Paper - Death by a Thousand Cuts

Great example from my practice yesterday on why EMR (Electronic Medical Record) adoption is critical to improving healthcare in the U.S...

There are some studies out there, and some loud readers of them, which argue that EMRs have never been shown to improve health outcomes. The argument goes that it's a "cost imposition" on practices to adopt these technologies with no clear benefit to patients. My day to day experience screams nonsense. The "benefits" of good communication and coordination of care are hard to measure in a system lacking these attributes, but that doesn't mean benefits aren't available. It just means you can't weigh something until you have some of it.

When my staff and I interact with practices that still document medical visits as if it's 1984, what we experience is a system with very poor communication patterns with patients and between physicians. Yesterday, I called a practice to which I send a large number of patients for consultations because we've had a consistent problem getting reports sent back to us. The excuses given by the office manager boggled my mind, "but doctor - we have PAs who see patients and their written notes need to be dictated and then reviewed by the doctor before being signed and sent to Medical Records and then brought back to the chart and we always make sure that after that we send..." yadda, yadda, yadda.

It's simply not acceptable that we continue to describe our dysfunctional and antiquated healthcare processes rather than stepping back and saying "wait a minute - a six week process for developing and sending a note can be streamlined to a few minutes with very minimal investment." Get an EMR, use it to document visits at the point of care, click on the button that says "send this report to consulting physician" and be done. It's just not that complicated, except that we lack the vision for simplicity.

I generate and send specialist referrals in the exam room during my visit with the patient. It takes about 30 seconds, reinforces to the patient the importance of making the appointment, and saves our office staff from the pointless form creation and faxing that wastes time and money. No other industry still operates as if nothing has changed in 30 years; only healthcare, with it's indefensible disconnect from quality improvement gets away with this nonsense.

By the way, I spent nothing on my EMR that documents visits, sends direct referrals, replaces written prescriptions with secure electronic ones, and allows me to access records anywhere and anytime that I have internet access. It's 2010. Very cheap or even free technology is ready to escort U.S. healthcare into this millenium if we have the vision to stop describing and start changing how we operate.

Insurance and me - so far so good...

Two months ago I made the difficult decision to start accepting major medical insurance at Ponce Primary Care. We became convinced that our use of technology and our commitment to keeping our overhead low would allow us to maintain the pillars of our practice (accessible, personalized and comprehensive care) while billing insurance companies for patient visits. This was a major change as in my previous professional life I came to see medical insurance and exceptional primary care as being mutually exclusive. Good news. The two month scorecard = so far so good.

We've found billing insurance companies to be surprisingly easy. A big part of this is that in keeping our promise to limit the size of our practice we generate fewer bills, which of course lowers the absolute number of hassles. Our paperless office is also a big deal as large insurers do much better with electronic claims. We don't have to translate my number scribbles into claim forms - an expensive and error-prone process that handicaps many practices.

We still offer simple visit fee schedules for those without insurance and membership plans for those who want services that medical insurance doesn't cover (direct cell phone access to the doctor, phone visits when appropriate, after-hours appointments, etc), but we've made it easier for many to get exceptional care by broadening the payment options.

I still believe that in an ideal system medical insurance would be limited to covering catastrophic events and we would all pay directly for routine care. The entire system would be much less expensive given the dramatically decreased cost of administering such a system. We could easily finance a safety-net program for those who truly couldn't afford care with a fraction of the savings. However, the recent healthcare law, if implemented as written (a big "if"), will dramatically increase rather than limit the role of insurance in healthcare. I'll continue to advocate for reversing this trend. In the meantime, visit www.ponceprimarycare.com to see how we're balancing an imperfect system in order to provide our patients with the best primary care I can imagine.

What we value...or don't.

An anecdote from the front lines of primary care...

A woman calls our office asking "do you fill out these sports physical forms?" No established relationship with the practice - just a mom needing her daughter's "forms filled out" for a sport starting the next day at an expensive private school nearby. "We have a pediatrician...but they can't see us today? Can you?" Given my practice structure we're able to offer a sports physical later the same afternoon. "How much will it cost?" Eighty dollars is the answer...much less than we would collect from an insurance company if we billed them for such a visit. "Eighty dollars! Walgreens will do it for $60!"

Do they have doctors at Walgreens? Is there any value at all in having your daughter's heart listened to by someone who went to medical school? Is there any value at all for a practice's ability to see someone on short notice? Does quality primary care still matter...or should we just go the "forms department" at our local convenience store for our care? Over $20k per year being spent for this girl's high school education and I have to justify why the care I provide as an accessible, quality physician is worth $20 more than what is purchasable at Walgreens.

I wish stories like this were rare. The truth is that primary care has been so systematically devalued by the government, third-party payors, medical schools and even many physicians that this attitude is neither unique nor surprising. We need to do a much better job of explaining that health outcomes are significantly improved when primary care physicians are the first point of contact for patients. We need to do a much better job of explaining the various roles of physicians, nurse practitioners and physician assistants and when they are and are not interchangeable. We need to do a much better job of enlisting our specialty colleagues in the fight to save primary care in this country.

What's in a name?

What exactly is a family doctor? How about an internist - is that a person who specializes in an organ called the "intern"? If so, where is this mysterious organ located? What's the difference between a pediatrician and a family doctor who takes care of kids? Fundamentally, people need to know where to go first when they get sick or want a doctor to help them stay well. The divisions we physicians have created within primary care don't help patients answer this question.

