Ideal Medical Practices

Insurer-backed medical home demonstration projects: Potemkin Villages?

For years I've worked to demonstrate the value of effective primary care as a critical pathway in fixing health care in the US.  At first I was surprised and dismayed to hear from insurance execs that I needed to demonstrate a return-on-investment if they were going to fund this good work.  I was demoralized by their requests to document every aspect with randomized control trials and depressed when I was turned aside by savvy medical directors claiming that there was no proof.

Finally I began to suspect that maybe, just maybe, the insurance industry was not negotiating in good faith, that their motivation to remain in total control of the money trumped any study, any data, and ultimately any chance at improvement.

I'm shocked, just shocked (not really) to read the account of an industry insider who says essentially the same thing:

Don't trust the insurance industry's stance on health reform, says Wendell Potter, former corporate communications chief for Cigna.

Companies may support reform in public, but behind the scenes they'll do everything they can to derail policies they don't like, claims Potter, who was for many years a consummate industry insider.

Based on Mr. Potter's confessions and my repeated experience of lip-service support for innovation as well as opportunities to review many medical home demonstration project proposals that lack any meaningful funding for the new work demanded of struggling primary care practices, I have concluded that medical home projects backed by the insurance industry are likely to build Potemkin villages and not the homes we need.

I know it's probably career suicide to call out these deeply entrenched interests with their deep ties to policymakers, but I'm hoping (here's naive me again) that there are more folks like Wendell Potter in these companies and in the halls of Congress who would rather take the high road and do the right thing (and I really do think that there could be many more like him) .

If you're one of them, please remember these things:

• The status quo of health care is broken beyond simple repair and needs fundamental reform
• Supporting effective primary care has been demonstrated in the literature as well as in all other developed countries to lead to improved outcomes, improved experience of care, and to reduce the costs of health care when compared to the US norm
• Front like docs like the IMPs have demonstrated once again their willingness to take the high road and achieve the good results
• We welcome your participation in one of the more exciting innovations in health care delivery in the US

L. Gordon Moore

New business models of medicine - shedding complexity in favor of patient care

I don't believe that charging patients directly for their health care expenses is the ultimate solution to our health care problems - there are too many unintended side effects of this model.  It works for some, though, and where it does work, it opens the door to innovation that is blocked by insurance company rules that get in way of good care and desired outcomes.

I am impressed by the level of innovation practices like those cited below.  They can scale new heights because they are able to work directly for their patients without the costly and (often but not always) counterproductive interventions brought to bear by the insurance industry.

There is a lot we can learn from practices that have shed the tyranny of Evaluation & Management Coding from the AMA, especially those that have captured their new found freedom to enhance and improve patient care & reduce the cost of care to those served.

Here are back to back interviews with Garrison Bliss of Qliance in Seattle & Jay Parkinson of hello health in NYC.

L Gordon Moore

High-volume team based care - one end of the medical home spectrum

A nice piece in Business Week online about primary care and the medical home highlight Dr. Peter Anderson's practice in Newport News VA.  He works with a large staff and sees 30-35 patients a day, has nurses spend the bulk of time with the patients.

"The history-taking just kills the doctor's time. I don't have to do any of that," Anderson says.

This is one end of the spectrum of practice models that can theoretically deliver care that leads to better patient outcomes, improved experience of care, and make health care more affordable because it lowers the total cost of health care.

Cory Sevin, others and I published an article about creating high functioning teams.*  We know that a highly trained, highly choreographed team can - through careful intention, measurement and continual attention - achieve very good results.

But just like sports teams, we cannot assume that all teams are 'high performing.'  We must not presume that 'team' in and of itself will achieve good results.  Barbara Starfield points out the lack of literature supporting 'teams' as an intervention to improve population health:

Family medicine appears to have acceded to the concept of the “patient-centered medical home” (PCMH), but proposals for the PCMH are not very patient-centered. They are justified on the basis of evidence regarding the benefits of primary care, but the criteria for assessment of PCMHs, such as those promulgated by the National Committee for Quality Assurance, concern organizational features such as electronic health records, computerized guidelines and amorphous “teams,” none of which have been demonstrated to be pursuant to good primary care. - Starfield B.  Family Practice Management

I love that Dr. Anderson is innovative in his practice delivery and that he's been able to demonstrate some good results (though to be honest, there's not much "patient-centered" about achieving the NCQA recognition). 

As we work to create effective delivery systems, let there be a range of solutions.  I want to point out in particular that solo and small practices have demonstrated their ability to deliver patient-centered care that meets very well Dr. Starfield's definitions & that we've published the results.

