This is from a colleague who prefers to remain anonymous so as not to offend any of the other parties in this tale.
I wanted to share a recent experience to encourage you to keep slugging along...it can be worth it.
59 yo. Vietnam vet joined my practice 2 months ago. MI 5 years ago with two stents placed. Smoking a pack per day, BP 180/120, LDL 160 and taking zero meds (i.e. not even aspirin for the stents). Primary reason for not taking the meds was that he'd been placed on a number of non-generic meds Toprol XL, Plavix, Crestor, a non-generic ACE etc. His prescription bills would have been over $200 per month in copays alone.
The notes I received from his previous provider were typical template nonsense: a bunch of check boxes not amended from visit to visit, a "smoking cessation" recommendation checked in every plan section, all of the appropriate diagnostic ICD codes for CAD, HTN, hypercholesterolemia etc. automatically generated for every visit. All the P4P crap appropriately tagged and not addressed. There are probably 15 seemingly identical visits billed to Blue Cross Blue Shield with absolutely no evidence that anything was ever done for the conditions. Most of these were probably 99214 visits so the doc got paid somewhere North of $120 x 15 for apparently doing nothing but visiting with a patient for 8 minutes or so per visit and submitting a templated and barely amended chart note. Of course his abnormal and completely unchanging cholesterol was checked every 2 months or so along with non-evidence based comprehensive metabolic profiles and other random labs. All paid for by over-priced and wasteful insurance. Ridiculous.
Over the first month we got him on aspirin, generic metoprolol, pravachol, and lisinopril/HCTZ. Total med cost $16 per month with or without insurance. His pressure normalized and he quit smoking. Unfortunately, he developed atypical chest pain two weeks ago and his stress echo was positive.
Here's where a relationship like those the docs on this listserve have with their patients can matter. I have no way of knowing where or even if fault lies on either person, but the patient and the cardiologist who gave the stress test news didn't get along. The patient walked out of the clinic with chest pain to catch a flight to visit a relative. Fortunately, he called me before he left, and we were able to talk through the risks of traveling and make it his decision on what to do. He stayed in town, developed persistent pain that night, presented to the ER and was admitted for catheterization.
I went to the hospital where I don't have privileges to monitor his admission process. The docs there had no way of accessing his med list, no way of accessing his previous cardiac records, etc. They couldn't even locate the stress echo results that had been done 24 hours earlier in the same hospital system. It was typical admission chaos when I walked in. Doctors and nurses asking a patient lying on a gurney the details of a complex medical history while adjusting his nitro drip. Within a few minutes I printed his complete medical record off the internet (thanks PracticeFusion), helped the patient understand what was going to happen, and gave the docs/nurses the appropriate contact info for his family and myself. I wish I had a picture of the cardiac fellow's face when he saw me access a patient record over the internet. This guy probably banks on-line, socializes via FaceBook and Googles restaurants on his iphone, but in the realm of healthcare he was staring at me like I was an absolute magician for using their computer to get medical records from an outside server.
The interventional cardiologist later told him that in 20 years of practice he had never seen a non-admitting physician come to the hospital to facilitate care. I didn't think it was a big deal at all - took me about 45 minutes on a Saturday morning to be sure my patient was getting excellent, well-coordinated care. How is it possible that in the "Best Health Care System in the World" as the AMA likes to describe it a practicing cardiologist in a major city had "Never" seen a primary care doctor come to the hospital when one of his or her patients was admitted? During my training, it was an absolute expectation that we would make "social rounds" (i.e. care coordination) rounds on our primary patients if they were in the hospital on another service. Where did that expectation go?
The patient ended up getting a minimally invasive single vessel bypass a week ago and is already home. I made a house call on him yesterday and he's doing very well. Of course, the hospital discharge made him an appointment with the cardiologist he didn't like in the first place. We'll be changing that appointment today to make sure we continue to provide relationship-based care.
When you get tired of beating your head against the wall of this mess we call U.S. healthcare, please remember that what you do matters. Our patients still need us.
Cheers, Dr. X
Take a look at this nice piece from Anchorage Alaska on IMP Dan Steward.