The organizations who claim to represent these groups of doctors, namely the AAFP (American Academy of Family Physicians), the ACP (American College of Physicians) and the AAP (American Academy of Pediatrics) have failed to effectively coordinate their efforts to support primary care doctors. Too often, we've spent our energies promoting narrow agendas. Pediatrics claims the ethical ground as the ultimate advocates for kids. Internal medicine claims the "evidence" ground; they're rightly serious about the science of disease. Family practice claims the stump for the doctor-patient relationship and treating the "whole person."

All of this is noble and good-intentioned but fails to aim at the right target. Primary care is dying in this country. The average age of primary care doctors has increased significantly in the past 10 years and alarming percentages of those doctors want to retire early. Quality medical students are avoiding primary care to a degree never before seen. The vast majority of young doctors finishing their residencies are choosing to extend their training by a couple of years in order to specialize. It's an unsustainable situation largely ignored in the debate on healthcare. Until the primary care physician community that includes general internists, pediatricians and family physicians gets it's act together to advocate in a united way for our patients, the problem cannot be solved.

The size of our patients and whether we treat whole families or specific age ranges of patients may determine what tests we take when we become board-certified. It may have dictated which ICU we haunted during the endless nights of residency, but it does not define our responsibility to society. We hold a sacred trust to advocate for a system that supports accessible, comprehensive, personalized and coordinated primary care for patients. We need to get collectively focused on that. We need to stop angling for relative respect under the disrespected umbrella of primary care and start collectively leading healthcare transformation. Our patients deserve and want just that.

Enshrining the status quo...

We can tell a lot from the groups that have come out in support of the Senate's insurance reform bill and from those whose "opposition" is muted and disingenuous. The American Medical Association supports it, but threatens to withdraw support if the Sustainable Growth Rate formula isn't overhauled. Translation: We like the current dominance of fee-for-service reimbursement through third-party payors because it protects the incomes of most of our members who are specialists. We just wish the formula paid us even more.

The American Hospital Association supports it, but would also like provisions added that reduce the threat of Medicare reimbursement reductions for hospitals with high readmission rates. Translation: Like the AMA, we too like fee-for-service reimbursement based on volume of procedures and tests rather than quality. The system of disease focus rather than health focus serves us well as we're clearly in the disease business.

The Insurance industry publicly "opposes" the bill under the veil of "we care about our members - and think their premiums are going to go up." Simultaneously, they've quit spending much money or energy on stopping this thing, which they could clearly do if they wanted as a number of Democratic Senators are tied very tightly to the insurance lobby.

It's a classic and usually effective political strategy. They've set up the "I told you so defense" in advance so they can raise insurance rates after the no-preexisting conditions rules kick in. They then profit nicely from increasing premiums while the new laws force younger, typically healthier-than-average, and thus profitable people to buy insurance they previously decided they didn't need. Beautiful perfect storm. The Democrats provide the publicity cover, and the Insurance industry gets a mandate to take over even more of the health care pie.

Speaking of pies...by what logic does the growth of this pie slow under this plan? We provide more people with someone-else-pays-for-it access to a system still based upon doing rather than thinking, testing rather than listening, and treating rather than preventing. Any claims of cost savings are completely baseless...and cost containment is the whole deal. There's no reform without it.

Primary Care's Toxic Environment

In his blog (linked below), Dr. Richard Figaro captures the toxic environment that is killing primary care in this country.

Crocodile Tears Over Primary Care - Lamenting Primary Care

I agree with his points but wish he would emphasize that primary care doctors are not powerless. Patients respect and value what we do and in my experience will pay us directly for their care. Refusing to submit to the nonsense that DrRich describes in his blog is the most important step to keeping our costs low so the price of great care is accessible. See my practice website, www.poncepreventive.com, for specifics on how this can work.

Marital status needed to make an appointment?

Bizarre experience today as I again experienced as a patient the parallel universe that is healthcare in the U.S.

I'm turning forty this year so decided to make an appointment for a physical with my primary care doctor. I called the office and was told that the next physical available was at 3:30 pm six weeks from today. Not commenting on the lack of reasonable access, I asked if an early morning appointment was available so I wouldn't have to fast all day before my visit. "Why does that matter?" asked the receptionist. I can't imagine why it would be more unpleasant to not eat until 5:00 pm than to delay breakfast until 10:00 a.m. The receptionist couldn't imagine that either. She then informed me that the next morning physical available was in April. I'm an established patient of the practice that espouses access, quality, etc. all over it's website and they can't see me until April.

So I call another practice...a big one here in Atlanta with a strong, serious reputation. Access is better (three weeks rather than six until their first appointment), but the person on the phone proceeds to "get my information." Included in this antiquated process is the question "Are you married, single or divorced?" What? Why is my marital status the business of whoever answers the phone at a doctor's office? How is it relevant to my making an appointment with a physician? In addition, what if I were "none of the above"? I was tempted to say, "I'm a gay male previously divorced with six kids, now married in Massachusetts which isn't recognized in Georgia - so just call me single." Would have been great to hear the silent pause after that. Many of you know that I'm neither gay nor divorced and have two kids. I've only been to Massachusetts a couple of times in my life. The point is that the question would never be asked in any industry that treats clients like customers. It's rude - like a lot of healthcare in the U.S.