Health systems

Caution: I am liable to rant because I am just fed up with healthcare lately. UGH.

So today the US government shut down because one party is grumpy that the Affordable Care Act is going to happen and be implemented. Today is the day to start shopping for healthcare plans if you are in healthcare limbo and to sign up if you are eligible for subsidies to help pay for healthcare! I hear the website is a wee bit slow, probably because a whole lot of people are excited at the prospect of healthcare. I sure am. Here's the website where you can check out your options and find your state's insurance exchange (if it has one).

It confuses me to no end why 20 years after the Republicans proposed exactly this healthcare reform it suddenly makes them super mad and in a mood to object to every little thing it might change even though most people support the changes it will make. The bulk of the changes are nice things like affordable insurance for a great many people, children can stay on their parents' insurance plans a long time, and pre-existing conditions as a reason to deny health insurance are gone. That doesn't mention all the preventative healthcare services that are free and designed to reduce costs in the long term like free annual wellness exams, free shots to prevent diseases, and free contraceptives to prevent pregnancies or acne.

But health systems. ACA also includes some money for healthcare providers to get themselves together IT-wise and it would be amazing if it included money for meaningful use by pharmacists and pharmacies, but no. In case you were curious, doctor's offices pay nothing to send electronic prescriptions but pharmacies pay to be in the network to receive them. It obviously takes a computer system to do that receiving. I've been to a pharmacy that uses a DOS-based system, now, and it receives electronic prescriptions, which is awesome on the one hand (legacy system for the win!) and depressing on the other (I used that system on our home computer back a zillion years ago before I started kindergarten!). It's a shame there's no money from the government for pharmacies to upgrade their IT systems.

ACA also encourages the formation of new things called accountable care oganizations (ACOs) and a switch from a fee-for-service model to a patient wellness payment model. That amounts to encouraging groups of providers to work together to get and keep patients well rather than for each one to bill the patient for every little test they can manage to make the most money. Pharmacists turn out to be a really key part of making ACOs work (at least that's what the pioneer ACOs are finding and the data supports it, squee!) and yet we don't have status to bill as a healthcare provider. Another complaint of mine. Soon though, maybe pharmacists will count as real healthcare providers for billing purposes so we can get paid for our work getting patients to take their medications and to take the right combination to help keep them as healthy as possible.

BUT. This "providers work together" thing has gone various degrees of well for different newborn health systems. In my region there are a few big ones, markedly different ones at that. Where we used to live we had a real health system. Here we have a bunch of providers with a matching logo that actually have next to nothing to do with each other.

Let's use an example. In system A, where we used to live, patient Z needs to see a specialist for a foot problem (that's a podiatrist). Patient Z stops at the appointments desk after the visit with the primary doc who said the specialist was needed to make the appointment. The podiatrist works for the system and is only in Little Town one day a month, so Z needs to schedule to see the podiatrist in another location. This is no problem and the appointment scheduling person either looks up the full schedule of various locations using the computer or calls another location to do the scheduling right then. Obviously, because this is a health system, the appointment scheduling person has the appropriate number to call any other location within the health system to make sure the appointment gets scheduled seamlessly within minutes. The entirety of Z's electronic medical record will travel easily to the podiatrist at any location within the health system where Z might be seen and any reports/test results/notes made by the podiatrist will be easily accessible to Z's primary doctor in return.

In system B, where we live now, when Patient Z needs to see that specialist who is at the local location one day a month, if that day doesn't work, next month is an option. Z probably didn't see a primary care provider because the Big Awesome Hospital in the area recruits new hires to the outlying clinics and then promotes them to work at BAH without filling the vacancies. BAH probably set up the health system as a way to vet new hires and not as a way to make healthcare more accessible to folks in the surrounding area. Patient Z cannot find out when the podiatrist will be at any other health system locations from the scheduling assistant in Little Town because the department doesn't keep track of things like that! The scheduling assistant certainly can't get Z the number to call BAH and try to schedule a visit in the city because why would the department have that number? Health information needs a form to be shared between BAH and Little Town clinic despite them being under the same logo and presumably part of the same health system, and even when the form gets filled out, Little Town will call just to make sure it's really necessary to send all the records (which are paper and electronic in some very dangerous hybrid). It is unlikely that information will come back to any primary care provider from BAH either, not in a timely manner.

Two ways a health system is set up, one that is patient and provider friendly, one that is not. I get that joining a health system is a new thing for clinics and hospitals that operated in isolation before but refusing the transition because it's scary and new is a mistake. New things in healthcare are hard of course, but systems are the thing of the future. Even if on the business end of things the providers stay separate, sharing patient information electronically is the thing we'll be doing soon. I'm not sure how my state's health information exchange is currently going but I think it will exist sometime soon. Lives get saved by sharing information. Lives get saved when I can query the health information exchange in the ER and find out someone is allergic to penicillin before we give a dose even though they are unconscious. Lives get saved when we find out someone carries MRSA when they arrive in the ER so we can isolate them and help prevent its spread.

Health systems help patients get better care by facilitating data exchange. It tempts me pretty often to drive a couple hours to see a provider in our previous system just to avoid the headache of the dual paper/electronic chart and the wrestling match it takes to get a timely appointment to see a specialist for anything. The part that really bothers me is that it's so hard for me, someone who knows an awful lot about how healthcare works and how it should and can work. It took me hours to get in to see a specialist. How many people who are actually sick (I'm just getting continuing care, it's boring really) give up or get confused and quit bothering to try to get appointments they need? Why are we growing health systems that don't work like a system to help patients manage it all? It's important to focus on what we do when health systems grow and to make sure we fill primary care positions (and that's another issue entirely) and to make sure training is even across the system so things work like it's a system and not a bunch of discombobulated locations with a matching logo. Electronic health records really help that information sharing happen seamlessly (we hope) and it's high time to embrace them. Health systems need to grow because the payment model is shifting to ACOs, maybe not to gigantic proportions like Kaiser in California/the western US, but also pharmacists need to get in on building ACOs so patients get good care from the moment they walk in the door to the moment they head home with any new prescriptions from the pharmacy.