Ideal Medical Practices

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.

Primary care shortage, ethics, and the elephant in the room

MSNBC has been making some noise recently about primary care physicians going off the grid to provide better care for patients who pay directly for services:

Patients face bitter choice: Pay up or lose care
Clinic with two doors, a symbol of two-tier care
Opinion: ‘Concierge’ is another word for bribe

The statements are stark and harsh:

• Getting a doc's time and attention shouldn't require a premium fee
• No one should have to pay more to get decent, unhurried and attentive care
• The whole system of primary care has broken down

I couldn't agree more.  It infuriates me that the choice offered most physicians is between maintaining the status quo of low quality high volume care or exacerbating the physician shortage by downsizing, charging premium fees to deliver high quality to the few.

I've spent years studying the medical office practices and lead a national demonstration project showing how far we can go in delivery excellent care.  The results are everything we want and need - high quality, terrific experience of care & bending the cost curve. 

The problem is that this work is not valued in our current system.  Docs who deliver high quality care, docs who provide decent, unhurried & attentive care are punished financially and end up losing their practices as they re-enter the indentured servitude of industrial medicine.

I've spent years trying to get the payers to provide the resources necessary to achieve & maintain high quality care.  Everyone professes interest but pay only lip service.  What makes me want to tear my hair out is that the extra primary care funding results in total costs substantially lower than maintaining the status quo.

I hate that we're forced into this dilemma:

Maintain the status quo while study after study demonstrate bad outcomes, lousy experience of care and outrageous high costs.  Maintain the status quo that creates a prison-like atmosphere for primary care with docs in such abject misery that few medical students choose to enter primary care.  Maintain the status quo that is the very root cause of the primary care shortage.

or

Do what we can now to deliver high quality care.

I know there's always a middle course, but right now I applaud those doctors who choose a path of quality in the face of misinformed accusations of unethical behavior.  These practices are not holding their breath for health care reform that gets it all right.  Many have taken the less traveled path to demonstrate that:

• High quality can be achieved now
• Primary care can be an excellent career choice
• Physicians can get out of jail and control their professional lives

Health care reform is a messy process during which we will see good ideas with unintended consequences.  These docs are choosing to serve fewer people well & Congress is choosing to continue to leave millions of Americans out in the cold with no health coverage.  Rather than lashing out let us work together to bridge these gaps so that we can live up to Dr. Cohen's comment:

The truth is, we all deserve the kind of attention from our doctors that our grandparents routinely expected and their doctors routinely supplied.

Amen to that. 

Let's get back to a place where the doc didn't have to spend hours every day feeding the administrative trivia beast, playing 'prior authorization' and 'billing and coding jeopardy.'  Let's get docs off the hamster wheel and give them the breathing room they need for decent, unhurried and attentive care.

If you give smart people with aligned incentives the same set of facts, nine times out of ten they will come to the same conclusions about what needs to be done. And then they will do it.

Above is a quotation from Mike Troiano a social media pioneer @ Holland Mark agency.

via www.holland-mark.com

I'm often asked by health care improvement teams "how can I get the doctors/nurses/secretaries/you-name-it to buy in to the changes we need to make?"  The question can come in many guises but the root cause is often the same: the group of people working together are often not on the same page.  While they're not usually working in opposition to each other, there is a lack of coordinated effort that results in gross inefficiency as well as no consensus on how well things are going.

Example:

I was working with a pediatrics residency outpatient department that was trying to reduce the backlog of appointments so that they could possibly achieve 'open access.'  Their intervention was to do some evening sessions dedicated to well child check/school physicals in August.  Staff stayed late & worked hard.  A week later at a meeting I asked "So, did you achieve your objectives?"  The answers varied from "Absolutely" to "No."  Discussion of the variation in response lead to a recognition that individuals had different goals in mind and therefore had a different way of defining success.  The net result of all that time and effort was a disappointing realization that they'd have to do it all over again after coming together around defined goals.

Mike Troiano connects the dots between common objectives, aligned incentives, a defined set of measures (facts) that come to life as a cornerstone of effective management.  Medical office practices are complex systems.  We can use our gut and intuition and muddle through, but when we agree on principles and metrics we can achieve brilliance. 

