Ideal Medical Practices

Crocodile Tears Over Primary Care - Lamenting Primary Care

Crocodile Tears Over Primary Care - Lamenting Primary Care

Dr. Rich captures the toxic environment for primary care in the US.
Thank you Dr. Rich.
Gordon

A Breath of Fresh Air for Health Care - Opinionator Blog - NYTimes.com

A Breath of Fresh Air for Health Care

via opinionator.blogs.nytimes.com

Kaiser Permanente has poured enormous effort into its Thrive campaign and backed it up with improved patient experience in their hospitals, medical offices and creating a phenomenal set of online tools for their members.

I love that they are cognizant of the links between good design, good experience and good health care.  The aesthetic of our work environment plays a role in how we work.  I would not trade good clinical care for a nice chair, but if given a choice between equal doctors most would lean toward the office with friendly people, a clean and comfortable environment.

Elegant design is not restricted to the large institutional players, just look to Jay Parkinson in Brooklyn and Aaron Blackledge in SF for shining examples.

I didn't pay that much attention to aesthetic when I was focusing on getting the underlying processes right, but once I had the foundation of good process in place I began to understand the benefits of elegant design.  Now I wouldn't open or join a practice without careful attention to design.

The future is here but unevenly distributed: thriving happy PCP versus doctor hell

Like characters in a Dickens novel health care in the US demonstrates the best of times and worst of times.  We hear real horror stories and witness spots of brilliance.  My heart is heavy as Dr E's light is extinguished but gladdened by Dr B's resurgent hope.

These anecdotes highlight both the urgent need to change and what that change might bring.

We are crushing primary care practices with payment policies that fail to account for much of the work we should do on behalf of those we serve.  We exacerbate inadequate payment with unfunded mandates calling physicians away from their patients to address administrative trivia.  We thwart effective care with denials, delays, and mind-numbing bureaucracy that sap the time and destroy the spirit of the primary care work force.

But some physicians have figured out how to work outside this toxic environment and deliver great care in vital and satisfying practices.   They enjoy their work and the finances are lined up with doing right by their patients.  They are professionally and personally satisfied and delivering care in a supportive environment.

The worst of times

I've known Dr. E for years.  His soft caring voice and gentle manner must touch a lot of his patients.  As a primary care physician with a long career he has deep relationships with the people he serves that give him great insight into the right treatment recommendations and the compassion that is core to our work.

Dr. E can't sustain his primary care practice any more.  He's crushed by the administrative burden of the paperwork, the denials, the rejections that dog his every move to care for his patients.

The toxic policy environment takes down another good PCP and leaves a large number of people to seek care from strangers.

I enjoy practicing medicine.  But I hate spending so much time and energy dealing with the barriers and controlling inequities that 3rd party payers impose on my time and energy.  I am deciding to wind down over the next year or two,  giving  patients time to find other providers (I have a lot of Medicare pts who will not be happy about the task of searching for someone who accepts Medicare).  I just this week, called our local free clinic and told them I would volunteer for an additional day each month (if I am going to provide free care to patients under the disguise of insurance companies who refuse to pay,  I might as well avoid the hassles of dealing with them and up front, give care away ).    I can do locums work  for 6-8 days/ month and earn as much as I do now working 5 long days each week.  What is wrong with this picture. Sorry to sound so discouraged. 

The best of times

But not all environments are equally toxic and some have found ways to thrive. 

I was basically inspired by Obama "to be the change" and somehow decided to risk everything on some vague notion I had on how to create a medical clinic.  It was a bit of an experiment in some ways where I wanted to show that a Jr doctor with no name recognition, zero patients, no funding, and no media coverage could incorporate design into a medical environment and harness the power of social media to build a large and successful practice.   After 13 months and starting with zero patients, we are now staffed and open 7 days a week with 4 doctors and have seen over 3,300 patient visits in a fee for service model.  We have seen around 2,400 unique individuals and are averaging 7 new patients daily. 

Here's the predominant tone of patient experience in his practice:

This is the way medicine used to be and this is a refreshing change to the managed care that medicine has become. He reminds me of my grandfather who was a physician in a small town in Kansas.

I think I just found my new primary care establishment.  Right price, great service, and best of all, they value my time as much as their own.