Let folks build practices of many sizes and shapes so long as they commit to measuring and displaying the highest levels of quality.  Just don't tell me that solo & small practices are unable or unwilling to deliver high quality care (I'm speaking to some researchers & policy makers out there who believe the only way our nation will improve care is by forcing all docs into systems like Geisinger, Kaiser & Group Health - great systems to be sure, but why force the model).

We have done the work.
We have demonstrated the results.
We have done this IN SPITE of a system that systematically degrades and impedes effective primary care.
Where insurance rules make it impossible to deliver high quality care, we have done this in many cases by stepping out from under the crushing and impossible burden of insurance company nonsense.

We don't need anyone's permission to create high quality effective primary care.
We don't have to adhere to mistaken and tangential definitions of what constitutes a "medical home."

We're doing this work because it is the right thing to do for our patients.

L. Gordon Moore

*Sevin C, Moore G, Shepherd J, Jacobs T, Hupke C.  Transforming care teams to provide the best possible patient-centered, collaborative care. Journal of Ambulatory Care Management 2009 Jan-Mar;32(1):24-31.

Doctors creating affordable healthcare - another IMP in the news!

Way to go Moitri Savard!  Nice piece with John Hockenberry on The Take Away.  Also featured is John Wasson talking about ideal medical practices.

Caring and compassion - one physician's tale of the benefit of relationship

This is from a colleague who prefers to remain anonymous so as not to offend any of the other parties in this tale.

I wanted to share a recent experience to encourage you to keep slugging along...it can be worth it.

59 yo. Vietnam vet joined my practice 2 months ago. MI 5 years ago with two stents placed. Smoking a pack per day, BP 180/120, LDL 160 and taking zero meds (i.e. not even aspirin for the stents). Primary reason for not taking the meds was that he'd been placed on a number of non-generic meds Toprol XL, Plavix, Crestor, a non-generic ACE etc. His prescription bills would have been over $200 per month in copays alone.

The notes I received from his previous provider were typical template nonsense: a bunch of check boxes not amended from visit to visit, a "smoking cessation" recommendation checked in every plan section, all of the appropriate diagnostic ICD codes for CAD, HTN, hypercholesterolemia etc. automatically generated for every visit. All the P4P crap appropriately tagged and not addressed. There are probably 15 seemingly identical visits billed to Blue Cross Blue Shield with absolutely no evidence that anything was ever done for the conditions. Most of these were probably 99214 visits so the doc got paid somewhere North of $120 x 15 for apparently doing nothing but visiting with a patient for 8 minutes or so per visit and submitting a templated and barely amended chart note. Of course his abnormal and completely unchanging cholesterol was checked every 2 months or so along with non-evidence based comprehensive metabolic profiles and other random labs. All paid for by over-priced and wasteful insurance. Ridiculous.

Over the first month we got him on aspirin, generic metoprolol, pravachol, and lisinopril/HCTZ. Total med cost $16 per month with or without insurance. His pressure normalized and he quit smoking. Unfortunately, he developed atypical chest pain two weeks ago and his stress echo was positive.

Here's where a relationship like those the docs on this listserve have with their patients can matter. I have no way of knowing where or even if fault lies on either person, but the patient and the cardiologist who gave the stress test news didn't get along. The patient walked out of the clinic with chest pain to catch a flight to visit a relative. Fortunately, he called me before he left, and we were able to talk through the risks of traveling and make it his decision on what to do. He stayed in town, developed persistent pain that night, presented to the ER and was admitted for catheterization.

I went to the hospital where I don't have privileges to monitor his admission process. The docs there had no way of accessing his med list, no way of accessing his previous cardiac records, etc. They couldn't even locate the stress echo results that had been done 24 hours earlier in the same hospital system. It was typical admission chaos when I walked in. Doctors and nurses asking a patient lying on a gurney the details of a complex medical history while adjusting his nitro drip. Within a few minutes I printed his complete medical record off the internet (thanks PracticeFusion), helped the patient understand what was going to happen, and gave the docs/nurses the appropriate contact info for his family and myself. I wish I had a picture of the cardiac fellow's face when he saw me access a patient record over the internet. This guy probably banks on-line, socializes via FaceBook and Googles restaurants on his iphone, but in the realm of healthcare he was staring at me like I was an absolute magician for using their computer to get medical records from an outside server.

The interventional cardiologist later told him that in 20 years of practice he had never seen a non-admitting physician come to the hospital to facilitate care. I didn't think it was a big deal at all - took me about 45 minutes on a Saturday morning to be sure my patient was getting excellent, well-coordinated care. How is it possible that in the "Best Health Care System in the World" as the AMA likes to describe it a practicing cardiologist in a major city had "Never" seen a primary care doctor come to the hospital when one of his or her patients was admitted? During my training, it was an absolute expectation that we would make "social rounds" (i.e. care coordination) rounds on our primary patients if they were in the hospital on another service. Where did that expectation go?

