Ideal Medical Practices

Dr. Mintz' Blog: Insurance Free Medicine - a solution to the primary care shortage?

it was more about the hassles of primary care medicine and less about the how much money they would make that led students away from careers in primary care.

via drmintz.blogspot.com

Matthew Mintz is one of the authors of a study explaining why medical students avoid primary care as a career choice. In the study it turns out that money is an issue but more important is the gap between what we are forced to do every day and what we know we should be doing for our patients. 

With packed schedules and ever increasing demands to ramp up 'productivity' combined with the ever increasing demand to justify details of the work to clerks we have a primary care workforce in professional penury.

Take a look at his post above to get an idea of how good caring docs get stuck in systems.  I can sense his yearning for a practice environment that better supports the kind of care he's been trained to deliver. 

His current position is probably pretty good and he may be able to do a lot for trainees and patients but I wonder what it would be like if he were able to practice in a truly supportive environment.  I suspect the differences would be obvious and joyous not only for him and his patients, but for the trainees with whom he works.

Imagine that - a healthy and supportive work environment enabling great care.  That directly addresses a main reason medical students gave for avoiding primary care.  Now that's how I'd address the primary care physician shortage.

What would it take to create such an environment?

• Funding to support the full scope of work of effective primary care including the right technology and people (team)
  
• Elimination of the crushing distraction of administrative trivia that adds high cost and low value to health care
  

Some employed physicians have these things but most operate in systems that do not truly support the work.  Most who seek this practice environment find it only in getting off the insurance hamster wheel.

One of my doc heroes: doing wonderful work and receiving almost no support

Let's call her Dr. M.  She's a rural solo independent doc in a rural state with a high poverty rate, lots of unemployment.  Most of her patients are on Medicaid or Medicare with a smattering of patients with commercial insurance.

Dr. M does not live large.  She drives a car with >150K miles clocked and sweats blood when she has to replace her fax machine.  She earns one third of the typical primary care income and one tenth what a cardiologist earns in a modest year.

Conventional wisdom tells us that only large health systems are capable of pulling off quality improvement in health care, that solo independent docs are either unwilling or unable to step up to the plate, and that we just don't know what the heck to do with rural practices.

The solution to these problems in the conventional thinking is that we have to take the solo docs and mash them up into large groups and attach them to hospital systems so that we can achieve the 5000 Medicare beneficiaries researchers require to be sure of their predictive models.

If the predictive models require 5000 Medicare beneficiaries they'll never be much use in the real world of practice where each doc responds to their individual performance data.  Patients may be curious about how a network performs, but they're much more interested how their own doc performs.

If the model can't get there, then maybe the model is wrong.  If we are ever going to get out of this mess we're in we need to start with a little bit of unconventional thinking.

It turns out that Dr. M performs quite well.  In a report from her state Medicaid agency she stands out. In fact they called her up to find out what she's doing because she stands out a lot.

By delivering exemplary primary care (oh by the way, her quality indicators are great as well) she saved her patients from unnecessary care that may have hurt them.  She saved the State more than $50,000.  Dr. M would really like to invest more in technology that would help her reach out better to her patients.  She would like to have tools and/or time to better manage the coordination of care for patients of hers who need specialty intervention.  With adequate funding of primary care she would be able to do these things. 

Her State has a quality bonus system in place to reward docs who do good things.  She received $800.  She has the new fax machine but she and her patients deserve so much more.

It's time to stop writing off rural practices.  It's time to start funding the full scope of work of exemplary primary care.  The practices can deliver and are willing to be held accountable if the accountability paradigm makes sense.

Let's do right by Dr. M and fund her work.  Use modeling that accurately represents her work and stop with the conventional wisdom that flies in the face of what's right.

Dust up between insurer and hospital system: cracks in the armor of the status quo?

Standoff Between Continuum and UnitedHealthcare Over Costs - NYTimes.com

A front in the national health care battle has opened in New York City, where a major hospital chain and one of the nation’s largest insurance companies are locked in a struggle over control of treatment and costs that could have broad ramifications for millions of people with private health insurance.

via www.nytimes.com

Call me perverse, but I'm somewhat jazzed by the dust-up between a major insurer and a major hospital system. 

These two entities (in general, not these specific players) represent two of the major powers in health care backing the status quo. 

Hospital systems want their beds full and to maximized 'bed-turns' (like turning a table over in a restaurant) since 'bed-turns' generate revenue.  Some hospital systems work on quality but most assiduously ignore their primary care networks since robust primary care reduces the need for hospital beds.