Why Medical Students Should Choose Primary Care - Not for the Reasons You Think

The current generation of medical students are not choosing primary care and instead are flocking to specialty care medicine in droves. Unlike decades ago when the best and brightest often went into internal medicine, the vast majority of students opt for dermatology, radiology, anesthesiology, and ophthalmology. Reasons for doing so include better predictable schedules, work-life balance, and compensation. (read more via davisliumd.blogspot.com)

Dr. Liu reminds us that most organic process is cyclic.  In this case the nadir of primary care in which we live is beginning to show signs of an upswing that should re-energize primary care in the US.

Just when things look dark and awful to so many I see immense opportunity and green shoots of joy for PCPs who reject the status quo and incremental improvement strategies based on the grudging willingness of others.

What is an ideal medical practice?

We are the cutting edge of office practice innovation in the US.  There are  many who would wear that mantle, but the clothes don't fit.

The cutting edge does not define primary care as a branch in a carefully designed hospital based system flow chart.

The cutting edge does not define primary care as a thousand details calling for endless analysis of minutia to justify every act, every stroke of the pen.

The cutting edge does not define primary care as grateful recipients of vendor technology to achieve 'meaningful use.'

The cutting edge does not define primary care as the practice capable of running fastest on the hamster wheel while spouting off about guideline adherence for a handful of clinical conditions.

We are the foundation of effective primary care.  Our patients are more likely to say:

• I can get care when and how I need it
• I have a PCP who knows me as a person
• My PCP cares for the bulk of my health care needs
• My PCP coordinates any care I need in the health system

The shape, size, financial arrangement, team configuration are means to the end.  We vary in shape, size, financial arrangement, team configuration to better serve our patients in vital and professional practice.

(Please also consider reading my comment below)

"It is abundantly clear that our medical system wastes enormous amounts of money on health care that doesn't make people healthier."

What a breathtakingly honest assessment from David Leonhardt of the  NYT.  Of course now we all need to discuss how to recoup the enormous waste.   The problem is that policy folks must find the right level of policy intervention:  blanket policies with major but imprecise effect or targeted policy that should address a specific problem?

Blanket policy is sweeping in effect and simple but often fails to address the underlying issues well and thus fails in intended effect. 

Take for example the Sustainable Growth Rate (SGR) policy that ramps back Medicare spending through automated across-the-board cuts to Medicare payments to the health care delivery system.  You'd think that this would lead to savings, but in the real world the health care delivery system responds by ramping up the volume of services and the total cost of Medicare continues its seemingly inexorable march to consume the nation's GDP.

The targeted policy approach holds much appeal as legislators can pick their pet peeve or help their corporate sponsors but unintended consequences can swamp the intended effect.  Even if well intended the targeted approach can fail if it is not aimed at a root cause of the problem and/or if it has unintended side effects. 

Take the example of Prior Authorization (real example from my practice days in Rochester NY): 

• Head MRI costs a lot and is often done without appropriate indication (waste)
• Managed care plan new policy mandates prior authorization for head MRI
• Staff in MD offices spend more time on calls @ prior auth, the docs and nurses spend more time figuring out how to get the MRI anyway, the MRI center hires more staff to make sure the prior auth
• To make up for the added costs (estimated @ $65-85K per doc per year) the practices crank up the volume of services and add more cost to the health care system
• And the MRI is done most of the time anyway

The good news is that we're not stuck.  There is blanket policy that can improve outcomes, improve the experience of care and 'bend the cost curve.'  Multiple studies document these as the result of effective primary care. 

Blanket policy that fully funds the work of effective primary care will improve population health, improve the experience of care and reduce per capita health care costs.

This policy  can and should be linked to primary care delivered effectively.  Patient experience defines the level of achievement of effective primary care:

• I can get care when and how I need it
• My PCP/nurse know me as a person
• My PCP/primary care office cares for the bulk of my health care needs
• My PCP/office coordinates all care I need in the larger health system

Blanket policy addressing the four pillars of effective primary care addresses root cause while avoiding adding massive bureaucracy by attempting to track an overwhelming volume of minutia (e.g. most approaches to 'PCMH').

Addressing the primary care shortage - encouraging innovation and meeting population needs

In my own practice and working with others I've been exploring answers to the question "What does it take to be a PCP in the US delivering great care while having an enjoyable and fulfilling professional career?"

The good news is that we have a pretty good idea of what it takes, the bad news is that in almost every practice we have to get the doc off the hamster wheel where productivity has trumped health care.  When we push volume of services beyond the capacity to fulfill our professional obligations we end up with ethically unsound practice and a compromised and unhappy work force.

