trin a prescription for an anti-anxiety drug, which helped a little.
When Trin heard about the group, he quickly volunteered. By session five — the midpoint — he was sure it was helping. His sleep improved. The breathing exercises were things he could use to calm down. And having the group itself helped — men who had been through what he had gone through. On the last day, the group passed around stones — one for each participant. When your stone was passed around, each group member had to say something nice about you. "We put all that energy and kindness into each stone," said Trin. He carries his in his pocket.
Trin's program is a 10-week course designed by the Washington-based Center for Mind-Body Medicine. It is one of perhaps half a dozen different kinds of alternative therapies being tried for PTSD in military and V.A. hospitals.
You name it, and it's being used somewhere in the veterans' health system: The National Intrepid Center in Washington is one of many places using acupuncture to treat stress-related anxiety and sleep disorders; it has been shown to be effective against PTSD. At the New Orleans V.A., the same clinicians who ran Trin's group also did a small study using yoga. They found vets liked it and attendance was excellent. The yoga reduced the veterans' hyperarousal and helped them sleep. There is even a group in the Puget Sound V.A. Hospital in Seattle that treats PTSD — including among Navy Seals — using the Buddhist practice of "loving kindness meditation." ("We had a little bit of debate about changing the name," said Dr. David Kearney, who led the group. "But we decided to keep it, and it worked out just fine.")
One of the most promising techniques is mindfulness, inspired by Buddhist teaching, which emphasizes awareness of the present moment in order to choose how to respond to thoughts, feelings and events. Dr. Amishi Jha at the University of Miami is working with the military to develop mindfulness-based training for soldiers before they deploy, and Dr. Kearney has done a very small study of the effect of mindfulness on PTSD.
The Center for Mind-Body Medicine's program — the one Trin did — is the most comprehensive of all of them, giving participants a variety of different strategies to choose from: breathing, meditation, guided visual imagery, bio-feedback, self-awareness, dance, self-expression, drawing. And it is the one with the strongest evidence that it works to cure PTSD. In a trial in a Kosovo high school, students with PTSD who did the 10-week program had significantly greater reductions in PTSD than a control group of students assigned to wait for the course. Other before-and-after studies (with no control group) in Gaza have found an 80 to 90 percent reduction in PTSD with the technique, and those results still held months later. This is significantly better than any currently used individual therapy.
The Mind-Body program is in use at various V.A. hospitals, military bases, and at the National Intrepid Center. In some places it is studied, as well. At the Minneapolis V.A. Health Care System, for example, the psychologists Beret Skroch and Margaret Gavian found that in a Mind-Body group of patients with numerous problems, about 80 percent showed improvement.
Trin's group in New Orleans is part of the first randomized controlled trial measuring the program's effect on PTSD among U.S. veterans. Researchers are still measuring whether the results lasted two months after the last session, but Dr. James S. Gordon, the founder and director of The Center for Mind-Body Medicine, said that the patients' improvement at the last session was "at least as good" as the individual therapies the V.A. uses, with significantly lower dropout rates.
If those results hold up, then mind-body medicine is a potentially valuable addition to the V.A.'s limited menu of widely used therapies. It is built for large scale: psychotherapists are welcome but not necessary. Some of the groups are run by lay people; in Kosovo, high school teachers ran the groups. In Gaza, Center staff have trained 420 group leaders and worked with 50,000 people. Gordon said the center is currently capable of giving 10-day training and support for 1500 group leaders a year.
Another advantage is that the program is broad-spectrum, showing success not only with PTSD, but depression, pain, sleep disorders and substance abuse. Dr. Barbara Marin, chief of addiction treatment services at Walter Reed National Military Medical Center, uses it there for patients with substance abuse problems. She calls it a "very effective" model.
Mind-body medicine and the other alternative therapies, moreover, may be more attractive to soldiers than the individual treatments, which have a 20 percent dropout rate. Both C.P.T. and prolonged exposure ask the patient to relive his trauma — an upsetting prospect for many soldiers. Some veterans avoid psychotherapy because they do not want to be singled out, judged and labeled deficient.
The alternative medicine groups, by contrast, have a dropout rate of virtually zero. Members can talk about their past trauma if they wish, but there is no pressure to do so. Instead, the groups are centered on the present, helping members to learn practical skills they can employ immediately. The facilitator does not sit in judgment — she's a participant in the group, sharing skills she might use herself for better sleep or stress reduction. Everyone, after all, can use help dealing with the stress of re-entry to civilian life. Going to a skills group instead of psychotherapy could remove much of the stigma of treatment.
