Healthcare, medicine & pharmaceuticals

Keeping patients satisfied rather than well

If you thought nurses were there to give the best medical care to their patients, think again. Now they are there to provide great customer service. Some of them even speak to a script, talking up the quality of their hospital and the doctors, saying the same things again and again. This might sound like a Walt Disney nightmare, but unfortunately it is true.

In America, the Affordable Care Act allowed the withholding of 1% (2% in 2017) of Medicare reimbursements from hospitals. Only hospitals with high patient satisfaction scores would get them back and top performers would get a bonus. The method of checking is a 32-question HCAHPS survey to patients (Hospital Consumer Assessment of Healthcare Providers and Systems). This survey mostly asks about nursing care, with questions like: “after you pressed the call button, did you get help as soon as you wanted it?”

Ironically, Medicare’s register of hospitals shows two-thirds of poorly performing (in three or more categories) hospitals scored higher than the national average on the crucial recommendation answer: “YES, they would definitely recommend the hospital”.

By treating patients like customers, hospitals are following the dangerous belief that the customer is always right. So if a patient demands and gets something that is ill-advised medically, that is keeping the patient satisfied.

A national study found patients who were most satisfied with their doctors had higher healthcare costs and were more likely to go into hospital than patients who were less satisfied. They were also more likely to die within four years. This makes it even more ironic that some doctors and nurses are being paid or given bonuses according to how satisfied their patients are!

Hospitals are turning into 5-star hotels, with live music, valet parking, VIP lounges and room service. Nurses are being trained to talk to their patients according to certain positive scripts, like people in call centres or salespeople. Actors are being hired to help them do it. As Alexandra Robbins says in her book, The Nurses, “the concept of ‘patient experience’ has mischaracterized patients as customers and nurses as automatons”.

It is no surprise that one of the companies advising hospitals on these cultural changes is Walt Disney. It would be a huge joke, if it were not a tragedy. Is this the future of healthcare? Is healthcare merging with the entertainment industry? And if it is, who is paying for that?

Time to swallow a robot

In the next 5 years, patients will have to swallow more than just their pills. Thanks to new digital technologies, and our propensity for ‘nano’ everything, patients will be swallowing ingestible chips that can track, among other things, whether or not they have swallowed their pills. Half of patients do not comply as prescribed.

We are all familiar with the plethora of machines that can track our health from the outside, such as MRI scanners, X-rays and ultrasound. The new revolution in medicine is the ability to track your body from within, using cameras, robots, sensors and chips, all of which can be swallowed.

The FDA (US) has already approved a transponder carrying someone’s entire medical history, injected under the skin; a pill that can search the colon for tumours; and an ingestible chip that checks you have taken your pills. Next are nanosensors that look for signs of disease and send information to smartphones, or little robots that can diagnose disease, send drugs to the right spot and even do surgery.

In America, old people are being targeted because they often forget to take their medication. The Proteus Digital Health chip is 1mm square and activates when it meets stomach acids. It works with a patch worn on the torso. After the patient has swallowed it, the chip sends a code to the patch that then conveys information to a nearby phone or tablet – where it can be shared with whoever needs to know. Sensors can also be used to track temperature, heart rate, movement, or sleep.

In Britain, the NHS is already using this technology with heart patients to encourage compliance and in Switzerland, Novartis wants to use it in medications for patients who have had transplants. But the chip is still in its testing phase.

Privacy advocates are deeply concerned about people having to swallow something that gives third parties all kinds of information. Worse – the patient cannot get it out again. Once swallowed, it goes through the body and is then passes out into the plumbing, with metals like magnesium and copper going into the waterways. The other concern is an ethical one – will patients be forced to take medications they do not want to take or be refused further treatment? Will law enforcers use the technology to see whether people are taking illegal drugs?

Rate your doctor

The idea of giving ratings online is nothing new but, in America at least, it is becoming more common to rate doctors. Some doctors have reacted adversely, as you might imagine, by filing lawsuits. Others simply question the relevance and accuracy of this kind of feedback, not to mention the problem of responding while maintaining patient privacy.

One American site, ZocDoc, includes doctor reviews as well as allowing patients to make appointments. ZocDoc found 85% of doctors on its site looked at their own ratings.

Vitals uses a quality indicator for doctors, based on 170,000 sources. Castlight Health gathers prices from insurance bills and other data and found big discrepancies, for example, $264-$3,271 for the same brain scan! In China, there is a site run by Hao Dai Fu (‘good doctor’) that profiles 300,000 doctors and offers over a million reviews.

