Ideal Medical Practices

"Knowing all of your patients" = breakthrough for Geisinger says more @ the US baseline than improvement

"The patient-centered medical home allows you to do primary care the way you would want to do it," said Graf. "From our perspective, it is really the way we do business now. It is about knowing who all of the patients in your entire populations are, where they are, what is going on with them and then being proactive about managing them."

via article from www.aafp.org

Let me start by saying that I respect and admire Geisinger and their immense efforts to roll out quality throughout their entire organization, but I am dismayed.

I am dismayed not by what Geisinger is doing but why it is necessary to do this work and why it deserves mention not only by communication engines of the AAFP but the President of the United States.  What is so special about 'knowing who all of the patients in your entire population?"  This is supposed to be the case in every primary care practice and is in fact a fundamental attribute of primary care.

As I've written in the past, primary care is different from the rest of the health delivery system because:

• It is the first point of contact: yet the reality is that most Americans must wade through intolerable waits and delay due to practices policies regarding panel size and productivity, and to slog through barriers erected by public policy (our national shame of letting personal income dictate access to care).
• Has relationships over time: yet we fracture and dishonor relationship through our 'next available' scheduling protocols (another consequence of practice policies regarding panel size and productivity), and by growing practices beyond any human ability to "know all of my patients."
• We offer comprehensive services: yet our productivity/throughput standards make it nearly impossible to address the full scope of our patient's needs so we miss opportunities to address meaningful issues and/or push our patients off to specialists for care we might have delivered well if we had the time.
• We coordinate the care our patients need from the rest of the health system: but because this work generates no revenue it is pushed to the side.

Geisinger makes headlines by doing incredibly basic work but the root cause of the problems remain unaddressed.  The root cause is way we pay for health care.  We pay for piecework. 

The more 'visits' or 'encounters' we produce, the more money we get.  Because we work under strictly regulated price caps we respond (as any economist will predict) by increasing the number of visits.  Increasing regulatory and policy burdens (such as endless reporting of trivia to an increasing crowd of public and private agencies demanding data) add to our cost of business.  With fixed price caps we respond again (as any economist will predict) by increasing the number of visits.

Ron Paulus MD, EVP for clinical operations "pointed out that the PCMH has been in the medical literature since the 1960s, but the concept has not "really taken off" because insurers and other entities are reluctant to pay for it."

Why might insurers be reluctant to pay?

• The US spends more per person on health care than any other developed nation in the world and has worse population health results to show for it. Let us all agree that spending even more is dead on arrival until we have exhausted our efforts to spend it more wisely.
• Shifting funds to support excellent primary care comes at the expense of hospitals and high end specialty interventions.  Since hospital systems are fierce and powerful negotiators any significant shift to support primary care could launch an all out war.
• Insurers have deep investments in their own disease/case management (even though we have yet to see significant improvements despite years of these investments).  Shifting these dollars to effective primary care would call into question these fiercely defended programs.

Geisinger deserves headlines not so much for doing the incredibly mundane work of "knowing your patients" - this is one of the foundational attributes of primary care. Geisinger deserves headlines because it is WILLING to do this work when the net effect reduces income to their own hospital.

Hospital systems willing to look to the future and risk the life of their own cash cow are rare. I for one applaud and encourage their efforts.

I would like to point out that "knowing all of your patients" is a fundamental attribute of practices ascribing to the Ideal Medical Practices model.  By reducing their own overhead these practices have eliminated the waits and delays, gotten off the hamster wheel and spend more time working for their patients.  The work is deeply rewarding to their patients, deeply satisfying to the practice, but to once more quote Paulus:

"...the concept has not "really taken off" because insurers and other entities are reluctant to pay for it."

I'm waiting for the headline: "Insurer fully funds effective primary care and is able to reduce premiums by 25%"

Being valued for the work we do - a positive story from the front lines of primary care

I wanted to share this with fellow IMPs [Ideal Medical Practices] to thank you for making a different
 to people:



I went to visit a patient at a hospital I haven't been at since I stopped
 doing OB a year after my second daughter was born (so 11 or 12 years)....I
 didn't see anyone knew. I was lost looking for things in an unfamiliar
 chart and wandering around the huge remodel.

A cool thing happened though. 
The nurse taking care of my patient saw me coming down the hall with a 
stethoscope around my neck and yelled out, "You must be the doctor from
Irvine who does house calls; we so wanted to meet you."