IMP doc Marty Schulman is featured in this KPBS piece on concierge medicine.
The good news is that people are starting to recognize the value of practices that take the time to care for their patients. We haven't solved all the health problems of the US, but we're doing what we can to improve care and keep the hope of primary care alive.
I know some health policy folks will hear Dr. Steward say he's caring for 800 people and worry about exacerbation of the primary care shortage. These policy folks need to better understand the source of the shortage. The primary care shortage is due to the intolerable nature of primary care as a career choice. We don't solve the problem by forcing docs to work on a production mill basis, seeing patients as "billable visits" rather than as human beings.
These practices exemplify the caring and compassion that are the core of our profession. Too many of our colleagues are trapped in jobs that daily erode their ability to maintain compassion in the face of productivity targets.
The choice between "maintain primary care supply through high volume care" versus "deliver compassionate care to fewer people" is false. IMPs have changed the paradigm of care, focusing on compassion, relationship, and care. The choice rests with policy makers to support this type of care for all people.
The health care clinicians do not choose the financing paradigm that limits choice and rations care - that is the choice of our policy makers. It is time for new policy.
Real health reform should provide universal access to practices like this.
Lots has been written about the wasteful administrivia that primary care physicians have to engage in to provide our basic services, like getting a patient the appropriate medication. Recent studies published in Health Affairs have estimated annual costs to individual doctors in large groups of over $85,000.00 a year, just for the overhead of getting authorizations and dealing with insurance companies for billing and case management. Primary care physicians, especially solo or in small groups are hit even harder. But the real problem is that our system hurts patients and sours doctors by forcing them to do unpleasant, wasteful tasks that do not benefit the patient or the health care system in any way, while raising the costs to the system as a whole. The biggest cost is that primary care physicians get so disgusted that they retire early, or move into other kinds of practice, such as cosmetic medicine or urgent care, where they do not have to deal with actual long-term patient management.
Let me give you an example of how I spent the last hour today:
I have a patient (let’s call him “Joe”) I have been treating for the last 15 years with a problem for which the medications we had tried would lose their effectiveness over a period of months to years. The specialist who treats his daughter for the same problem, recommended that he try a new medication, which was working for his daughter. Joe asked me to prescribe it, and I researched it and agreed it was reasonable to try, so I wrote him a prescription.
A week later, Joe’s pharmacy faxed me a note indicating that I needed to go through a preauthorization process to get the medication authorized. They sent me the only phone number they had for this, which was for the patient’s pharmacy benefit manager, so I called it. The phone tree did not have a choice for “doctors who want to preauthorize something,” so I chose one of the selection choices, waited on hold for 5 minutes, and got a pleasant woman who needed to verify my name and DEA number, Joe’s name, date of birth, SSN, and employer. The nice woman put me on hold for a couple more minutes to look things up, and then told me that I needed to be transferred to the preauthorization department (which I told them at the beginning). She kindly transferred me there.
After 5 more minutes on hold, I was connected with another pleasant woman who once again had me provide my name and DEA number, Joe’s name, date of birth, SSN, and (after a couple of more minutes of waiting) I was told that I need to get this authorized through the insurance plan. She kindly transferred me there.
After being transferred again, and after about 5 more minutes on hold, another pleasant and helpful woman asked me to provide my name and DEA number, as well as my Tax ID Number and the name of my practice, Joe’s name, date of birth, and Social Security Number. After checking for a minute or two, she told me that that this actually has to go to customer service. She kindly transferred me there.
Customer Service was quite busy, so it was 7 minutes on hold this time. A pleasant woman answered the phone, and after I had provided my name, practice name, Tax ID number, DEA number, Joe’s name, date of birth, SSN, as well as Joe’s age and diagnosis, and I am told that his employer will not allow them to dispense medications “in that class” without a written letter of medical necessity. She couldn’t explain why he had tried six other drugs “in that class” without needing to get a preauthorization, nor could she explain why his daughter, who has the same diagnosis, was provided this medication without preauthorization from her company. She did give me number to fax a letter to, and told me I needed to document his diagnosis, all of the medications he had tried, the outcomes of each of them, and why I felt it was necessary that he try this new medication.