Insurers manage actuarial risk and deal with the administrative burden of claims.  They've been charging increased premiums for the added services of managing population health but their impact has been extremely limited and the results have not lead to any breakthroughs on quality & cost.  They too have ignored robust primary care because it would compete with the plan-based population health management cash cow.

I freely admit that this is a somewhat simplistic and harsh assessment, but I have yet to see support for exemplary primary care from such players (ok, a few exceptions- I'll grant you Group Health in Seattle and a handful of others, but these are rare exceptions).

So I'm jazzed because this battle may signal a willingness to bust up the status quo - a willingness to at the very least support some meaningful pilots of exemplary primary care.  I won't credit any of those anemic Patient-Centered Medical Home projects as true support. 

Covering up to three conditions and a small handful of preventive measures and congratulating yourself for adopting some technology is so far from the goal that it's almost laughable (I would laugh if the amount of money and hyped expectations spent on such minor incremental change were not such a huge distraction from real improvement).

Exemplary primary care provides a foundation of excellence for all patients, not a subset with one of several conditions.  Exemplary primary care doesn't credit "I bought some cool software and have a policy describing how we'll use it" but focuses on processes and outcomes that are meaningful to the population served:

• I can receive 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
• I am much less likely to end up in the hospital or emergency room
  
• I am better able to avoid the risk of unnecessary procedures
  

So UnitedHealthCare - go for it.  Dust it up.  In the meantime if you want to take the high road I suggest you look beyond the typical status quo nonsense and partner with exemplary primary care.  You want to really take on a hospital system?  How about truly supporting a primary care network whose work will absolutely reduce the need for unnecessary high end specialist interventions and hospitalization.

The Ideal Medical Practices group and others know how to do this work and are as ever eager to engage.  Support us so we can provide the care your members want and need.  This will not only make you look good but will actually help your members get better care and outcomes.

Op-ed: Ease ER overload | KevinMD.com - My mom as case in point

Emblematic of soaring health care costs, which are projected to reach $3 trillion by 2011,is the nationwide crisis of emergency department overcrowding. More than $18 billion is wasted annually on unnecessary visits to the ER,with volume rising by 32% and wait times almost doubling to one hour during the past decade.Relieving this strain will be critical to any health care reform.

via www.kevinmd.com

My mom called me this morning. Yesterday she fell while walking and her right hand hurts at the base of the thumb.

We skyped this AM and it looks bruised and swollen. It hurts a lot and she's worried about long term complications if she delays treatment.

Today is Saturday. She lives in NYC.

I advised her to call her PCP. He called back promptly and recommended going to the emergency department. [I want to be very clear that this is an excellent doc operating in a system that does not support exemplary primary care. Exemplary primary care is punished by current payment policies.]

I checked out an orthopedics text and read up on 'fracture of the base of the thumb metacarpal' and found nothing her scenario that indicated the need of an emergency room visit.

Looking on line I find no orthopedist with weekend office hours.

I curbside consult an orthopedist who tells me that as long as my mom is not exhibiting certain specific signs (we go through a list & she has none of them) then the most the ED will do is put her in a splint and recommend she follow up with ortho on Monday.

I talked my mom through the splint, linked her to a video on Thumb Gutter Splint from Ottowa and gave her the signs of bad stuff.

This is basic primary care:

• Access when and how you need it
• Relationship (I know she's very capable and can build a splint and can recognize the bad signs)
• Comprehensiveness - willing to take on the bulk of people's needs and recognize the right time to call in specialists
• Care coordination - I can take the time and do what's right for her regardless of the fact that I'm in Seattle and she's in NYC.
  

This is how we decompress the emergency department. Fully functional primary care is an essential part of the solution.

Fund primary care so we are loosed from the fetters that bind us to a dysfunctional system.  If we shift 5% of the current funding pie to primary care we can fully fund exemplary primary care - the necessary technology, teams, expand the supply of primary care by making it a less repugnant career choice for medical students (and remember that this 5% funding shift is more than offset by 15-20% net savings).

Stop the stupid policies that equate only 'office visits' with meaningful care.

We in the profession have to get over our knee-jerk "go to ED" mentality and think instead: "What does this patient really need?"

What are the root causes of the primary care shortage

http://feedproxy.google.com/~r/AcpInternistBlog/~3/EbA-C6C4KIA/what-are-root-causes-of-primary-care.html

Kevin Pho (aka KevinMD) exposes the irrational thinking behind blanket expansion of residency or medical school slots as a solution to the primary care shortage.