Running a hospital: There is no billing code for compassion

"there is no billing code for compassion,"

via runningahospital.blogspot.com

A short blog post from a hospital CEO recognizing the value of primary care.

I've worked with hospital systems struggling to keep up with emergency department demand. The process improvement teams analyze causes of the delay and explore interventions like speeding up the hospital discharge process to open beds more quickly so that ED admits get to the floor more quickly.
We read about cool new innovations like the 'hospital bed coordinator' and hospitals collaborate in learning how to 'increase bed turns' (like turning over a table in a restaurant - increases throughput & revenue).

These are all logical solutions and can indeed improve ED flow, but how about an analysis of the ED demand?

A major insurer on the East coast told me a couple of weeks ago that about 60% of ED visits for their members were totally unnecessary (could have been cared for in other ways).
The main problem was a lack of primary care access.

Hospitals rarely think about helping solve the primary care problem - I've even had a hospital CFO tell me to stop trying to fix primary care 'cause it would decrease the ED revenue engine.

It's nice to see Paul Levy from Beth Israel Deaconess acknowledge primary care.

Reforming the way we work in health care doen't have to wait for political reform

For years I've lived health delivery reform - in my own practice, vicariously through others, and in teaching  & studying medical office practice redesign with hundreds of practices all over the US.

Without a doubt I can state that current policies & the mode of payment are immense barriers to redesigning the way we work.  Changing health care policies and payment to create an environment supportive of doing the right thing for our patients would be a wonderful thing.  I yearn for the day, but I won't hold my breath.

Political health care reform is, well, political.  That means its often irrational, does the right thing for those who write big checks to congress, but often fails to do the right thing for the patients I serve.

Without any health care reform or insurance company changes or universal coverage or any of those wonderful things, I was able to totally retool my practice to better focus my time on what my patients really need:  better access to care, improved relationship & communication, more coordination of care as they navigate the complex health system.  I was able to do this because I assumed I had the power to change what I did.  I gave up being a victim of the system and stepped way out on a limb to try new stuff.

Hundreds of docs from all across the US are doing this now.  It's not all wonderful - some of these brave souls have taken big personal risks and been punished by their local environments that prove too toxic to primary care (we call these "dead zones"), but many more have succeeded and the shared learning of pitfalls and smart moves is making it easier for successive waves.

Keep hope alive folks, it's possible to break free of the broken system, it's possible to be the professional you envisioned when you started your training.  Don't hold your breath while Congress makes sausage, get out there and create the practice of your dreams.

I've moved to Seattle for my wife's new job & I'm excitedly planning my new office using the best & latest tech & solutions to ideal care.  Join me in re-energizing primary care - it's a great career choice if you get to do it right.

Is this Really How We Should Measure Quality? « See First Blog

The good news is Massachusetts doctors do better than the national average on these measures.  The bad news is it’s hard to say what that means as far as how good any doctor is who is measured this way.

via www.seefirstblog.com

Read a very thoughtful post regarding health care quality measurement in Massachusetts.

What sounds good in a speech or in a news article is often found wanting in reality.

The vanished health care system? Diminished maybe but not dead yet!

In a NYT Health Blog Dr. Dena Rifkin describes how far we've come from "the vanished health care system in which doctors were available for their own patients 24 hours a day..."

The blog then describes how the health system can work around the lack of continuity & broken relationships that are so fundamental to good primary care.  This is a troubling evolution due the strong links between relationships-over-time (aka continuity) and important outcomes.  Turns out that when we break up continuity our patients suffer - fewer patients follow through on needed preventive and chronic disease care and more end up in the hospital.

Why do we have to accept workarounds and the kinds of risks described in the post when it is not only possible but delightful to practice in the 'vanished' system of 24 hour care for one's own patients?
Until my family moved out to Seattle for my wife's new job and I had to close my practice, I took 24 hour call for my patients. It was delightful to know the people and back story when I received a call from someone with a need. 

I was very pleasantly surprised to find that the number of calls I got after hours dropped dramatically and I was awakened from sleep only about twice a year.

This old school approach may have vanished from much of the US but it's not gone yet. Doctors are rediscovering the incredible benefit to themselves and their patients when they reduce the barriers and open themselves up to their patients. 