The patient ended up getting a minimally invasive single vessel bypass a week ago and is already home. I made a house call on him yesterday and he's doing very well. Of course, the hospital discharge made him an appointment with the cardiologist he didn't like in the first place. We'll be changing that appointment today to make sure we continue to provide relationship-based care.

When you get tired of beating your head against the wall of this mess we call U.S. healthcare, please remember that what you do matters. Our patients still need us.

Cheers, Dr. X

Another Billing Weekend

I just finished catching up on the office billing today. Although I send the daily invoices out to the clearinghouse at the end of every day, the mind-numbing work of downloading the subsequent EOBs and putting that data into the computer so I can then print out and mail statements to patients I save up and do every other month or so. The process in my office is mostly automated (only the Medicare secondary insurances have to be entered by hand) taking about an hour a week to complete, but it is so mentally painful to do, I cannot muster up the energy to do it more regularly.

I have been asked numerous times why I don't outsource this task if it is so painful for me to accomplish, and the answer is twofold. First, economically it does not make sense. If billing takes me an hour a week to complete, that means I spend about 52 hours a year doing billing. Most billing companies charge 6-8% of all collections to do the billing. Last year, my little office collected $280,000. So, I would pay a billing company between $16,800 and $22,400/year or between $323-$430/hour. Even worse, I would still have to provide a significant amount of oversight to make sure everything was done properly. Following this train of thought, I am "getting paid" 5-7X the salary to do the billing than I do to see patients (of course, I am getting off easy, a recent study estimated the cost of collections at $68,000 per physician). The second reason is that I learn a lot about my patients and their economic situation by looking at their bills. I realize who has recently switched to a high deductible plan, who has not paid me in a while, who is only paying $10 at a time, and who never pays. Financial stability may be the most significant factor in health, and doing billing gives me a glimpse through that window.

Still, the whole process is stupid and makes me grumpy. Why is it so hard to get paid for what we do? Why do we need 10,000 codes and 10,000 procedures? Why do I need to know that Insurance A pays for depression, while I need to code it "fatigue" in order for Insurance B to pay? Why are we forced to play these stupid games which dramatically increase cost and does little (other than what I mentioned above) to enhance my relationship with my patients?

Health Care reform is all the rage right now, but the general theory is that we should just somehow make things better by improving what we do and not starting from scratch (which, by the way, is not what the Institutes of Medicine called for in their book, Crossing the Quality Chasm). Reform should start by eliminating this huge cost to primary care practices. I vote to give docs $1/patient/day, allow patients to rate the level of care provided so the practice can continue to improve to meet their needs, and watch as health care costs decrease, quality soars, and primary care docs become less grumpy. The solution is simple, the question is whether anyone is really listening.

John Brady, MD

Nice to see some reporters getting the crux of ideal medical practices

Take a look at this nice piece from Anchorage Alaska on IMP Dan Steward.

IMP doc Marty Schulman is featured in this KPBS piece on concierge medicine.

The good news is that people are starting to recognize the value of practices that take the time to care for their patients.  We haven't solved all the health problems of the US, but we're doing what we can to improve care and keep the hope of primary care alive.

I know some health policy folks will hear Dr. Steward say he's caring for 800 people and worry about exacerbation of the primary care shortage.  These policy folks need to better understand the source of the shortage.  The primary care shortage is due to the intolerable nature of primary care as a career choice.  We don't solve the problem by forcing docs to work on a production mill basis, seeing patients as "billable visits" rather than as human beings. 

These practices exemplify the caring and compassion that are the core of our profession.  Too many of our colleagues are trapped in jobs that daily erode their ability to maintain compassion in the face of productivity targets.

The choice between "maintain primary care supply through high volume care" versus "deliver compassionate care to fewer people" is false.  IMPs have changed the paradigm of care, focusing on compassion, relationship, and care.  The choice rests with policy makers to support this type of care for all people.

The health care clinicians do not choose the financing paradigm that limits choice and rations care - that is the choice of our policy makers.  It is time for new policy.

Real health reform should provide universal access to practices like this.

Positive Deviants

Dr. Atul Gawande is quickly becoming my hero. Two weeks ago, I read his article in the New Yorker Magazine entitled "The Cost Conundrum" where he went to McAllen, Tx to figure out why healthcare there costs more than any other place in the country. By getting past all the stereotypical (and inaccurate) reasons people give for high medical costs, he delivers perhaps the most honest look at medical economics that I have ever read.

