Draft: front line provider statement on why we ask patients to pay more

The Ideal Medical Practices non profit organization exists to support health care delivery that aspires to an ideal.  The policy and payment environment in the U.S. right now is so far from ideal that it is in many ways toxic to our patients and toxic to our practices.

Funding the full scope of primary care is a fundamental solution yet all we see from the front lines is more lip service and unfunded administrative trivia burden that hurts the quality of care we would deliver to our patients.

Our organization focuses on quality yet more and more primary care providers are being forced either to quit their practices and re-join hamster wheel institutions or to explore other financial means to keep our doors open.

For that subset of our members we are drafting a statement to explain their choice to charge their patients extra fees.  This choice does not come easily or lightly and is based on complex environmental factors mostly outside of the control of these clinicians and the patients they serve.

We draft this in a public environment because we believe the ultimate solutions to the problem are available to policy makers but are being thwarted by those who benefit from the status quo.  Too many powerful interests feed in the health care trough at too great an expense to us all. A frank and open discussion can help shed light on the situation and explain this painful choice made to survive this toxic health policy environment.

Health policy discussions have lead to heated political posturing and some use the topic to whip up emotional frenzy for political gain.  The goal is not political, the aim is not emotional frenzy.  We are of many different political stripes but we come together to address policy that currently rewards volume of services while punishing real quality.

Please do comment on the issues in this draft but expect that political diatribes will not likely survive the comment moderator.

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We've often discussed the difficulties faced by primary care in a toxic policy and payment environment.  We've discussed 'dead zones' where lack of subsidy predicts financial demise of the practice.  We've put our houses in order with careful attention to (and reduction of) overhead.  Consistent with the national agenda we use technology to improve efficiency, yet in spite of everything we continue to suffer from payment policies that punish us for attempting to fully meet our patients' needs.

There is enough money going to health care in the US to fully finance effective primary care.  All it would take is shifting 5% of the budget to primary care so that we could guarantee payment to practices that:

• Allowed the practice to get off the hamster wheel
• Deliver superb access and relationship
• Demonstrate excellent communication
• Use technologies and processes that allow us to perform patient care gap analysis and outreach to those who fall through the cracks

Standing on the shoulders of giants in research we have demonstrated our willingness and ability to hold ourselves accountable to our own behaviors that predict good patient outcome and we have demonstrated our ability to achieve threshold improvement in those outcomes.

Yet still those that dictate policy and payment continue those policies that reward volume and punish quality, that reward infrastructure instead of care, that feed armies of consultants, arcane and Byzantine measurement companies instead of the front lines that actually deliver the care Americans want and need.

We could leave our practices and go back to the volume mills and institutional settings with their 10 minute office visits, where patients are known by their numbers, where productivity is king and compassion is tag line on an ID badge.  We choose a different path. 

Some of us choose to focus on our patient's need but to remain financially afloat in an environment where institutions hold all the financial cards.  We have already cut our overhead to the bone.  To remain in practice more and more of us are forced into the difficult position of having to ask for even more money from our patients when they have already paid too much for too little.

This is distressing to us as it is obviously not the solution our country needs but we despair at the ability of our politicians and policy makers to come to a reasonable and rational solution in the near future and we are unwilling to further compromise our patient's care.  This partial and hopefully temporary solution leaves some of our fellow citizens with an insurmountable financial threshold for the care we would deliver but to continue in the current paradigm is to enable it and we can no longer do so in good conscience. 

With these fees - that should be coming from the exorbitant premiums people and employers are already paying - we are able to:

• Provide superb access not only with same day appointment availability but with virtual visits, and online communication when clinically appropriate
• Take the time we and our patients need to address not only the presenting problem but address unmet health needs and to negotiate care plans that join our clinical knowledge with the individual's context
• Implement systems that help us perform analysis of gaps in prevention and chronic conditions and have the time/staff to reach out to those who have difficulty following up
• Provide the kind of care coordination our patients need as the navigate the complex silos of health care

With these extra fees we are able to help our patients achieve better health outcomes and improve their experience of care.  As predicted in the literature this level of care results in reduced hospitalization rates and reduced emergency room visits, thus reducing the total cost of health care.

While the current stakeholders in the status quo meet and talk and pontificate, they are paying only lip service for effective primary care.  The solutions offered by 'medical home' and other projects offer inadequate funds in exchange for a significant increase in administrative trivia that increases practice overhead - the opposite of what we all want and need.  These top-down solutions appear designed more to support the status quo by soothing national anger with sound bites and feel-good initiatives.  Success in these programs is designed around the size of the institution - the bigger the institution the more likely they are to 'win' - at the expense of real and substantive change.

An ever increasing number of primary care physicians, nurse practitioners and others are asking patients to fund this work while we all wait for better solutions from on high.  The practices come in many shapes and sizes:  high cost concierge practices for the rich and famous down to low cost primary care for average Americans looking for an alternative to high cost industrial health care.  Some practices accept only direct payment and some continue to accept insurance payment while asking for an additional fee to cover what are currently extraordinary services.

In the absence of reasonable and rational policy the solutions are as varied as the number of practices, but all are designed around better meeting the needs of their patients.

This level of care should be available to all.

Comments

[Drmavromatis]

I would emphasize that we are in favor of allowing patients to have choice in the type of primary care that they receive.

Here are my views:

Health policy and economics are pushing health care more and more toward the delivery of care by large employed groups of physicians. In the future policy will likely continue to favor change that fosters use medical technology and the large health care team to ensure primary care delivery to large panels of patients. These health systems, if successful, may be able to deliver inexpensive, high quality care to their patients, though will likely continue to de-emphasize the doctor-patient relationship in doing so.

We believe that patients deserve to have another style of primary care available to them. Our smaller practices place a high value on the doctor-patient relationship. We value a higher level of access and communication with one's own personal primary care physician. Unfortunately our type of care in not supported adequately by health insurance in the current environment, despite the high premiums paid by most patients. We hope that in the future patients will retain their ability to choose what type of primary care setting and doctor-patient relationship they prefer. But for now our non-insurance covered fees enable us to exist and deliver a type of primary care that we feel is worth investing in.

As activists, it is our hope that health policy and insurance reform will support practices such as ours in the future and will make our type of care a viable option for all patients.