I had faxed in the summary sheet from Amazing Charts as the patient was on 
his way.

My patient's wife said all the specialists, nurses and the social
worker were so impressed at how much information was and easy it was to 
read. It was nothing that we don't all do everyday, but I sometimes forget 
that much of the medical world is too rushed to do even things that seem pretty basic and straight-forward.



It was nice to be welcomed as an IMP (even though they don't know that 
term).



Sharon McCoy George MD


Renaissance Family Medicine

10 McClintock Court; Irvine, CA

Personal versus industrial medicine

I'm struck by the degree to which conversations regarding improving health care focuses on creating large vertically integrated organizations. While it is absolutely possible that such industrial scale entities can provide very high quality care (consider Group Health Cooperative in the NW, for instance), the human aspect of what we do seems to be at risk.

There are very good studies indicating the importance of human relationship in our work.  We know that 'trust in physician' is an important variable in helping people achieve the best rates of preventive care.(1)

We don't need elaborate studies to understand that discussing sensitive and difficult issues is easier when the other person is known.  There are numerous studies documenting the link between continuity (interacting with the same health care professional) and quality.

I've worked with a number of industrial scale health care organizations.  These groups were the ones committed to quality and willing to invest resources to demonstrate that commitment.  I found that even the best of intentions were often thwarted by large bureaucracies.  The very size of the organization became a massive impediment to change.  Layers of managers, Byzantine committee structures.  Getting things done require endless meetings, delays, and many changes died due to competing agendas.

On the patient side I saw the near universal experience of people objectified as patient and defined by their illness or 'complaint.'  Most of the rules of organization functioned to protect and serve the health care work force (and didn't even do that well I might add) while suffering people were forced to repeat demographic stats again and again, were subjected to interminable waits and delays, were forced to wade through layer after layer of staff just to make an appointment.

I post for your consideration two diagrams.  These are 'spaghetti' diagrams showing the movement of people in a medical practice (imagine you are looking down at a floor plan from above and watching people move around in their work - each diagram shows all the people movement for a typical patient office visit). 

Figure 1 shows a typical practice with patient (circle), secretary (triangle pointing up), nurse (square), and doctor (triangle pointing down).  Figure 2 is a practice that has been designed around the person seeking care (circle), and includes the doctor (upside down triangle) and support person (square).

No hypotheticals here, this was my practice of old and my new practice.  To do this I had to step out on my own.  The system in which I worked was and is very committed to quality and in fact invests a good deal of time and money in improvement efforts, but while they continue to do good work, they are not currently capable of achieving this level of change.

Small practices can turn on a dime, making substantive changes that dramatically improve the experience of care and quality.  Working with volunteer practices from around the US we demonstrated the ability of others to do the same.

Small practices don't struggle as much with human relationship.  The very structure of small practices encourages continuity and relationship.  The very lack of 'call centers' and telephone voice attendants and layers of staff make small practices more personal.  More personal, better relationships, better communication: these are all ingredients of better care and outcomes.

Small can be done well or badly.  Big can be done well or badly.  Weighing one against the other I'd bet that small is more likely to achieve meaningful interaction than big.

I'm not hot on the idea that big has to be the way of the future.  Most people are not keen on big box medicine.  Unlike big box stores the 'big box medicine' is more expensive, more impersonal.  As a nation we need to think deeply before we commit our national resources to initiatives that encourage and support industrial big box health care.

FIGURE 1

FIGURE 2

(1)Ling BS, Klein WM, Dang Q.  Relationship of communication and information measures to colorectal cancer screening utilization: results from HINTS.  Journal of Health Communication. 11 Suppl 1:181-90, 2006.

California Hospital Group Seeks to Coordinate Care - Is bigger better? Maybe not.

California Hospital Group Seeks to Coordinate Care - WSJ.com

This article gets right at the crux of an interesting issue in health care and health reform:  what are the costs/benefits of aggregating physicians?  It would seem obvious that larger groups would be able to achieve better efficiency and thus improve quality and reduce costs.  Indeed there are studies that link increasing size of the physician group to increased quality of care, but there is a flaw in this logic that deserves our attention.

I'm bringing up this WSJ article to point out some interesting risks that might flow from the notion that 'bigger is better' in health care.  Health care is about people not institutions.  Institutions are self-perpetuating organizations and have agendas that might not coincide with the best interest of the people they purport to serve.