Despite the vast increase in research money, studies of these skills groups have been small and isolated. Only randomized controlled trials are persuasive enough to get Washington to adopt a therapy on a wider scale, but these are too few and too slow, and starting new ones now would take years. It is time to take the most promising ideas and try them with thousands of people, not just a few dozen — and if they work, to expand them further. That is not cautious. But to continue with therapy as usual is to condemn hundreds of thousands of soldiers to a tour of duty without end.
On iTunes alone, there are more than 1,500 fitness software applications or "apps" from which to choose. In 2011, nearly 10 percent of cell phone users downloaded at least one of them to help track or manage their health, according to a 2011 Pew Research Center Internet survey.
In an effort to find out if any of these smart phone and tablet apps are actually effective, researchers at Brigham Young University in Utah analyzed 127 popular downloads and rated them for their ability to get users to change aspects of their lifestyles. Most apps fell short of this goal because, the researchers found, they weren't based on the sound scientific theories proven to spur real behavioral change.
Lead author Sarah VanWagenen said the most common sin committed by a fitness app is lack of customization. "The majority don't ask for age, height, weight or any kind of basic health information," she said. "You just sign up and they give you a program and some advice based on general recommendations."
Each app was scored based on features that promoted motivation, social networking, accountability and behavior tracking. According to VanWagenen, these are the tried and true features of any high quality behavior change program. The highest scoring app the team looked at was the hypnotherapy aid Sport and Fitness Excellence. It received a 28 out of a possible 100 points. The average score was 10 and more than a third of the apps received scores in the single digits.
Clearly there is room for improvement, VanWagenen said.
Part of the problem may be a disconnect between app developers and the social scientists who study behavior change. At this point, most developers are gamers or social media developers. Very few have backgrounds in public health or psychology.
Not that developers are against learning some lessons from traditional behavioral change models designed in labs. It's just that the world of app development moves so quickly. According to Brian Wang, the co-founder of the firm that markets the social networking app Fitocracy, there aren't the time or resources to review the literature or consult research experts.
"Based on my past ten years of experience, the common thread to success is a sense of community and strong social bonds. Without fail it works. We didn't need a controlled study to tell us that," he said.
Wang claimed that nearly 20 percent of Fitocracy members are active users and that about five percent are "super users" whose log-on time adds up to several hours per day. "Users are treating us like Facebook. It's where they come to stay in contact with likeminded people and all that support really makes a difference to them," he said.
VanWagenen doesn't necessarily disagree with that assessment, but said that social engagement is only one tool for successful behavior modification. For example, an app like Fitocracy may be appealing for someone who has already made the decision to make changes, but it may not be a draw for those who are still undecided about starting a program. On the other hand, a popular app like the diet diary MyFitnessPal may attract people who like the focus on counting calories but may ultimately lose a lot of users due to lack of social support.
VanWagenen does say that apps have been getting better as time goes on. Though the Brigham Young study was just published, the apps her team reviewed were offered by the iTunes app store in 2009. It takes time to do a study and get it published. Many of today's most popular apps weren't yet available.
And, VanWagenen said, many developers are stumbling into some good use of theory whether they know it or not. For instance, sites like Fitocracy plan to up their game in the near future by placing a lot more value on user feedback. Their long term plans include "crowd sourcing," techno-speak for pooling and analyzing aggregated data so they can spot trends and report them back to their users. They could mine the data from say, Fitocracy members who lose the most weight over a six-month period, and then use that information to lay out a diet and exercise blueprint for new users with the same goal.
The next day she underwent a CT scan, which led to a startling diagnosis: A surgical sponge was lodged in her abdomen, left behind, it turned out, by a surgeon who had performed her hysterectomy four years earlier.
Ms. Savage's doctor ordered immediate surgery to remove the sponge.
"What they found was horrific," Ms. Savage said. "It had adhered to the bladder and the stomach area, and to the walls of my abdominal cavity."
The festering sponge had spread an infection, requiring the removal of a large segment of Ms. Savage's intestine. She sued the hospital where the hysterectomy had taken place, and in 2009 she won $2.5 million in damages. But the award has been appealed, and her life has been in tatters. Suffering from severe bowel issues and unable to work, Ms. Savage, 59, has been racked by anxiety and depression. Most days, she said, she cannot bring herself to leave home.
"I never dreamed something like this would happen to me," she said.
Every year, an estimated 4,000 cases of "retained surgical items," as they are known in the medical world, are reported in the United States. These are items left in the patient's body after surgery, and the vast majority are gauzelike sponges used to soak up blood. During a long operation, doctors may stuff dozens of them inside a patient to control bleeding.