Systems that support continuity are putting a stake in the ground for quality and meaningful outcomes.  Dr. Rifkin urges us to remember the unquantifiable value of asking the right questions, but we can also remember to measure and hold ourselves accountable to good continuity and access: do our patients say that they can get care when and how they need it?  Do our patients know to whom to turn when they have a medical question or issue?  If not, our system is not supporting good care.  These issues are quantifiable and we know what questions to ask.  Now we just have to be brave enough to ask them and act accordingly.

Note to colleagues: 24/7 access is possible and even enjoyable only in supportive systems - so if you're in a hamster wheel practice you want to think twice about trying this out.  For the way-too-many of you in  non supportive systems, start thinking about your exit strategy.

More evidence that micromeasures provide poor insight into medical quality

Up to yesterday it was common knowledge that more mammography was a good thing.  This well accepted notion lead reasonable and thoughtful people to assume that we can judge the quality of care in a doctors' office by (in part) looking at the percent of women who have had a mammogram.  Low % = bad, high % = good.

Trying to get doctors to toe the quality line lead rational people to establish 'pay for performance' standards attaching dollars to more mammograms.

As of yesterday, we're in a bit of a bind.  One of the very thoughtful groups that make recommendations on screening is the US Preventive Services Task Force.  Yesterday they changed their recommendation saying that women between 40-50 should not receive mammograms and 50-70 year old women should only get them every two years (as opposed to the earlier 'every year' recommendation). 

Why the change?  Turns out that doing more mammograms results in more harm that good to the women according to recent studies.

This is hardly the first time we've seen such changes.  It used to be common knowledge that radical mastectomy - an extremely disfiguring surgical procedure - was the best way to manage breast cancer.  That is until studies demonstrated no additional value to women when compared to much less disfiguring approaches.

Now we have to unravel a complex tapestry of quality measures.  Of course quality measures will shift over time, but there's a significant chance of shift and perverse incentives when our quality focus is on the details of care we deliver.  Details are very important in care - but they provide a poor proxy for understanding the quality of care delivery. 

The US is too deep in the weeds on quality measurement.  We're chasing mammography rates, prostate cancer screening (yet another screening test with dubious credentials) and a host of other details.  Those metrics are important, but pale in comparison to how well an office eliminates barriers to access, how well clinicians communicate with and support their patients in becoming effective self-managers.

Big issues that make a huge difference in the quality of care: access, continuity, comprehensiveness of services & care coordination get short shrift or lip service while we chase the shifting sands of medical details.  These cardinal features of high quality care can be measured, can be used to improve office practices, and have a proven and substantial impact on overall quality of care, the experience of care and when patients receive care in offices performing well on these criteria, the total cost of their care is substantially less.

Enough.  The measurement community needs to break out of its rut & create a new agenda focused on what's meaningful, not what they've deemed measurable.

Little Benefit Seen, So Far, in Electronic Patient Records - NYTimes.com

"research shows that installing the technology does not necessarily mean that the hoped-for gains in quality and cost containment will follow quickly."

via www.nytimes.com

This study replicates the study published in 2005 by RAND.

Beware gizmo idolatry.  Our society is infatuated with the quick fix: the pill, the software, the technology that will make it so I don't have to do the hard work of really changing the way I work or live.

The greatest benefits in patient outcomes come not from simple electronification of our current work, but by using good technology to work differently. 

When I use an EMR to replicate the multi-step rife-with-delays process of approving a simple prescription refill request I've accomplished nothing substantive.  Using an electronic platform to support a streamlined prescription process that makes it so easy to review and decide that it cuts minutes and steps out of the work flow is a boon to my practice and a benefit to the patients I serve.

Below are before and after process maps of refill requests.  "Feet" = the number of feet someone had to walk to accomplish the step.

Old process:  big hassle for me & staff which lead us further down the path of dysfunction as we posted signs "Five business days notice for refill requests!"

New process: so easy to do that I could approve (or recommend other action) real time with the patient on the phone. 

Eliminating waits and delays helps our patients and helps our practices.

Old Rx Process with a paper chart:

 

New Rx process with electronic chart: