Stuck inside the U.S. healthcare system with the patient navigation blues again

As a venture capitalist, I am encouraged by the innovation pouring into the U.S. healthcare sector. As a typical healthcare consumer, however, I still find it surprisingly difficult to navigate the system. For example, my wife told me a year or so ago that I didn’t hear her well enough. So I used an online service to book an appointment close to work during lunch to remove some excess earwax. When I was in the waiting room googling the doctor, I discovered that the doctor’s wife once set fire to his office in retaliation against him for secretly slipping an anti-psychotic drug into her fruit juice (he successfully removed my earwax by the way).

But if you require an important procedure, more thought should go into the selection. I asked one of our advisory board members, Dr. Alan Guerci who is CEO of Catholic Health Services, how he would go about finding a doctor if he wasn’t a healthcare insider. He said he would first try to find a healthcare institution close by that gets high marks from U.S. News and World Report in the specialty of interest. Next, if it is a teaching hospital, he would call the Office of the Chief Resident in that specialty and ask the Chief Resident for a referral. For a community hospital, he would ask for a referral from the Office of Medical Staff Affairs.

Dr. Guerci’s suggestion mirrors the advice of other experts. Dr. Marty Makary, in his book Unaccountable, emphasizes that hospital employees possess essential inside knowledge. In fact, you do not want to get your care from a hospital where its employees wouldn’t want to receive care from their home institution or otherwise assign low ratings to their department’s teamwork or safety culture relative to peer institution departments. Unfortunately, Makary reports that at over 50% of the 60 reputable hospitals his team at Johns Hopkins surveyed, more than 50% of the hospital employees would not want to have their own care performed in the unit in which they worked. At only 12% of the institutions his team surveyed would 85% or more of the employees surveyed seek their own care from their department. One can hope that in the future regular consumers will gain access to this type of survey data so they can use it to make better decisions. Until then, you have to be a sleuth to make sure you get a quality doctor in a great department at a strong hospital. If you succeed, you can dramatically improve your chances of achieving a good outcome. Any and all detective work you perform could help you avoid “never events” such as the surgeon operating on the wrong side of the body or leaving sponges or instruments inside you.

Remind yourself that appearances can be deceiving as you investigate. A prestigious hospital can have a terrible department with 4x to 5x the complication rate of a less well-known hospital in the same city. The medical profession is rife with stories about the tall, good-looking, charming doctor with all the right credentials who is an absolute hack in the operating room. The nominal percentage of physicians impaired by substance abuse is 2%, but the actual rate is believed to be much higher and no authority governing physician licensure makes it easy to find out who they are. Do your best to make sure your surgeon wasn’t on call the night before your surgery and therefore didn’t get adequate sleep, because your chances for complications go up 83% in that scenario according to one study Makary cites.

Seeking a physician who performs high volumes of the procedure you require is a smart way to avoid trouble, because, according to Makary, and a New England Journal of Medicine study he cites, surgical death rates are directly related to a surgeon’s experience with that particular operation. However, Makary also points out that a surgeon who has orchestrated their practice to produce high volumes of the same procedure is often focused on efficiency more than a friendly bedside manner. Therefore, in the case of choosing a “proceduralist”, as opposed to a diagnostician where listening and patience are critical, Makary suggests, and Guerci concurs, you should focus on the surgeon’s experience more than their personality, especially when the procedure is very specialized. Experienced surgeons are more likely to have seen every variation of the procedure you need and be able to handle unanticipated problems expertly. When interviewing surgeons, ask how many procedures they perform per year and what their complication rates are.

A number of established companies and start-ups make procedure volume data like this available but the consumer experience is still cumbersome. Medical societies such as the American College of Surgeons and the Society of Thoracic Surgeons are creating scrubbed longitudinal databases that track patient outcomes which are risk-adjusted to account for hospital size, demographics and patient complexity. If the doctor you are considering has a low complication rate, you should find out if it is because he or she is really good or if he or she just operates on less risky patients.

The other place to be aggressive in the interview process, according to Makary, is to make sure you get minimally invasive surgery if it makes sense because when compared to open surgery it results in less pain, fewer infections, shorter hospitalizations, fewer medications, and lower costs. He is troubled by how random your chances are of receiving minimally invasive surgery. If open surgery is being proposed, he thinks the surgeon should tell you the percentage done open versus minimally invasive in the U.S. as compared to the doctor in question, complication rates for each method, and average days in the hospital for each. He also recommends getting a second opinion on the spot.

We would of course love to hear how our readers are “hacking” the system, as “Patient Navigation” is an investment theme we are pursuing with our portfolio company Vitals and one we intend to mine going forward.