The root causes have been described in studies and are blatant in the every day lives of those working in primary care practices:

Primary care has been thrust into the untenable position of delivering care below an ethical standard. Their employers - whatever their intent or motivation - have created an environment in which it is not possible to deliver the kind of care our patients need.

Without the time to build trusting relationships, lacking the resources to engage in the full scope of services our patients need, without the funding to do even the most rudimentary care coordination we have been forced to abdicate the very core of our work.

We have been eviscerated by the exigencies of the marketplace. A hobbled specialty unable to live up to reasonable standards of professionalism or ethics is not a magnet for eager medical students.

PCPs are exploring any means possible to exit this toxic environment. Right now some consumers are willing and able to pay for the full scope of exemplary primary care.  Practices that have figured out how to work in this space are creating micro environments that support excellence.  In those environments primary care is a vital and exciting career choice exploring the full potential of our specialty.

The current slate of intermediaries between purchasers and exemplary care appear to be invested in maintaining the status quo.  I'm no longer willing to wait for them to come around and I'm not going to play the game of "let's study this forever and do nothing substantive."

Employers can expand access to exemplary primary care if they partner with it in their local markets. There are good markers for exemplary practices that may be use to hold them accountable (and by the way, the NCQA's PPC-PCMH ain't it by a long shot).  This will be the next step in front line innovation that needn't wait for Congressional blessing or insurers to wake up to a new reality.

Exemplary primary care stonewalled

At a meeting today I ran into a colleague.  She's lectured around the country on her primary care network's efforts to deliver exemplary care to their patients.  They have invested huge sums of money  to bring their practices into the electronic age, have invested large amounts of human capital and cash in improvement and have a lot to show for the effort.

Their combined population health outcomes are very good.  The average patient experience of care is very good.  People who receive care in these practices are less likely to have unnecessary visits to the emergency room and are more likely to avoid hospitalization.

The docs and staff in the practices are much happier with the high level of care and how much better things are after years of improvement efforts.  So far so good.

The problem is that this doc wants to go even further.  She wants to invest in a health coach because she's read about and even participated in some pilot work with health coaches that leads struggling patients to better outcomes.  People are more likely to achieve their own health targets and avoid bad health outcomes (nice study by Tim Ahles et al @ Dartmouth describes the coaching model and outcomes).

The doc wants to hire a coach but she can't because her practice and the network are just scraping by financially after all the investments they have made in technology and improvement and extra time and effort to reach out to and help their patients.

She wants to hire a coach to help her patients but the current payment system won't fund that work.  The current payment system bottlenecks all care through the doctor and fails to recognize the value of well coordinated care with the help of other professionals.

Just as any good primary care physician will call in the help of a specialist for the patient who needs it, the PCP should be able to call in a person with special skills to help patients who would benefit.  The payment system blocks this work and my friend is hogtied. 

If she hires the health coach she'll have to ramp up the hamster wheel of care with all the attendant bad outcomes and miserable experience of care. 

Her group has terrific data they have used in negotiation with the regional insurers.  For all the insurer's professed interest in good outcomes and satisfaction of their members, they won't budge.  Her group has been at the negotiating table with these insurers for years and are getting nowhere.

In settings where insurers systematically thwart well documented interventions that truly lead to good outcomes and reduce the total cost I am at a loss for what to do other than walk out of the room.

My friend doesn't want to move.  I'm hoping that she and her group will begin to negotiate directly with local employers, unions and other groups who may show more interest in the results.  When insurers continue to stonewall progress while pocketing profits it is time to bypass them and create new means of financing health care.

I'm perfectly happy to work with insurers if they agree to fix two fatal flaws in their policies:

1:  Fund the full scope of exemplary primary care - shift 5% of the overall health budget to primary care and use the 15-20% net savings to make premiums more affordable.

2:  Dump the crushing burden of administrative trivial pursuit that keeps us from attending to the needs of our patients.

Primary care and insurers can work together in good faith negotiation with legitimate proposals, but if they are lacking it is time to step around the roadblock and do what's right for our patients and our country.

Health care reform will follow the 'thousand points of light' path even if the blunt axe from DC goes down to special interest

For a while I was dismayed by the inept and misinformed legislation dressed up as 'health care reform' by our representatives in Washington DC.  'If they mess it up we'll never be able to improve this beast, we'll be stuck right where we are and where we are is awful!' I feared.

This fear stems from all the observation that policy regarding how we pay for health care is the single most important roadblock to better care and outcomes at lower cost. 

To join the ranks of high performing health systems we must double our investment in primary care so that primary care may live up to its full potential.