Though no two cases are the same, the core of the problem, experts say, is that surgical teams rely on an old-fashioned method to avoid leaving sponges in patients. In most operating rooms, a nurse keeps a manual count of the sponges a surgeon uses in a procedure. But in that busy and sometimes chaotic environment, miscounts occur, and every so often a sponge ends up on the wrong side of the stitches.
In recent years, new technology and sponge-counting methods have made it easier to remedy the problem. But many hospitals have resisted, despite the fact that groups like the Association of Operating Room Nurses and theAmerican College of Surgeons have called on hospitals to update their practices.
As a result, patients are left at risk, said Dr. Verna C. Gibbs, a professor of surgery at the University of California, San Francisco.
"In most instances, the patient is completely helpless," said Dr. Gibbs, who is also the director of NoThing Left Behind, a national surgical patient safety project. "We've anesthetized them, we take away their ability to think, to breathe, and we cut them open and operate on them. There's no patient advocate standing over them saying, 'Don't forget that sponge in them.' I consider it a great affront that we still manage to leave our tools inside of people."
All sorts of tools are mistakenly left in patients: clamps, scalpels, even scissors on occasion. But sponges account for about two-thirds of all retained items.
When balled up, soaked in blood and tucked inside a patient, a 4-by-4-inch cotton sponge is easy to miss, especially inside large cavities. Abdominal operations are most frequently associated with retained sponges, and surgeons are more likely to leave items in overweight patients.
Hospitals traditionally require that members of a surgical team, usually a nurse, count — and then recount, multiple times — every sponge used in a procedure. But studies show that in four out of five cases in which sponges are left behind, the operating room team has declared all sponges accounted for.
Now hospitals have a more technological approach at their disposal. They can track sponges through the use of radio-frequency tags. In a studypublished in the October issue of The Journal of the American College of Surgeons, researchers at the University of North Carolina at Chapel Hill looked at 2,285 cases in which sponges were tracked using a system called RF Assure Detection. Every sponge contained a tiny radio-frequency tag, about the size of a grain of rice. At the end of an operation, a detector alerts the surgical team if any sponges remain inside the patient. In the U.N.C. study, the system helped recover 23 forgotten sponges from almost 3,000 patients over 11 months.
Created by a thoracic surgeon at Weill Cornell Medical Center in New York, the RF Assure system adds about $10 to the cost of a procedure, roughly the cost of a single suture used in surgery.
"It's a small price to pay to enhance patient safety," said Dr. Leo R. Brancazio, the medical director of labor and delivery at Duke University Hospital in North Carolina, which adopted the RF Assure system about 18 months ago, after a sponge was left inside a patient during a Caesarean delivery. "It's one extra step that takes 12 seconds at the end of a procedure."
Another tracking system relies on bar code technology. Every sponge receives a bar code, which is scanned before use and scanned again as it is retrieved.
Electronic tracking can be a safety net when manual counting fails. Yet nationwide, fewer than 1 percent of hospitals employ it, said Dr. Berto Lopez, an obstetrician-gynecologist and the chief of the safety committee at West Palm Hospital in West Palm Beach, Fla.
Dr. Lopez became an advocate for electronic tracking after he was sued in 2009 for leaving a sponge inside a patient — an error that occurred, he said, after two nurses assured him that all sponges had been accounted for. He now refuses to operate in any hospital that does not use electronic tracking.
"When something bad happens to you, you get religion," he said. "I've been rampaging ever since this happened. You study the subject, and you realize that this happens to a lot of people."
Dr. Lopez, who said he had no financial interest in tracking systems, said that even though radio-frequency tracking is relatively cheap, many hospitals do not want the added expense.
"In my heart, I think it comes down to hospitals not wanting to spend the 10 bucks," he said.
But Dr. Gibbs, of NoThing Left Behind, said technology should be only an adjunct to manual counting. Some hospitals now use inexpensive "counter bags" that resemble the shoe storage bags that hang from closet doors. Each sponge has its own compartment. If a compartment is empty at the end of an operation, a nurse can see that a sponge is missing. Then, Dr. Gibbs said, an electronic tracking system can help find the missing sponge.
At the same time, she added, sponge counts should not be the sole responsibility of nurses: Everyone in an operating room must share accountability. Surgeons can tell nurses where sponges are being placed, for example, and conduct thorough wound exams to look for sponges before stitching up a patient.
"Technology is but an aid," Dr. Gibbs said. "The way that safety problems are corrected and fixed is by changing the culture of the O.R."