Everyone on the phone was nice, and all of these conversations were recorded to prove it, but the bottom line is that it took me 28 minutes on the phone to find out that I actually needed to write a letter requesting coverage, and to find out where I had to fax the letter.
It would typically take me about 20 minutes to write a letter that documents a patient’s history regarding a given diagnosis, all of the medications that had been tried and failed, and why the patient should try a new medication, but I had some system problems with my EMR, and I had to use Microsoft Word to create a letter on my letterhead, and it gave me some trouble with the formatting, so it actually took 37 minutes to do the letter and to get it faxed out.
So, this time, it took a full 60 minutes rather than the typical 40+ minutes most of these preauthorizations take.
Most primary care offices have overhead cost of $2.00 to $3.00 per minute of doctor’s time, so the average cost of to the doctor for each preauthorization is $80.00 to $120.00 if the doctor does it all, or $55.00 to $75.00 if the doctor has staff do the phone work and just does the letter him or herself. There is no way to make the insurance company or the pharmacy benefit manager pay for this, so the doctor pays for it. In order to generate enough money to cover the cost of providing the service, a physician has to see an additional couple of patients to cover each one of these authorizations.
Most primary care doctors have pretty full schedules, so the only way they can see the additional patients they need to see to cover the expense of providing these services, is to reduce the time they allow for each visit. This results in less time available for seeing each individual patient, and the end result is that the quality and expense of care goes up because doctor often ends up ordering expensive tests (like MRIs and CT scans) that would have been unnecessary if he or she had adequate time to spend with each patient to make a diagnosis with a careful history and physical exam.
Fortunately, in my practice, which has a very low overhead (running out of the basement of my house) and which has no employees (except for my wife who volunteers to greet patients), there is no out-of-pocket cost to me for doing this. It just took an hour of my time that I could have spent mowing the lawn or catching up on charts. But, if I were able to spend the time every week I have to devote to these kinds of senseless medication authorizations (at least 3 – 4 hours a week in my half-time practice) actually seeing patients rather than getting authorizations, I would be able to provide quality primary care for couple of hundred additional patients. As it is, my “half-time” practice is actually full time and more, since medication preauthorizations are just one of many wasteful administrative tasks I have to do to make sure that my patients get even minimally adequate care. And, I turn down several new patients every week simply because there is not enough time in the day to do all of the administrative tasks I am forced to do by our dysfunctional non-system of medical care, let alone to take on new patients, too.
For medical students, when they are making a choice of what specialty they will go into, seeing primary care physicians being burned out doing pointless administrative tasks that take up half of their working hours and that do not benefit anyone, is a major turn-off for a primary care career. This is a much more important factor, according to my medical student friends, than the much lower salaries primary care doctors earn than physicians in other specialties. In order to develop the strong and efficient primary care workforce that our country needs, we need to make primary care medicine fun and less frustrating than it is now, so that someone will want to do it.
Donald T. Stewart, MD
Anna Maria Izquierdo-Porrera MD PhD describes below how it is she is able to continue to practice in and build ideal medical practices supporting vulnerable populations in Maryland.
I was at a triple aim meeting last month and Don Berwick used a metaphor that resonated tremendously with me. Let me share it.
He and his wife a building a house in the forests of the Northeast that will ran with 2000 watts (the equivalent of a hair drier). They are very committed to the endeavor. They have people around them giving advice and designs but they are faced with tough decisions at every turn. They are investing time, money, energy and personal interest. At the end though they will have a model, they will have learned how to build a 2000 watt house and when the time is good and the political and social climate changes making a 2000 watt house the acceptable option he will be there to teach us how to build it.
This is what we are doing. We are learning how to build a 2000 watt house of medicine. We are learning how to provide spectacularly good care. We have choices before us but if we manage, when the political and social climate changes we will be there to teach them how to do it. We will be the proof it can be done.
Me, personally... I sleep very well at night knowing I am doing the right thing. It may not be very economically sound but in my book a good night sleep is priceless.
Never give up, never surrender!
I met Beatrice (not her real name) a little more than 2 years ago. She had just turned 90, and her daughter brought her in because she had been feeling a little more tired and short of breath lately. As she put it, she was having problems "getting going" in the morning. She had rarely been to a regular medical doctor, preferring homeopaths, in line with her beliefs as a Christian Scientist.
Up until a year before, she had been living for 19 years in Ojai, CA, 9 of them with her husband who passed away 10 years earlier of lung cancer. She had been active and doing yoga up until 1 year earlier when she fell and broke her arm. Ever since then, she had been living in an assisted living facility closer to her daughter. She had also been developing signs of Alzheimer's dementia over the past 4 years.
Beatrice was a pleasant and cheerful woman who acknowledged having some memory problems but kept repeating over and over again how “grateful” she was for her life so far. She proudly told how she was one of the first female bank tellers before she became a permanent homemaker. She also mentioned how throughout her life she never liked to take medicine or see doctors.
After examining her, I discovered that she had atrial fibrillation causing mild congestive heart failure, which was also the cause of her shortness of breath and fatigue. She also scored 13 out of 30 on her Mini-Mental State Exam, consistent with moderate dementia. Beatrice went home without any medications because her daughter wanted more time to think about what to do next. This first visit took 90 minutes.
After a series of e-mail communications and a follow up visit, we agreed to start Beatrice on some medication to help her breathe better. Over the next few months, she gradually improved with medication to the point where she was breathing comfortably again. Her daughter told me that while Beatrice couldn’t remember anything about what we had talked about, she did remember me and liked me.
I would see Beatrice several times for follow up over the next 12 months, and even though she couldn’t remember what she had for breakfast, each time she would smile and say how “grateful” she was for everything. That seemed to be the one thing she would never forget. She remained stable as far as her breathing but her dementia continued to worsen ever so slowly, and eventually she started having trouble with agitation and even remembering who her daughters were sometimes.
Unfortunately, this happens all too often with many elderly patients in this day and age. Even as you wonder if this is the kind of life they, or anyone, would want to have, it is often too hard to stop giving medications that you know are helping to keep someone alive.
In a typical busy doctor’s office, there just isn’t enough time to talk about what is really important to her or her family. It would just be assumed that we should just do our best to keep her heart from going into rapid A-fib and developing congestive heart failure, and to do otherwise would be unmerciful. And so, Beatrice would continue to take her Digoxin and Lasix, and her mind would continue to gradually wither away, losing bits and pieces of herself as time went on.
And eventually she would get a stroke and lose her ability to walk, speak or feed herself. Or she would fall trying to get out of bed in the middle of the night and break her hip. And she would end up bedridden and develop pressure ulcers on her fragile skin. And finally, if she didn't die of something else first, she would end up in a “persistent vegetative state”, her self-awareness gone, left with only a thin, frail body curled up in a nursing home bed, kept from malfunctioning further with well-intentioned medications, waiting to die.
That is, she would have if she had received care as usual.
Instead, I had long discussions with Beatrice’s two daughters that started 9 months ago, in person, by phone and by e-mail. We discussed the likely outcomes of continued treatment along with that of stopping treatment. We discussed adding medications to treat her agitation and anxiety and their potential side effects. We discussed what Beatrice valued in life, what her preferences would have been and what she would have chosen for herself, if she were able. We discussed their concerns that their mother not suffer.
After 4 months of discussion and reflection, her daughters decided that a palliative approach was what their mother would have wanted and started inquiries into hospice programs. A month later, she had enrolled with a hospice program, and I stopped directing her medical care, since the hospice program already had a physician.
Yesterday, I received an e-mail from Beatrice’s daughter saying that, after a few weeks of terminal agitation, her mother had passed away peacefully.
I’d like to think that Beatrice was grateful to go this way.
I'd be grateful if every primary care physician could be given the time and paid for the time to do the right thing for their elderly patients, rather than give "care as usual".
John is probably squirming over the "unsung heroes" part, but he is one to me, so I though I'd call it out.
Here's his story:
Just a little today example of why this sort of practice is worth it to me, and why I hope it can survive.