I quote from a report written by Laura Tollen (of the Kaiser Permanente Institute for Health Policy) for the Commonwealth fund. This report is representative of the studies of the issue of size of group and quality.  It has a number of interesting and nuanced findings. Tollen's conclusion in the executive summary:

Today, the state of that evidence is not great, but it is good enough to be intriguing and to prompt further study.

Too many of our policy discussions devolve to sound bites and ignore important nuance.  Right now one can wander the virtual halls of health policy folks and hear all sorts of talk about how we have to get doctors to join Accountable Care Organizations centered around hospitals.  Why?  Well the literature clearly supports that as the approach to improve quality and reduce costs. 

Hold on a minute!

Tollen's very well reasoned analysis of the literature (done by a person steeped in the culture of huge vertically integrated delivery systems) say no such thing.  In fact she notes that there is no clear understanding of links between organizational attributes and quality:

Until a better understanding is reached of how specific organizational attributes contribute to systemness, however, policymakers should strive to create an environment that rewards quality itself (rather than tying incentives to organizational attributes).

The Ideal Medical Practices project worked with volunteer solo and small practices.  We demonstrated that solo and small practices were able to measure and improve the quality of care.  We published results in peer reviewed journals.  The work has been cited by others.  The popular press has picked up the more titillating aspects (though sometimes missing more important points).

The important point is that small and solo practices are able to deliver high quality care.  With results better than a system with a robust quality improvement arm, we question the notion that bigger is better.

Further muddying the notion that big is better we as a nation have a wealth of negative experience with institutional delivery of care: it is often cold and distant, inhumane, lacking in dignity and respect, inflexible, unresponsive to individual needs, and very very expensive.

Many health delivery systems organized around hospitals appear to be more interested in maintaining market share and driving revenue than they are about quality of care.  This bold statement comes from repeated experience of watching front line office practices teams receive little or no support for quality improvement if that improvement would lead to reduced emergency room or hospital use.

"We can't continue our primary care improvement project because it results in fewer people going to the hospital, and we receive our funding from the hospital."

The first time I heard this response I was shocked, but over the past decade that shock has worn off due to repeated experience.

I do not mean to imply that big is necessarily bad.  Kaiser, Group Health, Geisinger and others all demonstrate high quality big organizations.  I do mean to state that big might be bad or good and small might be good or bad.  Size is not the issue.  Quality is the issue. 

I want to state clearly that policy makers must stop supporting and repeating the notion that big is necessarily good and that we have to get rid of small practices.  I like the idea of practices working collaboratively to improve outcomes for their individual and collective patients.  Let's continue the work we've done in the Ideal Medical Practices project and enroll solo and small practices in high quality groups that support them in improvement.

As Tollen concludes:

Until a better understanding is reached of how specific organizational attributes contribute to systemness, however, policymakers should strive to create an environment that rewards quality itself (rather than tying incentives to organizational attributes). [emphasis added]

I'm nervous about Accountable Care Organizations (ACOs)

Getting a handle on runaway health care costs is making a lot of very smart people bust out in a cold sweat.  The Health Reform legislation doesn't appear to fix how we deliver health care or how the money flows in the system - the two changes we must have if we are to get better results and 'bend the cost curve.'

Some very smart people in a cold sweat are proposing Ambulatory Care Organizations (ACOs).  The idea is simple - a vertically integrated delivery system can better manage costs since it has control of the vertically integrated system.  Give them a lump sum payment that on the average will reward them for the judicious use of medical resources.

So far so good.

The problem is that the experience in the past has not lead to the golden land of judicious and appropriate use that reduces costs while delivering excellent care.

Hospital are typically the anchor of these systems and if they do a good job to reduce the big ticket costs they have to slash the throat of their own cash cow: the hospital.  Hospitals make money on all the high ticket items done no matter if that is something helpful to the patient or only helpful to the hospital's bottom line.

In theory ACOs are a great concept but what will happen in the real world?  Science tells us that past behavior is the best predictor of future behavior.  In the past when hospitals and large systems took total risk as Managed Care Organizations (MCOs) most of them felt bad about taking the knife to Bessie and things muddled along pretty much unchanged (hence the current flood of perspiration).

I don't think hospitals or the people who run them are bad, but their organizational behavior in the past does little to convince me that they will perform any different as ACOs than they did in the past as MCOs.