The problem with getting the PCPs off the hamster wheel is that this exacerbates the primary care shortage in the US [of course the shortage is due to miserable professional working conditions, but that's another post].

Some folks think that it is unethical for a physician to reduce their panel size.  I think it is unethical to continue to deliver inadequate care to an overly large panel of patients; but I don't believe that we're stuck having to choose between two mutually exclusive options.

Our salvation is recognizing we have options - this is not an all-or-nothing choice.  As I mentioned in my previous post we can get at the root cause of primary care shortage by creating practices capable of delivering great care while having an enjoyable and fulfilling professional career.  We will see the ranks of primary care swell with new physicians, but this will take time. 

What to do in the meantime?

Consider reducing demand for primary care services and/or increasing primary care supply through investment in high functioning multidisciplinary care teams. Some examples:

Is it necessary in every circumstance for a person to have a face-to-face visit with an MD to obtain a vaccine?  We could offer vaccines as a community resource through pharmacies, schools, etc.  This would take a substantial amount of work out of the PCP office, allowing them to care for more people. 

I know that no solution is without difficulty - I'm just suggesting that "face to face with MD" need not be the only solution tested.

Is it necessary in every circumstance for a person to have a face-to-face visit with an MD to explore physiotherapy for musculoskeletal problems?  How about health coaching to improve self management of chronic conditions and improving lifestyle?  These ideas (tested and published) reduce the demand for face-to-face time with MD.

[I can hear a whole lot of physicians getting into "But what about nightmare scenario X!" thinking. Hold on a second guys - I don't discount 'nightmare scenario X' but let's agree that it is not always necessary to have a face-to-face visit with MD and go from there.]

Some smart health care delivery models offer direct access to non-MD services for those needs that do not require an MD, thus decompressing the bottleneck of primary care.  This approach can powerfully shift the demand for PCP and could potentially extinguish the primary care shortage.

What's in the way of solving the primary care shortage?

• Health care policy and payment that dictates face-to-face visit with MD as the source of $$$
• Doctors afraid that if other do some of the work their profession will be irrevocably eroded
• Work force skill deficits on how to do this well (exp high functioning care team)

So before folks out there start sharpening knives to carve up the audacious innovators who choose to get off the hamster wheel and deliver great care, consider your real willingness to explore the full slate of options.

How to increase primary care supply in the US: wishful thinking versus evidence-based interventions

We've all heard that there is a primary care physician shortage in the US.  This is troubling because more primary care results in better outcomes at lower total costs - a.k.a. "bending the cost curve."  The same is not true for any other medial specialty.

To address this primary care shortage current health reform legislation proposes to increase the number of training slots for primary care physicians.  This seemingly logical intervention flies in the face of facts.  While I'm not adverse to increasing the number of training slots, it's a bit like increasing the number of seats on the bus.  The problem is not that we have a crowd of medical students unable to ride, they're choosing to drive Hummers and the bus leaves the station unfilled.  

Karen Hauer and colleagues studied medical student avoidance of primary care.  Here are the findings:

• Medical students see current primary care physicians burning out at very high rates
• The current primary care work force loves taking care of patients but hate much of the rest of their work, and the non patient-care components are overwhelming the rest
• In general, primary care physicians work harder than and earn less than their specialty colleagues
• Primary care physicians are increasingly disillusioned and disgusted by being forced to do less than what is right for their patients

The primary care bus travels the road to perdition as we stop for lunch at the Hamster Wheel, have a snack at the Productivity Express, choke down meal at the Performance Report Card Cafe, all the while finding the toilets blocked up with prior authorization paperwork.

You want to drive a bigger bus and expect smart medical students to pony up for the ride?  Think again.

We increase the primary care pipeline when we make primary care an attractive career choice, when primary care physicians have the time and resources to engage in the full scope of their work.  I've been lucky to practice in a way that provides the time to truly engage in trusting relationships with my patients, that allows me the time to listen and understand why folks struggle with their health so that I can better guide their journey through complex conditions.

I broke out of the jail of status quo primary care and practiced on the lam.  I took the radical approach of starting it all over from scratch, building a practice from the idea that the relationship I have with my patients is the very foundation of what I do as a professional.

Don't get on that bus. It is possible to take a different path and achieve what we and our patients want and need.  Join those who eschew the status quo in favor of practicing at a more professional level.  When medical students see these docs they know the joy of a job well done, of retirement delayed, of primary care reinvigorated.

This is how we increase the ranks of primary care.