80+ y/o lady comes in with her nurse daughter. Has been declining cognitively and physically for years. On presentation, obviously has dementia, bad edema. Still lives alone, needing more assistance from family, but denies she has much of a problem. Has only been seeing her gyn, who tried to send her 1.5 hrs away for neuropsych testing, but pt would have none of it.
If I was still in a fast-paced practice: I would have been frustrated by the slow history-taking. Would have managed a rushed MMSE (mini mental status exam). Would have given her Aricept that she would not have taken. Would have tried to send her to a consultant to confirm her diagnosis, and she would not have gone. Daughter would have been quite frustrated at not getting enough answers. Appropriate care would have been delayed, and the patient may not have been safe.
Today, I was able to spend nearly 2 hours with this patient. We didn't get to everything, but we became comfortable and respectful together. We completed a full MMSE, a fascinating clock-drawing test, and a vascular dementia score, and basically confirmed the diagnosis of AD-type dementia, although we are doing a few tests to screen for other issues. She was comfortable with a trial of medication. We discussed safety and prognosis issues at length and are getting a full home evaluation and assistance through home health. Maybe, when she's ready, we'll get a neurology consultation. We were able to meet (figuratively) where the patient and her daughter were, not where I was in my day, even though I was awfully busy.
This is why I do what I do.
Unfortunately, my ability to provide for my family would have improved if I had spent 30 minutes, ordered more tests and consultations, written a prescription, and had her return with great difficulty for a 15 minute visit next time. We saved the system a lot of money today...a shame that a portion of the savings came out of my pocket.
John Watts Haresch, MD
Kill Devil Hills, NC
Just thought I'd share a little story that reminded me of why it sometimes makes sense to work this hard, because sometimes the system works.
A woman, pretty healthy, very active, a few medical problems, had a breast biopsy 2 years ago. She had bleeding complications from the biopsy and had to be transfused, then had a bizarre transfusion reaction, but in the end the biopsy was benign (after 2 weeks and much drama in hospital).
Last year she had another vaguely abnormal mammo - obviously not anxious to jump to biopsy again. Surgeon recommends MRI (reasonable). The patient stalls and stalls and stalls, afraid MRI will show something that needs biopsy again and she will be forced to make a tough decision.
She finally schedules the MRI. Day of the MRI she asks the brilliant question of the safety of MRI with a St Jude heart valve (d'oh! I hate when I miss stuff like that, and I thank God for smart patients). The MRI tech looks in her book, says it should be fine, patient decided to call the cardiologist.
The cardiologist NP is one of the smartest and most caring people I know. She called the radiologist, looked online, and investigated the serial number of the patient’s particular heart valve, found that it does contain some tungsten and would "probably be safe" in a less-than-3-tesla MRI, but after talking to the radiologist decided that the chance of artifact rendering the test useless was high and that "probably fine" wasn't good enough.
Then she called the patient and they discussed the risks and benefits, then, then (this is where it gets good) she CALLED me to go over everything with me. (Actually she stopped by her office is on the same block). So I called that patient and now, get this, WE ARE ALL ON THE SAME PAGE!
I’ll talk to the surgeon Monday, and its beautiful. (No answer on the abnormal mammo yet). But this is what happens if everyone wants what is best for the patient and is willing to pick up the phone and act on it.
The fact that this is so rare sort of bugs me, but for now I am basking in the moment that if we work together we can provide good care.
And I'm not even a NCQA certified PCMH.
Elizabeth Crowley, MD
Cape May Courthouse NJ
I plan to work on NCQA certification for a patient centered medical home very slowly.
I fear that by just saying “bah humbug” immediately gets me dismissed as someone not interested in moving family medicine forward, but if I were able to qualify as a Level 3 PCMH (and I think I can), then hopefully I can work from within the system to tell people the certification is ridiculous and will not result in a better or more efficient system. Why?:
1) A huge portion of the PCMH is database stuff—Do you have the EMR necessary to collect the data? Do you have protocols for how to handle the collected data? Do you have authorized personnel who can then translate the data to the patient and to the government?