In my book, Unaccountable, I detail the transparency revolution in medicine, give consumers tools to navigate the system, and warn of the perverse incentives that flawed measuring systems produce.
Little did I know that the book and my recent article for The Wall Street Journal would ignite a national conversation about how to fix healthcare and make it safer.
The most gratifying aspect for me has been the outpouring of emails from doctors and nurses who feel a growing divide between their front-line wisdom and a new corporate hospital climate. Transparency is their manifesto.
The many patients who have sent me their personal stories remind me that the problem has a tremendous emotional as well as financial cost.
For example, in response to my recent article for The Journal, Cynthia McLendonshared this story:
As a surgeon at a large referral hospital, Dr. Jones' comments echo true to my world.
I, too, take care of sicker, more high-risk patients, which is why we need to use doctor-endorsed ways of measuring quality. Flawed rating systems that do not take this difference into account run the risk of steering patients the wrong way and punishing doctors like Dr. Jones for doing admirable work.
Doctors' groups measuring quality, like the American College of Surgeons, have developed mathematical ways to appropriately adjust for differences in patient risk seen at one hospital versus another.
In addition, patient satisfaction survey questions asking: "Was your plan of care explained to your satisfaction?" also measure universal best practices. While there is no single best way to measure healthcare, there are many databases managed by doctors associations that measure hospital outcomes. The question we must now ask as a society is: Do patients have a right to know about the quality of their hospitals?
Transparency has the potential to change the focus of a marketplace. Currently, we have competition in healthcare, but the competition is at the wrong level. With increased transparency of performance and the realities of patient experience, hospitals will respond by allocating resources into quality and an improved experience.
As a medical student, I never heard of the problem of medical error or overtreatment discussed, let alone quantified. Later, the Institute of Medicine reported the estimate that those problems result in up to 98,000 deaths each year. Proud of my profession, I, along with my peers, disputed the figure.
But study after study by respected institutions have shown that the highly-cited 98,000 deaths figure vastly understated the problem.
More recent, more valid studies put the figure far higher.
The latest Institute of Medicine report cites a leading study that quantifies the problem at nearly double the prior estimate (180,00 deaths) among Medicare beneficiaries alone, which would rank preventable harm as the number 3 cause of death in the U.S. after cardiovascular disease and cancer.
We as a nation spend a lot of money on heart disease and cancer, but with preventable deaths, we are still debating if we even have a problem?
The problem of over-treatment and under-treatment also gets bigger the more we study it.
Physician specialists have been reporting in their own peer-reviewed literature and in our top journals that individual services (stents, PAP smears, follow-up radiology tests, certain prescribed medications, etc.) are not indicated up to 40% of the time.
We need to step back and take a global look at these studies in aggregate and put them in the context of what front-line doctors are telling us about the vitals signs of our healthcare system.
If we are going to finally get serious about addressing the large burden of waste in healthcare so that American businesses can thrive and healthcare can accommodate our projected aging population, the first step is to be open and honest about the task.
Sarah Morse recently sought out a new physician after moving to Annapolis, Md., to take a job as a college admissions official. She opted for a large medical practice that offers extended walk-in hours, email access and an online portal where she can make appointments, request prescription refills and get test results.
Ms. Morse's previous doctor, a traditional solo practitioner in Baltimore, had no such amenities.
"In this day and age, people need to provide those kinds of services," says Ms. Morse, 57 years old. She recently made use of the extended hours after coming down with a sudden case of poison ivy that needed treatment first thing in the morning.
Things are changing at the doctor's office, giving people who need to find a new family doctor more options to choose from—and some things to watch out for.
A growing number of primary-care physicians, who traditionally provided basic checkups and treatment for everyday medical problems, are aiming to take on a more ambitious role overseeing all aspects of their patients' health. Many are giving up self-employment and are going to work for big hospital systems, which might push up certain costs for patients. Other doctors are opting out of insurance-payment systems and asking patients to pay them directly, sometimes through monthly fees. And primary-care practices can increasingly be found in some nontraditional settings, including clinics in the workplace set up by employers.
Choosing a new doctor can be confusing, and many people rely on recommendations from friends or co-workers. Among other reasons, people may seek out new physicians if they move to a new city, or if their doctors relocate or stop accepting their insurance. Experts say it is increasingly important for patients to lock in a primary-care doctor soon because of expected increased demand for physicians starting in 2014, when the new federal health-overhaul law will add millions of people to the health-insurance rolls.
