Thursday, January 30, 2014

In cities, the average doctor wait-time is 18.5 days

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Need to see a doctor? You may have to wait.

survey of physician practices in 15 metropolitan areas across the country, which was taken before the health law expanded coverage, found that the average wait time for a new patient to see a physician in five medical specialties was 18.5 days.  The longest waits were in Boston, where patients wait an average of 72 days to see a dermatologist and 66 days to see a family doctor. The shortest were in Dallas, where the average wait time is 10.2 days for all specialties, and just five  days to see a family doctor.

"We have too few providers, which is creating a significant access problem," says Travis Singleton, senior vice president of Merritt Hawkins in Texas, which conducted the survey. The health care and physician search consulting firm spoke with 1,399 medical offices between June and November 2013 in five different areas of specialization: cardiology, dermatology, obstetrics/gynecology, orthopedic surgery and family practice. Researchers called the practices and asked for the first available appointments for new patients needing routine care, such as a heart check-up or a well-woman visit.

The good news is that wait times actually decreased slightly, down from an average of 20.4 days when the survey was last conducted in 2009, and down from 20.9 days in 2004. Singleton attributes the slight improvement to practices employing more mid-level providers like nurse practitioners, better health-care IT to help with scheduling and an increase in the number of urgent care centers.

Even Boston, which has eye-popping wait times, has gotten better. The city's average wait time dropped from 50 days in 2009 to 45 days in 2013. That's brings it closer to its level of 39 days in 2004 before Massachusetts adopted its version of health care reform.

The bad news is that fewer doctors are accepting Medicaid: An average of 45.7 percent of physicians surveyed take Medicaid coverage, down from 55.4 percent in 2009. Acceptance rates varied widely, however, ranging from 73 percent in Boston to 23 percent in Dallas. An average of 76 percent of physicians surveyed accept Medicare.

The rates of Medicaid acceptance are likely to prove problematic as more and more Americans sign up for Medicaid under the Affordable Care Act. "At the end of the day, it doesn't matter how many physicians you have," says Singleton. "If no one will take your insurance, you're going to end up in the same place, and that's probably the ER."  And with more patients covered both by Medicaid and private insurance, he says, wait times are likely to get worse.

But Ken Hertz of the MGMA Health Care Consulting Group, which consults with physician practices, says wait times don't always increase in proportion to patient volume. As plan deductibles and co-pays have gone up in recent years, patient volume in outpatient settings have actually declined, he says.

And long wait times can be attributed to many things other than patient volume, he adds, including operators not understanding the scheduling system. "Most practices are working diligently to see patients and see them in a timely manner, but there are a lot of moving parts," he says.

"The successful practices will figure out new ways and approaches to shortening wait times. This isn't going to be acceptable" in the long term, says Hertz.

This article was produced by Kaiser Health News with support from The SCAN Foundation. Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Sunday, January 26, 2014

How Long Have I Got Left? - NYTimes.com

As soon as the CT scan was done, I began reviewing the images. The diagnosis was immediate: Masses matting the lungs and deforming the spine. Cancer. In my neurosurgical training, I had reviewed hundreds of scans for fellow doctors to see if surgery offered any hope. I'd scribble in the chart "Widely metastatic disease — no role for surgery," and move on. But this scan was different: It was my own.

I have sat with countless patients and families to discuss grim prognoses: It's one of the most important jobs physicians have. It's easier when the patient is 94, in the last stages of dementia and has a severe brain bleed. For young people like me — I am 36 — given a diagnosis of cancer, there aren't many words. My standard pieces include "it's a marathon, not a sprint, so get your daily rest" and "illness can drive a family apart or bring it together — be aware of each other's needs and find extra support."

I learned a few basic rules. Be honest about the prognosis but always leave some room for hope. Be vague but accurate: "days to a few weeks," "weeks to a few months," "months to a few years," "a few years to a decade or more." We never cite detailed statistics, and usually advise against Googling survival numbers, assuming the average patient doesn't possess a nuanced understanding of statistics.

People react differently to hearing "Procedure X has a 70 percent chance of survival" and "Procedure Y has a 30 percent chance of death." Phrased that way, people flock to Procedure X, even though the numbers are the same. When a close friend developed pancreatic cancer, I became the medical maven to a group of people who were sophisticated statisticians. I still dissuaded them from looking up the statistics, saying five-year survival curves are at least five years out of date. Somehow I felt that the numbers alone were too dry, or that a physician's daily experience with illness was needed for context. Mostly, I felt that impulse: Keep a measure of hope.

These survival curves, called Kaplan-Meier curves, are one way we measure progress in cancer treatment, plotting the number of patients surviving over time. For some diseases, the line looks like an airplane gently beginning its descent; for others, like a dive bomber. Physicians think a lot about these curves, their shape, and what they mean. In brain-cancer research, for example, while the numbers for average survival time haven't changed much, there's an increasingly long tail on the curve, indicating a few patients are living for years. The problem is that you can't tell an individual patient where she is on the curve. It's impossible, irresponsible even, to be more precise than you can be accurate.