Bending the health care cost curve by eliminating waits & delays

As the nation careens toward individual mandates to purchase health insurance many are wondering how this will do anything to reduce health care costs in the US.  Massachusetts is a few years into the same experiment and noticing that the results are not as good as one would hope if you're hoping that the experiment results in reduced health care costs.

The good news is that there are things practices can do that improve care, delight patients, make the office a better place to work and reduce unnecessary costs.  As I've written before, primary care practices that eliminate waits and delays and improve the timeliness of communication help people avoid going to the emergency department for care that could have been delivered in their primary care doctor's office.

This is no small help - a major insurer in Massachusetts told me last week that 60%+ of emergency visits are unnecessary.  A visit to the ED costs 10 to 20 times more than a visit to the PCP.  For a patient with a bad headache, the ED might perform a raft of unnecessary tests & drive the costs to 100x of an office visit, to say nothing of the massive inconvenience to patients & family of an ED visit.

The biggest impediment to practices trying to pull this off is that each doctor has more patients than they can manage - their 'panel size' is often 2000-3000 patients per doctor.  Some argue that the doctors should take even more.  The problem is that these boated panels cost patients not just intolerable waits and delays but patients suffer worse outcomes. 

From studies by John Wasson et al (ref below) we see that patients served with waits and delays have less control over their chronic conditions, are less likely to have preventive care needs met, are more likely to miss days of work & school and are more likely to end up in the ED or even be hospitalized.

The right panel size is that which the practice can manage without creating waits & delays.  Taking on too many patients results in unintended harm to those patients and should be stopped.  Failure to address this at the policy level is a clear example of pushing practices to hurt their patients.

Improve access and relationship for ALL patients in the practice, not just the lucky few with a particular condition.  This is one of the pillars of effective primary care.

Wasson, J. H., Johnson, D. J., Benjamin, R., Phillips, J., & MacKenzie, T. A. Patients report positive impacts of collaborative care. Journal of Ambulatory Care Management, July-September 2006 29(3), 199–206.

Public reporting of physician data: a good idea implemented badly

I know I'm going to take heat from my colleagues on this one, but try to bear with me a bit as I explain my position.

With very rare exception we adhere to the idea of delivering high quality medicine.  We would each be willing and proud to report openly our results IF we had measures we could trust and a process we could follow without further eroding the care we deliver to our patients.  The problem at the moment is that we have neither.  We have external bodies using the data they have (e.g. insurance claims) that are highly prone to error, and a process that lays a very significant uncompensated work burden on us when we're struggling just to keep our heads above water.

One of the problems we face in the current paradigm of measurement approach is that we're held responsible for factors mostly outside our control. 

Using the Evans and Stoddard model as a framework, health and wellness is a result of the interaction between the following:

As a physician I have the most control over the delivery of health care.  I have the ability to recommend and advise a patient regarding their disease.  I can offer advice on physical & social environment, note the effect of prosperity, cheer on helpful behavior.  All of this I can and should do, yet I recognize the limitations of my intervention in the face of a society that allows income to determine health access & outcome.  How much impact can I have on diet when Congress supports the worst of diets with agriculture subsidy to huge business conglomerates? 

Judge me and my practice not on the complex and messy data but on how my office works as a system.  Office practices are high performing when they eliminate waits & delays, provide superb communication, solve the access problem for their patients, support their patients so that the patients report high confidence in management.

All of these factors can be measured through the aggregate experience of patients served in the practice - thus allowing statistically meaningful analysis even to the level of the individual physician.

Horizon BCBS of NJ has implemented a program of publicly reporting physician performance.  It is probably using claims data and a member satisfaction survey.  If so, this is the wrong data set.  For all we know they're judging practices based on increasing the rates of mammography between 40-50 and prostate cancer screening in men - both highly controversial and thus bad measures of 'quality.'

Horizon BCBS of NJ allows physicians to request the data and on their own time perform a laborious chart review.  If the physician responds in time the insurer will allow changes to the report card.  This unfunded mandate is a crushing burden to practices.  The physician responses I've read on line to this initiative:

• "just send all complex sick patients to the ER and get them out of your practice - you'll be burned by their bad outcomes."
• "what time do we have left for our families after appeasing the gods of managed care???
  enough!!!!"
• "This  is extremely alarming"

These are good doctors being crushed by policies that look good on paper but fail the front line test of reasonableness.  As I said at the start: I am in favor of public reporting, but the data must be valid and the process reasonable.  This initiative appears to fail on both.