This week, Dr. Gawande is at it again. His current article is a print out of the commencement address he gave at the University of Chicago School of Medicine. In it, he states the solution to the health care crisis lies in finding "positive deviants." These are people and organizations who are doing what is right as opposed to doing what makes the most money. He believes that by following their example, the rest of health care can and will benefit. I love this idea because he is not saying we need to spend billions of dollars looking for a solution. He is saying that we have the solution right under our noses, we just have to look more to the fringe than the mainstream to find it.

Having spent the last 6 years of my life trying to figure out how to deliver great care to my patients despite the toxic insurance environment, I understand exactly what he is saying. Mainstream medicine is wrought with practices which have done a great job maximizing revenues from procedures and labs. But this has only served to increase overall costs while neither increasing life expectancy or the patient's quality of life (in fact, many times it decreases them). Financially, the temptation is constantly looming to jump into the fray and start offering more procedures even though ethically, offering these tests creates a dilemma of whether the decision to test is being done because of true evidence-based medical necessity or because it generates money. Despite this, there remains a staunch group of us on the fringe (in the ideal medical practice movement and otherwise) who continue to sacrifice in order to fight the honorable fight for our patients. I love the idea of being a positive deviant. I'm sure my patients love it too.

John Brady MD

Effective whole person care (i.e. family medicine) should define health reform - B Starfield

Once again Barbara Starfield beautifully describes how we might as a nation achieve meaningful health care reform (from her article in Family Practice Management).

She describes the inadequacies of the NCQA's proposed definition of technology as the medical home and instead proposes the deeply evidence-based attributes of primary care:

• First contact care, which requires accessibility and responsibility for reducing unnecessary specialist care,
• Person-focused care over time delivered by the patient’s chosen physician, who assumes responsibility over long periods of time for all health care,
• Comprehensiveness of care, and
• Coordination of care when people have to go elsewhere for problems outside the competence of the primary care practitioner.

I urge my colleagues to read this short but important piece.

How we deliver care matters.  We have an opportunity to change the way we work, to live up to the full promise of primary care.  The IMP Project has demonstrated our willingness & ability, but we can't do it alone.  We need meaningful reform of the way money flows inside health care so that we are supported and not punished for doing this work.

Is the public waking up to the empty promise of universal health insurance?

Let me start by stating again that I am enthusiastically behind the idea of health care for all in the U.S.  I want this to happen.  It will be a good thing.  [I know it will create a mess if we don't reform the health delivery system, but that's another post.]

The problem as I see it is that Washington D.C. is talking not about health care for all but about health insurance mandates for all.  These two may look the same to the public but are fundamentally different.

As I've noted before, having health insurance is no guarantee of getting health care, of being protected from personal bankruptcy if you have a major medical problem.  Having health insurance right now results in limited choice of doctors, rationing dressed up as "pre-existing conditions" and prohibitive deductibles & co-payments, and intolerable waits and delays from insurer administrative denials.

We could do so much better than this.  We deserve better than this.  I won't stand in the way of insurance for all, but I'll only be able to swallow that kool-aid if there is some promise of reigning in the egregious excesses of the insurance industry - stop them from hurting our patients and making it nearly impossible to survive as a primary care doc who cares about quality.

At least the blogosphere seems to be developing a growing awareness of the gulf between health insurance and health care.

Here's a recent piece by Paul Loeb in the Online Journal

But why assume that the insurance companies are our friends? Why appease them at all? It’s not as if they’ve played a helpful role in our current system. Rather, they’ve gamed it in every possible way, leaving our country with the highest health care costs in the world and worst health outcomes of any advanced industrial country.

Here's a pathetic real life story from a front line doc:

I had a girl come in yesterday who was on the schedule as a new patient appointment.  She had purchased an individual policy after she lost her job last fall.  The agent had her convinced what a great deal she was getting; only $108 per month for major medical coverage.  What she didn’t understand was that she had a $3000 annual deductible that had to be paid before this great insurance paid anything and that she had an 18 month preexisting condition clause in the policy.  She was coming for her annual pap and BCP prescription; she had not had a pap in 4 years.  Her co-pay for an office visit was $40 which if her deductible had not been met was not applicable since the whole visit was her responsibility.  Who did she get mad at when confronted with the information and the request for payment by my staff?  Not the agent that sold her the worthless policy, but rather my staff who informed her of the deductible.  My staff was wrong; she had insurance they have to pay.  She was in tears when she left.  My staff had put her on the phone with someone at her insurances customer service department so they could fill her in on what the agent hadn’t bothered to tell her before taking her money.

Everyone is talking about credit card reform  over the ridiculous interest rates etc that are being charged, what about the insurance policies that people are being sold because they have been conditioned to believe they have to have health insurance.  You see ads everyday for these plans that really don’t amount to much.  If the insurance industry isn’t taken out of the mix in the healthcare reform debate, GOD HELP US EVERYONE.