This investment would reduce the frequency of unnecessary specialist interventions, inappropriate testing, wasteful emergency room use and avoidable hospitalization.  None of these things are benefits to patients.  The evidence of Wennberg & Fisher* tells us in fact that these things hurt patients.

With the dramatic savings (estimated to be between 15-20% even when factoring in the full funding of primary care) we could improve access to care and reduce the crushing financial burden on individuals and employers.

So what are we going to do if health reform from DC goes down or if it comes out so corrupted by special interest that fails to change the status quo?  Premiums will continue to spiral out of control, benefits will shrink, the out of pocket costs to employees will skyrocket, fewer people will be able to afford access, the hassle factor interventions from insurance companies will continue to drown primary care pushing even more into retirement and exacerbating the primary care shortage.

But this Dickensian 'worst of times' comes coupled with a shining opportunity.  The status quo is so broken and so toxic to employers, employees, governments and the uninsured that some of these people may discover a willingness to engage in true innovation - to break from the status quo and try something really new.

This is the time to step up and deliver care that astounds, delights, and performs.  We know the attributes of high performing primary care.  We can deliver care in a way that achieves brilliance and excellence, so that the people we serve can say:

• 'I have access to care when and how I need it'
• 'I have a PCP/nurse who know me as a person'
• 'My PCP meets the bulk of my health care needs'
• 'My PCP coordinates any care I need in the health system'

This is not incremental change, this is not for the faint of heart or those who think that the health system is doing pretty well.

For any who are sick of the status quo and close to burnout, it is time.

For those who suspect a crushing administrative burden hidden behind the pennies of a misinformed 'patient-centered medical home' initiative, it is time.

For those in the emotional and ethical purgatory of hamster wheel care where we feel forced to deliver less than what our patients want and need, it is time.

For those who see 'help' extended through high cost consultancies pushing volume and valuing dollars more than patients, it is time.

It is time to reinvigorate our profession with the ethics and passion that attracted us in the beginning.

Learn from the vanguard practicing in new models of care, using technology to enable low overhead and high quality.  Learn from those who have been able to discover solutions to toxic payment policies.

Let our combined strength and data help the nation see what is possible when our full potential is unleashed.

* Fisher ES, Wennberg DE, Stukel TA, et al. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138:273–287.

 

Fisher ES, Wennberg DE, Stukel TA, et al. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288–298.

Solo practices let doctors spend more time with patients | democratandchronicle.com | Democrat and Chronicle

When Dr. Linda Lee sees patients, she brings them from the waiting room, typically spends a half hour with them, cleans up the exam room and submits the insurance claims online. She's the one who returns phone voicemails, and she gives patients her cell phone number for urgent after-hours needs.

via www.democratandchronicle.com

Hooray and congratulations to the inspiring docs on the cutting edge of health care.
This is an example of what is possible (though still difficult due to inept policy and payment).
This model demonstrates that we don't have to write off solo and small practices as we envision of future of excellent care.
This is also an example of doctors who have awakened to the reality that the time is now and they can choose to create a better practice for their patients.
I'm not suggesting that solo is the only way, I'm not suggesting "work with no staff" is the ideal, just that it is one end of a spectrum that is often ignored or written off.
We can do this.
You can too.

IF AIR TRAVEL WORKED LIKE HEALTH CARE

via www.youtube.com

They totally nail it.
The only thing missing is a representation of how the grind of working in such dysfunctional systems exhausts a caring and compassionate work force, turning us into burned out zombies working on an assembly line of 'productivity.'
It is very cool to be able to work on a new airline.

Colorado Voters Craving Reform of Health Care and Congress - NYTimes.com

“This is good,” Mr. Seyfer remembers thinking. He expected Congress to “find out what Americans wanted.” But, he said in an interview at his shop, the Congressional debate deteriorated into a partisan brawl, and Congress has virtually ignored his biggest concern: holding down health costs.

via www.nytimes.com

I'm far from shocked by the reaction of the good folks of Colorado.

Cost savings in health care cannot come without pain and suffering to those invested in the status quo.

Since those with the deepest investment in the status quo are also those with the deepest pockets, and as the depth of pocket seems to predict legislation, I'm not anticipating much good coming out of D.C. in terms of cost cutting.

Many of us are ready and willing to engage in significant innovation that improves results and improves the experience of care and want only some interested party willing to fund the full scope of effective primary care.

Models show that 5% increased in overall budget directed at primary care can result in total net savings between 15-20%. This is a huge win, but not for everyone.

Anyone out there paying for health care have the guts to step out into the land of innovation in primary care delivery?