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Let’s face it, not everyone is an effective communicator.  Some people are more reserved and must put forth a great deal of effort to be sociable and interact with others on a daily basis.  For other people, it’s not difficult at all to put on a smile, chat with, and listen to others. And although sometimes it’s tough to listen to the problems of others, especially when we’re distracted by our own troubles, the bottom line is that as health care workers, our own needs and desires take a back seat to those of our patients.  Put yourself in their shoes:  When we’re not feeling well, or must have a procedure performed, we certainly don’t want to encounter a grumpy, rude, or disinterested medical office employee.  We want to be considered important, and we want to be able to interact  with caring medical staff members who act as though they truly are concerned with our well-being.  Therefore, as a medical assistant, it is imperative that you keep your own expectations and requirements in mind when you are dealing with patients.  Remember, you represent the physicians and the entire office staff.  The attention and impression you give will improve or detract from the quality of the patient’s encounter, as well as the overall success of the health-care facility.

As the key link between the office and the patient, you must learn to give patients the individual care that they require and deserve.  You must learn to assess a patient’s needs quickly so that you can address their problems and concerns effectively. Part of this process is being able to tailor your response to each individual.  For example, you certainly would not communicate with a sick child the same way you communicate with an 80-year-old patient.  Think about how would you deal with a patient who speaks little or no English.  Would you greet a patient coming to the office for an immunization shot differently than you would treat a patient coming in to be treated for HIV?  Throughout your Medical Office Assisting program, we’ll consider the answers to these critical questions.

In learning how to individualize your approach to helping each patient, you will also learn about Abraham Maslow’s hierarchy of needs in this program.  As well as being able to assess the needs of a patient, you must also understand how those needs can be met.  To determine this, you must decide where you perceive those needs falls in the hierarchy of needs.  Maslow believed that basic, physiological needs must be met before higher goals can be reached.  For example, if a patient is homeless, his primary concern will be that he has something to eat and a place to sleep tonight, not that his blood pressure is elevated and he may have a stroke someday.

With respect to terminally ill patients, we will focus a lot on Elisabeth Kubler-Ross’s five Stages of Dying.  You should take note of her highly insightful theories.  The chances are very good that you will at some point manage patients who are terminally ill (these five stages also apply to patients suffering from grief).  Knowing the emotional state of the patient makes empathy and communication easier.  The stages also explain why a patient might be cooperative and pleasant one day and angry and combative another day. 

Remember, it’s a privilege to work in a medical office.  I never take this privilege for granted and encourage you to demonstrate the same kind of pride when dealing with your patients.  At the end of the day, we’re here for the patients and are held to standards of excellence that should never be compromised.

John E. Long
Medical Office Assisting Program Instructor
Ashworth University School of Health Care

From Hannah Waight of Experience:

No longer is healthcare confined to doctors and nurses - now more than ever jobs are available for people with all types of interests within this highly diverse industry. Although you may not look forward to that trip to the dentist or those yearly shots from the doctor, no one can deny that healthcare is an essential aspect of all of our lives.  People who are willing and able to work in the health industry will always be in demand.  In fact, healthcare has long been one of the biggest industries in the nation, and now, because of the aging population of the United States and advances in medical technology, the need for qualified workers is only going to increase.  Your ideal job is within your grasp as long as you have the appropriate background and inside information.

As an industry, healthcare offers a diverse range of jobs for many different types of people.  You can work in the traditional health provision sector as a doctor or nurse, or in a wide variety of medical fields.  Preventative medicine and recovery is getting increasing attention from insurance companies looking to keep their costs down: dietitians, counselors, and physical therapists all play key roles in keeping people healthy. Research in academic medicine and biotechnology provides opportunities for professionals interested in discovering the next generation of treatment.  The people- and paperwork-oriented are needed to run the business and administrative side of the industry.

Copyright © 1996 - 2008 Experience, Inc. - All Rights Reserved

To read more of Hannah’s great article, login to the Ashworth University Career Center through the student portal and click here.

Ryan Rode
Interactive Services Manager
Ashworth University

          Thanks to Lorianne DiSabato for permission to use this Photo. 

It is time, I think, to face the realpolitik of health care reform. That means asking a question few reformers dare to discuss:  How will we win the Congressional votes needed to pass serious health care reform? The American Prospect’s Ezra Klein put this question on the table at the “Take Back America” conference last week.  A pragmatic progressive (in the best sense), Klein pulled no punches:  “There are so many people in this town [D.C.] who do such smart policy thinking,” he observed. But “what we don’t give enough thought to is the politics of reform. This is a political problem. Until we have the votes in the Senate, we can’t get anything done.”Without the votes, Klein told reformers, “you don’t have a plan; you have a position.”

Some assume that, if we elect a progressive president, he will “put the votes together” to achieve reform. But the fact is that even an optimistic, charismatic JFK wasn’t able to persuade Congress to unite behind healthcare for the elderly in the early 1960s—a time when seniors were the poorest group in America. It was only after Kennedy was assassinated that a wily LBJ (who had grown up in Congress and knew where all of the bodies were buried on the Hill) was able to leverage a martyred president’s last wishes to help pass Medicare in 1965. The fact that LBJ had won by a landslide sealed the deal.

This time around, nailing the votes that would secure something like “Medicare for Everyone Who Wants It” will be much tougher. As I noted in my first post in this series, “Obstacles to Health Care Reform,” the lobbyists representing the for-profit health care industry enjoy enormous power. The money at stake in the health care industry has grown exponentially since 1965. And thanks to generous campaign contributions, the industry’s lobbyists wield great influence, even among liberal politicians.                  

Who can counter that kind of power?  Citizens who vote.  Lobbyists have dollars, but a billion dollars won’t help a politician if his constituency has made it clear that it won’t re-elect him unless he passes a particular piece of legislation that voters want. Nevertheless, any hope that pressure from voters will give Congressmen the spine to stand up to the lobbyists turns on the assumption that voters share common goals. With that assumption in mind, I decided to take a hard look at where most voters stand on health care reform. Polls show that the majority of Americans say that they want universal healthcare—but drill a little deeper, and you’ll find that different groups have very different priorities.

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               Thanks to Rachel Zack for permission to use this Photo.I want you to understand how truly wonderful an experience massage can be for the terminally ill.  No matter what condition the person is in, conscious or unconscious, it’s nice to think that somehow, on some level, he or she knows that you are there and are caring for them in such a gentle, loving way.  This type of massage may not seem appealing to you.  Maybe you have a hard time dealing with death.  That’s okay.  Never do anything that makes you uncomfortable.  But if someone you love is at the end of his or her life, you may be surprised by the strength you are able to find.  It is very important that you practice self-care in this situation.  If you are able to maintain your emotional well-being, this massage can be a very powerful experience for both the receiver and the giver.  This memory will be one you will cherish after your special friend is gone.  Also keep in mind that massage can be a blessing to the grieving family members of the person who has passed.  Be prepared for emotional release.  Just be loving and understanding.  That’s all you can do. Kristy CarterMassage Techniques Program InstructorAshworth University

             Thanks to Kimberly Hurst for permission to use this Photo.

The following Wall Street Journal article should be of great interest to our medical students.  Insurance companies, never on anyone’s sympathy list, have long been complaining that they should not be responsible for paying out insurance claims related to hospital errors.  This position in itself is reasonable; however the issue also contains elements of a slippery slope argument.  Instead of simply refusing accountability for grave errors (mistaken operations, infected blood transfusions, etc.)—industry experts foresee private insurers, much like Medicaid, gradually widening the definition of “errors” to include non-coverage of patient infections alledgedly contracted during a hospital stay.  The CDC states that approximately 99,000 deaths occur annually due to hospital-based infections!  With added pressure being placed on them from the insurance industry, hospitals find themselves under fire for not improving their health safety standards.  In response, hospitals say that increased regulation will only increase health care costs for the patient and further complicate a hospital system already drowning in bureaucracy. 

The medical billing implications are also intriguing.  Due to dense and often confusing medical billing language, many patients are more often than not unaware that they are being billed for hospital errors.  Now that private insurers are beginning to adopt the Medicare model, patients may well be more informed about what exactly is on their medical bill, but hospitals will ultimately have to find new ways to offset the added costs they absorb to raise their infection prevention standards.  As this story continues to unfold, I have a feeling that the patients’ best interests will get lost in the details. 

Ryan Rode
Interactive Services Manager
Ashworth University School of Health Care       

 
                Thanks to supergiball for permission to use this Photo.

On the surface, it seems that American voters have made their will clear.  Poll after poll shows that they are calling for a major overhaul of our health care system.  But when you look closer, their responses bristle with contradictions, contradictions that I think the reform-minded presidential candidates will have to consider when deciding how to approach health care reform. 

In a poll reported in Health Affairs at the end of last year, sixty-nine percent of respondents rated the US system as “fair” or “poor.” Yet in the same survey, when asked about their own experience with receiving medical services or with their own physician, 80 percent who had received care in the last year ranked their care as “excellent” or ”good.”  Other polls reveal the same pattern.

According to a survey released by Greenberg Quinlan Rosner in July, voters express doubts about the quality of the American health care system (with 49 percent dissatisfied), while 74 percent were dissatisfied with the cost.   Yet, “at another, more personal level,” the pollsters note, “a slightly different picture emerges. Fully eight in ten (82 percent) describe themselves as satisfied with the quality of the health care they receive personally. This number jumps to 90 percent among seniors (64 percent very satisfied), but includes impressive majorities of nearly all groups…”

Nevertheless, when the pollsters asked the same group about health care reform, three-quarters called for “major changes” or “completely rebuilding” the system.  If they are satisfied with the care they are receiving, why would they want radical change? Because they don’t feel secure that they will be able to keep what they have:  “There’s a precariousness to Americans’ contentment with their own health insurance coverage,” the Kaiser Family Foundation reported after looking at a number of polls at the end of last year.  “Among the insured, six in ten are at least somewhat worried about being able to afford the cost of their health insurance over the next few years, and nearly as many (56 percent) said they worry that by losing a job, they or their family might be left without coverage.”

This, then, is why so many Americans want universal health care: it would guarantee that they and their families would always be covered. (more…)

 
           Thanks to Megan Walton for permission to use this Photo.

For the past year, progressives have begun to talk about health care reform as if it is inevitable. Listen to the Democratic Party’s presidential candidates, and it seems just a question of what form the health care revolution will take, how quickly it will happen, and how we’ll finance it. After all, the polls show that the majority of taxpayers, employers and even most doctors want to see a major change.  Moreover, health care research shows that if we cut the waste in our system, we could fund universal coverage. What, then, is stopping us? (more…)

As any policy-maker knows, catering to public opinion, ensuring the public interest, and managing costs can seem an impossible task–especially when what the public thinks it wants is at loggerheads with what it needs. But in the case of health care, there may be an opportunity to do all three at once according to a proposal in the September/October Health Affairs.

The proposal argues for cost-effectiveness analysis (CEA) “to set priorities for Medicare coverage of new or costly interventions” through a citizens’ council made up of “a cross-section of users” who can provide leadership with “well-considered social-value judgments.” This citizens’ council model is borrowed from the UK, where a group of 30 men and women advise the National Institute for Health and Clinical Excellence (NICE) on behalf of the public.

The British experience shows that there are likely to be practical complications with implementing a citizens’ council, but it’s still an idea that’s on the right track. We need to turn “cost-effectiveness” from a bad word into a public interest issue in the US.

The authors of the proposal, Dr. Marthe Gold from CUNY, Shoshanna Sofaer from Baruch College, and Taryn Siegelberg from CUNY, envision the American citizens council as being an advisor to the Medicare Evidence Development Coverage Advisory Committee. The council would advise on the criteria for CEA—in other words, how to decide whether the effectiveness of a new intervention justifies its cost, and thus warrants coverage under Medicare. Issues to be deliberated would include: How should we assess weigh factors such as a patient’s level of suffering or disadvantage, behavioral choices, and age when making a decision? How effective must a treatment be to warrant coverage? Should we give a higher priority to preventions or cures?

These are profoundly difficult questions to answer definitively, particularly for members of the general public who lack medical expertise. As the authors note, information is a major concern—the council needs to know enough to function effectively. 

Unfortunately, striking the right balance between information/education on the one hand and deliberation/ autonomy on the other has proven difficult. A 2005 study from the Open University showed that the UK citizens council has “struggled less than successfully with understanding its role…and understanding the questions set.”

The council, caught between being the voice of the people and needing to understand complex health care issues, often lacks the right mix of “knowledge base, role, authority, and the design of the social situation.” It’s not always clear where the council fits into the decision-making process, in part because the council is expected to simultaneously learn about issues and comment on them.

                   Thanks to Jim for permission to use this Photo.

Because of these difficulties, NICE pays “more attention to the process than the product [i.e. citizens’ advice] and the way in which that product would be used.” Procedure trumps output. As a result, the citizens council is sometimes relegated to “abstract core tasks”—such as issuing general declarations rather than providing substantive guidance—a pattern that incurred the wrath of patient advocates who called the council a “toothless tiger.”

Anyone who wants to understand 21st century health care faces a steep learning curve. Balancing public input with the expertise and nuance needed to provide meaningful guidance is a tricky business, and the challenge of doing so should not be underestimated.

Still, the UK citizens council has only been around since 2002, and the Open University report notes that with every installment of the council, more and more kinks are worked out. And even if public input in health priorities represents a challenge, it’s by no means a fool’s errand.

Conventional wisdom assumes—without proof, as Gold et al. note—that Americans do not want to discuss health care costs because they view cost-cutting as a synonym for quality-reduction. But the absence of CEA in the US is due more to a lack of conversation rather than to resistance.

Polling data shows that Americans are ready to talk about cost. Indeed, it’s hard to argue that cost is a non-starter when the public views it as the nation’s most important health care problem. Back in 1999, Americans thought AIDS and cancer were bigger concerns, but today it’s the cost of health care that keeps Americans up at night. The average American is just as worried about cost as is the policy wonk, making now the perfect time to institutionalize a role for the public in cost management.

Requesting public inputs while setting health priorities can begin to demolish the misconception of “more care is better care” that conflates cost-effectiveness with stinginess. By opening the insular world of cost management to public priorities, we defuse the possibility of Americans viewing CEA as a means to “cheat” them out of care.

Will it be a bumpy ride? Maybe. But if democratizing cost-effectiveness helps the US move toward smarter, more sustainable health coverage, then it’s worth the effort.

Maggie Mahar
Creator of Health Beat
Ashworth University Contributing Blogger

*Maggie Mahar is a fellow at The Century Foundation and the author of Money-Driven Medicine: The Real Reason Health Care Costs So Much (Harper/Collins 2006) and Bull! A History of the Boom, 1982–1999 (Harper/Collins, 2003), a book that Warren Buffett recommended in Berkshire Hathaway’s annual report.  We would like offer our gratitude to Maggie Mahar for granting us the opportunity to share her brilliant perspectives with the AU student community.  Visit’s Maggie’s blog, Health Beat, for some of the best healthcare analyses on the Web.

So once again I’m in the weird position of having to defend something I’m actually against. 

The latest is from John Edwards, et al. Here’s the headline: Edwards unveils plan to control drug advertising.  Read that sentence, and decide what you think the intent of the plan is.  Is he talking about controlling the colors of the ads?

Most likely, you think it’s the effect the ads have on drug prices.  “The excessive costs of prescription drugs are straining family budgets and contributing to runaway health care costs…”

Let’s temporarily grant that that this statement is true.  What is the link between advertising and prescription drug costs?  Is he saying that spending on ads increases the price of drugs?  That would be wrong, and I have to believe he knows it.

First, Pharma spends about $4b on DTC ads.  It has yearly sales of about $200b, so even if every penny spent on ads was instead used to lower the price of the drugs, no one would actually notice.  Additionally, prices of branded drugs rise about 6%/year, regardless of how much they spend on ads.

Second, we should probably define “drug prices.”  If I roll into a pharmacy with a prescription and choose to pay cash, how much will it be?  The answer, as it turns out, depends on the pharmacy.  These are retail prices, that pharmacies charge no-insurance cash payers; on average, 15% more than insurance rates. But let’s be honest here: cash payers can’t afford a lot of these medications at any price.  If you’re one of the unfortunate working poor who don’t have a prescription plan, you can’t afford the medication at full price, 20% off, even 50% off. The price is irrelevant; what matters is whether you have a prescription plan, or a doctor who can provide samples forever.

So for everyone else, “prices” really means prices to insurance companies, or Medicaid/Medicare, all who  negotiate a price that has almost nothing to do with the actual patient demand for a drug.  A  price which is considerably lower than retail.  Medicaid apparently gets a 20% discount, the VA 40%. (1) 

So DTC advertising doesn’t affect the price because the consumer isn’t paying it.  The price was set in negotiation.  Certainly the price Pharma asks from wholesalers and insurers takes into account their costs, including advertising; and more ads (hopefully) means more scripts which means higher profits. But increases in advertising don’t translate directly to higher prices, they reduce the profits.  Higher prices are the result of  negotiations between parties that are immune to the effects of advertising.  That’s the problem.  

Third: perhaps what we really mean is that DTC ads raise the overall Medicaid/Medicare expenditures because more scripts are being written that would otherwise not have been written without the DTC ads.  Well, if this is what we’re saying, we should just say this; let’s not use factually inaccurate soundbites that play to the hearts of superficial idiots. 

But if we are saying this, then the problem isn’t the prices of the drugs, it’s doctors prescribing drugs they shouldn’t be prescribing.  The solution isn’t, therefore, to reduce drug prices; in fact, that’s the opposite of what you want, because it makes it even easier for doctors to prescribe what they shouldn’t be prescribing.  The actual solution would either be to raise drug costs (bad idea), controlling doctors’ prescribing (bad idea), or giving them a medication budget they have to stay within, but preserving prescribing freedom.

It should bring us pause that even the AMA refused to recommend banning DTC ads.  If Edwards plan was specifically about protecting the patients from half-truths or seductive graphics that compel patients to request medications that they don’t need or might compromise their health, then I’m behind him 100%. I already think DTC should be banned. But like all political soundbites, this isn’t about content but about ambiance, creating a feeling that he’s all about cutting costs— that’s he’s more than Hillary. Unfortunately, empty rhetoric like this distracts us from real problems, like Iraq, Iran, wealth divergence, recession, etc.

——

1.  As a horrifying diversion into drug pricing, let’s look at Medicaid.  Medicaid, by law, will pay (to a pharmacy who dispenses the drug) a percentage of the average wholesale price, plus a dispensing fee.  Both the percentage and the dispensing fee vary from state to state, but it’s on the order of 85% of average wholesale price, and $5 dispensing fee.  On average, Medicaid pays about $61 per prescription: $14 goes to the pharmacy, $47 to Pharma.   If anyone can tell me how DTC ads affect that, I’m listening.  So pharmacies don’t make a lot on this, and it’s a far cry from the markup the pharmacy can impose on a cash payer.  And pharmacies aren’t obligated to participate in Medicaid.

In practice, wholesale price is anything Pharma says it is, including some bizarrely inflated price.  But whatever it is, I hope it is clear that it has nothing to do with ads.

And then there are the rebates. I hope you’re sitting down.

In gratitude for this excellent reimbursement, Pharma agrees to rebate Medicaid about 15% or the manufacturer’s price, plus an additional rebate every year for the amount of price increase that exceeds inflation.  In 2003, the average rebate was 31%.

There’s another rebate.  Many insurances have pharmacy business managers (PBMs) who make preferred drug lists.  How does a drug get on that list?  It isn’t by being cheap; ask Illinois Medicaid in 2005, when they wouldn’t cover Seroquel, arguably the most demanded but hardly the most expensive.  What it takes is, as they say in Big Pharma, “our willingness to play ball.”  Another “rebate.”That money stays in the managed Medicaid’s pocket. The savings aren’t passed on to the patient, either directly or indirectly.   If you want an analogy, it’s the parking authority; revenue from tickets doubles, triples, but the amount they pay to the cities doesn’t change.   The extra “profits” goes back into the authority, to hire more people, pay more salaries. It’s a self-propagating bureaucracy.  I should also mention that, consistent with bureaucracies, it can’t even collect those rebates very well.

The Last Psychiatrist
Ashworth University Contributing Blogger

*”The Last Psychiatrist” is an academic psychiatrist specializing in forensics, a respected author, and an award winning blogger.  Selected as one of the “Best Doctors In America”, The Last Psychiatrist prefers to remain anonymous in cyberspace and allow his/her work speak for itself through their acclaimed blog.  We would like to express our gratitude to this very talented professional for providing us with the opportunity to share his/her exemplary work with the Ashworth University  student community.  We encourage you to visit The Last Psychiatrist blog for additional insights.  Thanks Doc! 

Defensive medicine is indeed a problem. This isn’t the example that tells that story. Oh, and my friend Kevin looks pretty good on TV.

From cbs.com:

“It started as a simple stomach ache, but Alexandra Varipapa, a sophomore at the University of Richmond, decided to go to the emergency room. There, doctors ordered a full CT scan, a radiation imaging test, which found a harmless ovarian cyst. She never questioned the CT scan, CBS News correspondent Wyatt Andrews reports.”

Wow, she walked in and just got a CT scan! Oh, wait, she also got a history and a physical exam, but you wouldn’t know that from the slant of the article.

But her father did - when he got the $8,500 bill, $6,500 of which was that CT scan.“I was pretty flabbergasted,” said Robert Varipapa, himself a physician. Varipapa says his daughter’s pain could have been diagnosed far more easily and cheaply with a $1,400 ultrasound.“A history, a pelvic examination and probably an ultrasound,” he said. And he would have started with the ultrasound.

              Thanks to Rick Audet for permission to use this Photo.

Aah, a doctor relative with a retrospectoscope. Stepwise testing works just fine in the clinic, but in the ED we need to do a lotta things in a hurry:

• rule out the horrible thing
• get a diagnosis, or exclude the killer diagnosis
• get the patient out of the ED to make room for the next patient

But the hospital defends the CT scan, saying an ultrasound might have missed something more serious.“It would not have ruled out appendicitis obviously, it would not have ruled, necessarily, out a kidney stone,” said Dr. Bob Powell, ER medical director of Bon Secours St. Mary’s Hospital.Varipapa agrees, but asks why not start simple - and do the CT scan only if necessary?“Well it’s my opinion this is defensive medicine,” Varipapa said.

Well, you may be right that it’s defensive medicine, but that doesn’t make it incorrect, or bad medicine. A better question would be the 6K charge for a CT scan, but bashing the ED is a lot easier. Frankly, this is not a terrific example of defensive medicine, but is a good example of a) the different though processes between clinic and EM doctors, and b) a cautionary tale of current ED costs. Kevin looked very reasonable and professional (and wasn’t wearing his pajamas)! Here’s his CBS video. I recommend it, mostly to see my friend Kevin before he moves to Hollywood.

Dr. Allen
Creator of GruntDoc
Ashworth University Contributing Blogger 

*Allen earned the alias GruntDoc through is his work as a doctor in the USMC infantry and has carried the name through his current work as an Emergency Physician.  Dr. Roberts obtained his MD from Texas Tech University and is board certified in emergency medicine.  In recent years, he has become one of the most popular and respected bloggers on matters related to health care and medicine.  We’re honored to welcome Allen as a member of our contributing bloggers’ network and would like to specially thank him for the opportunity to share his knowledge, skills, and experience with our student community.  To learn more about the life and work of Dr. Allen, visit his outstanding GruntDoc blog.  Thanks Allen!