My tangential question is “how many docs enjoy doing billing?” The answer is, of course, none. Why? It is a mind numbing, frustrating, infuriating process of data processing. So, how many docs will do their own data collecting? Well, none. So are we just creating an entirely new field of “chronic disease analyst” so we can then pay someone else the extra income we are making (if we make any) so the appropriate boxes will be checked? Well, yes. So how does having more people between the doctor and the patient strengthen the doctor-patient relationship and how does that impact a med student’s decision to choose family medicine as a career?
2) The PCMH criteria are skewed toward large practices—I have to write up protocols stating that I have written guidelines on how to treat diseases so all the providers (which would be me) follow the same guidelines. Umm, I hope that I am relatively consistent with how I treat my diabetics, but the protocols must be written anyway.
3) There is little evidence which shows incentive payments for data analysis actually improves outcomes. This is a little scary to talk about, but there was a study (Coleman et al., “The Impact of Pay for Performance on Diabetes Care in a Large Network of Community Health Centers”) which showed that P4P initiatives lead to increased testing, but that there was little impact on the results. In fact, overall HgbA1C went up showing that getting the data does not necessarily mean that data will impact the patient’s life resulting in better outcomes. Think about this for a moment. The entire argument for the patient centered medical home is that it will save money through providing superior care, but there is paltry evidence (that I have seen) which shows giving docs incentives to meet a laundry list of guidelines works. This is no surprise because data collection is not as important as a good relationship in instigating change.
4) Does going through the process actually make a practice better? Not likely. Practices which are doing a good job will likely get certified but the process will not make them better. Poorly performing practices cannot get certified so they won’t try. Others will do what they need to do to get certified but will not change the way they practice. This is because changing behavior, even if it is dysfunctional, is very difficult (ask anyone on a diet).
I always go back to the most important question in such passionate discussions. Does what I am doing improve my relationship with my patient? Having looked through the certification process a fair amount, I do not believe getting certified will. And, if it does not improve that relationship, then it will not succeed in improving quality or stopping the failure of primary care to recruit new docs into the ranks. Unfortunately, my fear is that it is a potentially dangerous distraction at a critical time in our specialty--which is why we need to speak up now.
John Brady MD
Newport News VA
We are not going to do ePrescribing.
We will not do NCQA.
We are high tech/high touch ideal medical practice.
We have documented quality measures 15-25 % above national norms with the ACP:Center For Practice Improvement Project with Dr. Michael Barr.
We have been audited for being a medical home by consultants from ACP, but found we did not have eprescribing and a few other technical shortfalls on the medical home.
They did find great quality and cost effectiveness. They did think this is what was needed in the solo-practitioners office across America, but they could not quantify it by NCQA standards.
I could. The cost of PQRI reporting was higher than the reimbursement. The quality was already there. We only have one patient with A1C above 9. Why report on all those that are controlled? We worked for over one year with Illinois State Quality Alliance and were one of two paperless offices that submitted data to PQRI, but they and our EMR vendor could not get the data out of our EMR. Hours and hours of wasted time.
Eprescribing has been evaluated and the added time to document prescriptions and the cost of eprescribing itself does not pay or improve the safety of a printed prescription handed to my patient or faxed to the pharmacy. Again the quality is already there and has been for the last 5 years of our practice. We run at extremely low overhead of $2/min. So any increase in time for reporting costs us and the patient money.
We did PQRI on 20 diabetics in 2008 took an extra day of appointments probably worth it.
But reporting on every parameter at every diabetic visit is not practical or prudent or financially responsible.
Lastly, for NCQA certification there has to be a benefit to my practice in efficiency, my patients in quality, and myself financially. Otherwise I am already providing great patient care and I need to be compensated appropriately.
Finally, I know what it costs to provide great quality care in a primary care setting it averages out to be about $1/day per patient across all insurance. So for $365/year or $30/month I could greatly improve services to my patients. Right now I believe medicare pays only $120/year while the patient pays $130/year on average for my services to medicare patients. That is only 66 cents per day.
America can do better.
Kevin D. Egly, M.D.