Primary-care practices that coordinate automatically with specialists, track patients to ensure they get the right tests and generally oversee patients' broad health needs are commonly known as medical homes. Nonphysicians are taking on a greater role in this team-based approach, so patients should make sure they feel comfortable with a practice's nurses and physician assistants. The number of medical-home practices is growing, according to the nonprofit National Committee for Quality Assurance, the biggest certifier of medical homes. The group recognized about 4,770 medical homes nationwide as of August, up from about 1,500 at the end of 2010.
Ted Davidson, who lives in Washington, D.C., recently found a primary-care practice on the recommendation of a physician acquaintance. The 25-year-old likes how his new doctor has his medical information on a digital tablet during visits. After Mr. Davidson was recently referred to a cardiologist because of some incidents of dizziness, his primary-care doctor at his next visit had the specialist's notes and test results available electronically. "Having someone there to guide me through the whole process was so much more reassuring than doing it all myself," says Mr. Davidson, who works at a business-valuation firm.
Some doctors say they can't offer patients the best care under the current insurance-payment structure. This typically provides fees for visits but not always other services, such as drawing up a care plan for a person recently discharged from a hospital. As a result, some doctors are refusing to accept insurance, and are requiring patients to pay them directly. For instance, at Qliance Medical Management Inc., which doesn't take part in traditional insurer networks, patients typically pay between $49 and $89 a month for care at the health provider's five clinics in Washington state, says Erika Bliss, Qliance's chief executive.
David Usher, a doctor in Menomonie, Wis., recently left the Mayo Clinic to start his own solo direct-pay practice. He now offers his patients longer visits, typically 30 minutes or more, for a charge of $55, he says. The prices of other services are posted in his waiting room and online. "Patients like the extra time, as do I," he says.
Some practices cater exclusively to the well-heeled. So-called concierge physicians may offer house calls, constant cellphone access and personalized assistance navigating the health-care bureaucracy. Patients may pay a yearly fee of $1,500 to $5,000, and even as much as $20,000 or more, for these extras, in addition to the fees their insurers pay the doctors for treatment, says Tom Blue, executive director of the American Academy of Private Physicians, which represents direct-pay and concierge doctors. His group estimates there are 4,400 direct-pay and concierge practices, up about 25% from last year.
Hospitals increasingly are hiring primary-care doctors and buying up practices. For patients, this can bring benefits, since hospitals often are better able to invest in technology such as electronic medical records. The hospital systems also may foster greater integration between primary care, specialists and hospitals own operations. But physicians employed by hospitals may be more likely to refer patients to hospital imaging departments and labs, where services are often more expensive than at independent facilities.
A growing number of employers are launching workplace clinics, aiming to reduce health-care costs, improve their workers' health and offer convenient care that may reduce time away from work.
Oerlikon Fairfield, a Lafayette, Ind., maker of gears, hired a medical-management company called WeCare TLC LLC to set up a clinic at its factory in 2010. It includes three exam rooms and a small pharmacy, and has a doctor and a nurse practitioner on duty full-time. The manufacturer, which has about 1,225 employees, says patient visits at the clinic cost about half the amount Oerlikon Fairfield pays when its workers go to doctors at local practices and hospital systems that have contracts with its insurance carrier, says Jane Wolfe, the company's employee benefits manager. The clinic also promotes preventive-care efforts such as a weight-loss program.
Some workers initially had privacy concerns about seeing a doctor at work, Ms. Wolfe says. Now, the clinic is usually booked up and recently added more hours and a physical therapist, she says.
Traditional word-of-mouth is often still the most powerful source. "As important as anything is personal recommendation," says Glen Stream, president of the American Academy of Family Physicians. Some doctors admit that a reference from a colleague or a patient they like may get you into a practice that's normally closed to new people.
Of course, many websites include patient feedback, or rely on surveys of local doctors. Patient advocates say that while they can be useful, they should be taken with a grain of salt. "They're basically popularity contests," says Caron Cronin, executive director of the Informed Patient Institute, a nonprofit. Her group's site, informedpatientinstitute.org, lists and rates doctor-quality sites, and it includes links to the growing number of groups that try to pull together data measuring doctors' quality of care.
To get some sense of patient feedback, you can try checkbook.org, a site hosted by the nonprofit Consumers' Checkbook, which surveys patients to rate doctors in certain localities. Health plans also increasingly offer their take on doctors' quality and efficiency.
Mark Smith, president of physician recruiting firm Merritt Hawkins, suggests looking for the "big uglies," such as safety or legal problems. You can start with a Google search, of course, but also worthwhile is a check of state medical boards and related resources through docboard.org and patientsrighttoknow.org.