Cool new "doc on call" or another external intervention that siphons money from interventions that really help

A colleague of mine sent out a link for a new 'doc on call' system.  She is of course dismayed by this and she should be and so should her patients.  Breaking up the primary care relationship with expedient 'other' fractures care.  Fractured care degrades outcomes.  Fractured care hurts people.

From a nice review of the medical literature we see consistent links between continuity of care and good outcomes:*

• Patients who have a continuity relationship with a personal care physician have better health process measures and outcomes.
• Multiple visits over time with the same provider create renewed opportunities to build management and teaching strategies tailored to individual progress and receptivity.
• Continuity of care increases the likelihood that the provider is aware of psychosocial problems impacting health.
• Continuity has been shown to achieve quality at a lower cost.

The public knows this:  having someone who knows you improves the chances of good outcomes.  Having a stranger get involved in your care is less than optimal. 

The public turns to strangers when their doctors are not available, when it is hard to get an appointment, when it is hard to be heard, when they feel disrespected by onerous process and wasted time.  The  problem is not solved by further fracturing the already messed up primary care system by adding new whiz-bang 'stranger on a phone' solutions but by addressing root cause.

The root cause is that we fail to recognize the essential role and value of effective primary care.  We burden primary care docs with all the administrative nonsense dreamed up by insurance 'utilization' managers while withholding funding for the most basic element of time to listen and care.

Forcing primary care to run on a hamster wheel reduces its core value by making relationship and continuity harder.  Solutions like "disease management companies" and other interventions that work around but fail to address the root cause will never solve the problem.

Enough with the work-around solutions that exacerbate the root cause - help primary care get off the hamster wheel with funding adequate to the work & time to listen and care.

*Rosenthal (September/October 2008) The Medical Home: Growing Evidence to Support a New Approach to Primary Care.  JABFM. Volume21 Number 5

Comments

[L Gordon Moore]

This is where the heavy lifting starts. I see the answer to your questions as a team effort.

Im looking any chances to put the right ingredients in front of the right folks for a pilot. I say pilot not because we really need more study but because of the need to clarify the very issues you raise so that we can move forward based on data and results.

Im game. I know lots of PCPs who would be game. Can we spark a fire here?
Gordon

[gjudd]

G,

I'm auto-monitoring your page precisely because you both regularly update with strong material AND field comments & questions so well! Many thanks for your reply. Re:

We hereby propose that adequate funding means shifting an additional 5% of overall medical spending to primary care.
We know from studies and demonstration projects that this funding - coupled with and contingent upon attainment of thresholds on these indicators - predicts total net savings of 15-20%.

I know you have shared a couple of examples of existing studies with me. Employers who control their budgetary destinies like those models, and continually search for designs that are easy for them to replicate and measure. YOU are confident in the findings of the studies you mention - developing confidence among, say, self-funding employers - takes another tier or two of confidence-building....

As you're probably aware, any specifics that can be provided to 'pre-digest' the operational steps for a) securing c-suite support b) assessing baseline data c) tapping ongoing studies d) developing relevant objectives and metrics for their own populations always accelerate the growth of backbone necessary to tackle this kind of pilot....So I will stay tuned....

[L Gordon Moore]

The path is pretty clear in many ways but the journey requires input from many players so that we can arrive at a better place.

We start with the core functions of primary care that predict good population health outcome and reduce total cost:
Access
Relationship over time
Comprehensive services
Care coordination

We then define a level of performance on these (what I call) system attributes that predict vastly improved outcomes and significant cost savings. (We did this work as part of the IMP project.)

We recognized that the current funding scheme does not afford practices the breathing room to perform at or above the thresholds.

We hereby propose that adequate funding means shifting an additional 5% of overall medical spending to primary care.
We know from studies and demonstration projects that this funding - coupled with and contingent upon attainment of thresholds on these indicators - predicts total net savings of 15-20%.

Moving in this direction requires simultaneous funding of the full scope of work and delivering on the promise of a high functioning system of primary care. We cant create the system without the funding.

The only market that appears willing to fund effective primary care are self-pay consumers looking to buy a better health care experience. Its a small but growing market in the US as more and more consumers find themselves on the hook with high deductible plans.

If that's the only market willing to buy, well focus our efforts there. I'm eager to explore larger markets as soon as they are willing to engage in serious pilots.
Gordon

[gjudd]

Doctors Moore & Stewart: I'm not a clinician and am relatively new to Dr. Moore's Ideal Medical Practices model, but I have to say that I struggle to see, in the face of demographic, political and economic trends, a pragmatic path that arrives at the solutions you yearn for. Many things other than reimbursement alignment would have to change to create a chance for it to come about.

If you've already laid out scenarios in which that path is illuminated I would be interested in learning more about them, via web pages, presentations, etc. If not, I urge you to give some thought to imagining those scenarios and fleshing them out. Reimagining a primary care future is important, is vital: imagining it begins and ends with how primary care doctors are paid seems overly limited.

[Donald T. Stewart, MD]

I recently had a lengthy discussion with one of the principals of a similar program in the Seattle area. This company started by offering housecalls to Microsoft employees, and did save the company money by eliminating many unnecessary ER visits. They had a EMR and the patient's PCP, if identified, would get a legible visit note via fax the next day.

They are now trying to expand by offering a service that allows patients to speak directly on the phone to a provider, usually an ARNP, immediately day or night. They promise to "try to arrange appropriate care," by calling the patient's PCP, if it sounds like an appointment is needed, by doing a paid phone visit (if more than triage is necessary), or by arranging for a home visit. Their financing is similar, with a monthly charge automatically deducted from a credit card for immediate phone access to the ARNP who will triage them, and then add-on charges for phone visits or home visits.

They are marketing this to physicians as a "service" that takes the strain off the reception staff on busy days and which reduces the number of calls to physicians on call at night. When I explained that my patients schedule their own appointments without talking to anyone by going on-line to my scheduler and that all of my patients have my cell phone number, she admitted that the service probably didn't have much to offer me (unless I wanted to take a day off).

The problem with our system, and the niche these kinds of services can offer, is that provider contracts with insurance companies make it difficult to charge the patients separately for instant phone access and triage, since this is supposed to be included in the woefully inadequate amounts we are paid for those patients who come in for a visit. So, effectively, the insurance companies discourage the physicians from contracting directly with the patients for this sort of thing, while the insurance companies have no problem if an outside (not contracted) company sells these services to the patients, even though it disrupts continuity of care and even though it contributes to the collapse of our fragile primary care system. This is exactly the same problem we have with outside "disease management" companies, who are paid lots of money to try to do the sort of things primary care physicians would be doing for their patients with chronic illnesses, if only they were paid enough that they could afford to spend enough time with the patient to provide the patient the comprehensive care that is needed.

It appears that our national strategy for health care is to destroy primary care by "divide and conquer" tactics that siphon needed money from the primary care pot into the corporate pots of those companies that dream up new ways of interfering with the physician-patient relationship.

[Kent]

They're a VC-funded outfit that appears to have just been capitalized this month. Given that pretty much all of their "services" are available from almost any primary care doctor's office at no charge, I give them six months.

Of course, maybe we should all be charging for this stuff. ;-)