University of Utah runs a few hospitals and clinics and, responding to this trend, decided to publish patient feedback to help them do a better job. It discovered most reviews are positive and patient satisfaction scores improved after they started to do this. Other hospitals will probably follow its lead. America’s healthcare system, Medicare, now links payments with patient feedback, see story, above, Keeping patients satisfied…

German doctors and hospitals are opposed to linking funding with quality of care and do not accept the concept of patient reviews. We think there is a difference between funding for quality of care compared to funding for ‘perceived’ quality of care. Patients who feel good about their care are not necessarily getting the best care. After all, it would be a rare government department that funds a service just because people are happy with it.

Healthy elites will widen the longevity gap

The growing gulf between rich and poor across the world is well documented. But as scientists find ways to prolong life – and to improve the quality of this life – there is a new gulf already opening up. The life expectancy gap between the affluent and the poor working class in America is already more than 12 years. White women who are college educated can live til they are 84, compared to uneducated women, who die 11 years earlier.

The life expectancy gap has always been too large for indigenous people, compared to white settlers, in America and Australia. White people have been less inclined to question this. But some say, rather than fight over money, the next battle will be between those who die young and those who live long. After all, why should white, educated people have a better life and so much more of it?

It’s hard to imagine having the maturity and wisdom of age, combined with the juicy vitality of youth! Many baby boomers think that having healthy habits and positive attitudes will stave off the inevitable. But it seems genes are what matter. Scientists hope to make an anti-ageing pill that synthesises these magic genes.

Scientists are working on finding compounds that can slow down ageing and delay the onset of diseases associated with ageing. A team at Harvard fed mice NAD, which enhances mitochondria (cell’s energy factories) and it took only a week for the tissue of older mice to look like the tissue of 6-month-old mice. This is similar to someone in their 60s looking like a 20 something.

Yet, poor people lose out in almost every way, They are less educated, more likely to live in crowded environments, eat junk food, have less access to healthcare and they get sick more often.

The healthy elites don’t smoke, have time to exercise, eat well, and live in healthy environments. Already, nearly 30% of people over 85 remain in excellent health and more than half say their health does not stop them from working. Imagine if, in the future, people could live to 120 and still be able to say that! It could set off another revolution if the wealthy not only earn much more but start to live twice as long as the poor.

The doctor or the device?

Every industry is coping with the explosion of Big Data and what to do with it all. It is no surprise the medical industry, which holds vast amounts of information, is the focus of so much activity. Venture capitalists and companies like Google, Samsung and Merck have invested more than $US3 billion in healthcare information technology, so we know where the smart money is going.

One way to view the medical system is as an ecosystem of data, drawn from many different sources. These include the environment, public health, medical records, insurance claims, genomic data, mobile health apps and family health history. Using analytic algorithms and predictive modelling, these data can help patients, doctors and researchers enjoy and encourage better care. Or can they?

There is no doubt the information is there. Some 100,000 health apps have been approved for smartphones. Yet 80% of data are unstructured, such as emails, photos, doctors notes, or simply unsaid.

Vinod Khosla, who once founded Sun Microsystems and now heads Khosla Ventures, believes 80% of what doctors do can be replaced by machines. (It’s a typical tech-oriented stance.) He quotes a study of 40 cardiologists, where half said a person should have surgery, and half said that person should not. Two years later, they showed the same data to the same cardiologists, and 40% of them changed their minds! It’s a compelling argument – who would trust them?

He says machines can diagnose and write prescriptions, but only people can offer comfort. Yet, medical schools select for IQ and hard work, not compassion. So why do we train doctors to do what machines can do?

Express Scripts, for example, processes 1.4 billion prescriptions a year and, using data from doctors, pharmacies and laboratories, can detect patterns that show possible adverse reactions. Doctors can even know in advance which of their patients probably won’t take their medicine.

Another company, ginger.io, collects data from mobile phones – with permission - to assess the behaviour of people who have a mental illness. It can tell whether they staying in touch with people they love, exercising or getting enough sleep. WellDoc uses a ‘patient coaching’ system, based on the information from their mobile phones, such as blood sugar levels and recent meals and offers encouragement.

IBM is working on a version of Watson (developed to play Jeopardy) that will be used in the treatment of lung, colorectal and breast cancer. One of the team says physicians are “too burdened on paperwork and squeezed on revenue to keep up with the latest literature”. (We hope they are wrong.)

Watson takes only minutes to convert genomic data to a treatment decision, something that would normally have taken 5-10 months. Watson has had its struggles too – understanding doctor handwriting for one! It has also misunderstood acronyms or failed to grasp different terms for the same thing in medical journals.

The idea behind medical technology, so they say, is patients can play a more active role in their own health. Yet, though 10% of Americans own a tracking device like Fitbit or Jawbone, more than half no longer use them. PwC says more than 66% of people who have downloaded one have stopped using it.

So it may be early days for mobile health or as one commentator said wryly, “between the peak of the hype cycle and the trough of disillusionment”. But this is not going to stop the investors who know good information is, and always has been, power.