One would think, then, that when my oncologist sat by my bedside to meet me, I would not immediately demand information on survival statistics. But now that I had traversed the line from doctor to patient, I had the same yearning for the numbers all patients ask for. I hoped she would see me as someone who both understood statistics and the medical reality of illness, that she would give me certainty, the straight dope. I could take it. She flatly refused: "No. Absolutely not." She knew very well I could — and did — look up all the research on the topic. But lung cancer wasn't my specialty, and she was a world expert. At each appointment, a wrestling match began, and she always avoided being pinned down to any sort of number.

Now, instead of wondering why some patients persist in asking statistics questions, I began to wonder why physicians obfuscate when they have so much knowledge and experience. Initially when I saw my CT scan, I figured I had only a few months to live. The scan looked bad. I looked bad. I'd lost 30 pounds, developed excruciating back pain and felt more fatigued every day. My tests revealed severely low protein levels and low blood counts consistent with the body overwhelmed, failing in its basic drive to sustain itself.

For a few months, I'd suspected I had cancer. I had seen a lot of young patients with cancer. So I wasn't taken aback. In fact, there was a certain relief. The next steps were clear: Prepare to die. Cry. Tell my wife that she should remarry, and refinance the mortgage. Write overdue letters to dear friends. Yes, there were lots of things I had meant to do in life, but sometimes this happens: Nothing could be more obvious when your day's work includes treating head trauma and brain cancer.

But on my first visit with my oncologist, she mentioned my going back to work someday. Wasn't I a ghost? No. But then how long did I have? Silence.

Of course, she could not stop my intense reading. Poring over studies, I kept trying to find the one that would tell me when my number would be up. The large general studies said that between 70 and 80 percent of lung cancer patients would die within two years. They did not allow for much hope. But then again, most of those patients were older and heavy smokers. Where was the study of nonsmoking 36-year-old neurosurgeons? Maybe my youth and health mattered? Or maybe my disease was found so late, had spread so far, and I was already so far gone that I was worse off than those 65-year-old smokers.

Many friends and family members provided anecdotes along the lines of my-friend's-friend's-mom's-friend or my-uncle's-barber's-son's-tennis-partner has this same kind of lung cancer and has been living for 10 years. Initially I wondered if all the stories referred to the same person, connected through the proverbial six degrees. I disregarded them as wishful thinking, baseless delusion. Eventually, though, enough of those stories seeped in through the cracks of my studied realism.

And then my health began to improve, thanks to a pill that targets a specific genetic mutation tied to my cancer. I began to walk without a cane and to say things like, "Well, it's pretty unlikely that I'll be lucky enough to live for a decade, but it's possible." A tiny drop of hope.

In a way, though, the certainty of death was easier than this uncertain life. Didn't those in purgatory prefer to go to hell, and just be done with it? Was I supposed to be making funeral arrangements? Devoting myself to my wife, my parents, my brothers, my friends, my adorable niece? Writing the book I had always wanted to write? Or was I supposed to go back to negotiating my multiyear job offers?

The path forward would seem obvious, if only I knew how many months or years I had left. Tell me three months, I'd just spend time with family. Tell me one year, I'd have a plan (write that book). Give me 10 years, I'd get back to treating diseases. The pedestrian truth that you live one day at a time didn't help: What was I supposed to do with that day? My oncologist would say only: "I can't tell you a time. You've got to find what matters most to you."

I began to realize that coming face to face with my own mortality, in a sense, had changed both nothing and everything. Before my cancer was diagnosed, I knew that someday I would die, but I didn't know when. After the diagnosis, I knew that someday I would die, but I didn't know when. But now I knew it acutely. The problem wasn't really a scientific one. The fact of death is unsettling. Yet there is no other way to live.

The reason doctors don't give patients specific prognoses is not merely because they cannot. Certainly, if a patient's expectations are way out of the bounds of probability — someone expecting to live to 130, or someone thinking his benign skin spots are signs of impending death — doctors are entrusted to bring that person's expectations into the realm of reasonable possibility.

But the range of what is reasonably possible is just so wide. Based on today's therapies, I might die within two years, or I might make it to 10. If you add in the uncertainty based on new therapies available in two or three years, that range may be completely different. Faced with mortality, scientific knowledge can provide only an ounce of certainty: Yes, you will die. But one wants a full pound of certainty, and that is not on offer.

What patients seek is not scientific knowledge doctors hide, but existential authenticity each must find on her own. Getting too deep into statistics is like trying to quench a thirst with salty water. The angst of facing mortality has no remedy in probability.

I remember the moment when my overwhelming uneasiness yielded. Seven words from Samuel Beckett, a writer I've not even read that well, learned long ago as an undergraduate, began to repeat in my head, and the seemingly impassable sea of uncertainty parted: "I can't go on. I'll go on." I took a step forward, repeating the phrase over and over: "I can't go on. I'll go on." And then, at some point, I was through.

I am now almost exactly eight months from my diagnosis. My strength has recovered substantially. In treatment, the cancer is retreating. I have gradually returned to work. I'm knocking the dust off scientific manuscripts. I'm writing more, seeing more, feeling more. Every morning at 5:30, as the alarm clock goes off, and my dead body awakes, my wife asleep next to me, I think again to myself: "I can't go on." And a minute later, I am in my scrubs, heading to the operating room, alive: "I'll go on."



http://www.nytimes.com/2014/01/25/opinion/sunday/how-long-have-i-got-left.html?