Physician Free Thyself http://physicianfreethyself.com The Hello Health Doctor Blog posterous.com Thu, 09 Sep 2010 13:53:03 -0700 Some of the hidden costs that pile on when practices are managed by health systems http://physicianfreethyself.com/some-of-the-hidden-costs-that-pile-on-when-pr http://physicianfreethyself.com/some-of-the-hidden-costs-that-pile-on-when-pr There's a little storm brewing in Pittsburgh PA.  The Post-Gazette reports that some folks are getting angry when they find extra fees on their doctor's office bill.

"It turns out that she and many other patients are expected to pay facility fees, which cover office overhead expenses such as utilities and maintenance, when the doctor's office is part of a hospital campus -- or, sometimes, even if it isn't -- in cases where the physician practice is owned by the hospital or a health system."

Read more: http://www.post-gazette.com/pg/10245/1084467-114.stm#ixzz0z4C6ztAl

Maybe that practice is offering extraordinary service.  Maybe they have implemented a system that allows patients to access personal health records, make their own appointments on line, have secure messaging when office visits are not clinically necessary.  A new technology bundle that stands out as extraordinary might justify an extra fee.

Somehow I don't get that this is the case for the people of Pittsburgh.  I get the impression that they're getting the same service as ever: access to care means running through the mine field of "Press 9 if...," playing "mother-may-I" with harried secretaries for scarce appointments, being offered a visit now with Dr. Stranger or next month with their own clinician.

The toxic payment and policy environment in the U.S. drives too many primary care practices out of business and into the arms of the local hospital system.  Some hospital systems may have a benevolent mission in their community and are trying to create environments supportive of good primary care, but too many use primary care merely as a loss-leader to fill hospital beds.

The patient is never the winner in this game.  The public deserves health care without these perverse incentives.  Hello Health practices and others demonstrate the potential of new environment in which physicians are able to offer services like those I listed above.  The experience of care in practices like this is breathtaking.

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Tue, 07 Sep 2010 11:47:13 -0700 Rational solutions to a shortage in primary care physicians in the US http://physicianfreethyself.com/rational-solutions-to-a-shortage-in-primary-c http://physicianfreethyself.com/rational-solutions-to-a-shortage-in-primary-c "Historically, general practitioners provided first-contact care in the United States. Today, however, only 42 percent of the 354 million annual visits for acute care—treatment for newly arising health problems—are made to patients’ personal physicians." Health Affairs article published 9/7/2010

We know from good research that access to good primary care is essential to any high performing health system.  This is certainly no mystery to the average person who feels more comfortable discussing things with someone they know rather than a strange doctor.  

It turns out that populations who receive care in practices where they have really good access (24/7 care not just adding office hours - that is so 1980s - but with virtual communication) and really good communication are more likely to get care before conditions get out of hand and land them in the emergency room.(1)

So can we improve the supply of primary care?  Right now too many physicians are leaving primary care because of the toxic payment and policy environment for primary care in the U.S.:  payment for a fraction of the work coupled with a truly monstrous burden of unfunded administrative trivia that keeps us from our patients' needs.

There are a number of solutions that are supposed to trickle down to the front lines of primary care: loan repayment, more funding for Community Health Centers, Accountable Care Organizations, and the "Medical Home."  These may work, but I'm not holding my breath as top down solutions often fail to recognize the reality of the front lines and these initiatives are no exception to the rule.

  • Reducing medical student loans: according to a study of career choice in 4th year medical students, loan repayment played a small role compared to the powerful dis-incentive of a beleaguered and dispirited work force limping toward early retirement and burnout.
  • Community Health Centers do great work for disadvantaged populations and some exceptional CHCs are wonderful places to work but typically have a tough time recruiting PCPs.  Federal $ does little to change the factors that limit their attraction as all too often these dollars disappear into complex budgets with no substantive change in the front line professional realities in CHCs.
  • Accountable care organizations:  unless I'm missing something the gorilla in the room is the hospital in this equation.  The are supposed to give up $$ to primary care so that we have the funding to do better care coordination, etc and prevent hospitalizations - thus slitting the throat of the hospital.  There will be some enlightened hospital systems that see their way forward in this scenario - gain market share, show good will, be part of the future - but I think too many will fail to take the high road.
  • Medical homes:  lots and lots more paperwork and unfunded reporting mandates with vague promises of extra funding that may or may not materialize down the road if the insurers feel generous.  We've tried this in the past with 'managed care' and it wasn't so good.  There are some good PCMH programs that may really live up to the vision, but there's also a lot of very legitimate cynicism.

On paper some of these strategies might address root causes of PCP misery, but if the strategies fail to materialize in substantive improvement in the day to day lives of front line PCPs these efforts will have been a waste.

In the absence of policy that lines up with the reality of the front lines there is a growing trend of PCPs taking control of their own professional lives.  Instead of waiting to see if vague promises coalesce into real change, these PCPs are facing the problem head on.  Adopting technology like Hello Health to shed complexity and costs in their practice and asking the ultimate payer - their patients - to fund the work that closes the gap between current state and care the way our patients want and need.  This is no promise of a vague future - this trend addresses the day to day professional lives right now.

Moving from a toxic to a supportive environment is a sure way to make primary care an attractive career choice, expanding the pipeline of supply and reducing early retirement.  There is no perfect solution, but too many of us in the front lines are tired of lip service and top down solutions that appear to be more support for status quo than real change.

(1) Starfield, B:  Threads and Yarns: Weaving the Tapestry of Co-morbidity Ann Fam Med 2006;4:101-103

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Mon, 30 Aug 2010 08:01:00 -0700 How to link high deductible health plans with high performing primary care http://physicianfreethyself.com/how-to-link-high-deductible-health-plans-with-0 http://physicianfreethyself.com/how-to-link-high-deductible-health-plans-with-0

2-3% annual rate increases compared to 10-12% is covincing employers that it is time to move to high deductible health plans (HDHPs).  As noted in the Agile Health blog the annual savings per employee makes it possible to fun employee health savings accounts.

Employers interested in the significant savings from HDHPs can help their employees make good health care choices by steering them to practices that lower the threshold of access with same day appointments and virtual visits. 

Medical practices differ on attributes that make it easy or hard for people to get the care they need when they need it.  These differences lead to outcomes important to the patients and employers alike:

Patients are much less likely to miss time from work, end up in the hospital, emergency room, or needing expensive specialist interventions, they are much more likely to be satified with their care and have preventive needs met when they receive their care in practices that have excellent:*

  • Access: same day appointments with their own doctor with the option for virtual visits (avoiding unnecessary trips to the doctor's office)
  • Relationship:  excellent communication and the ability to tailor interventions to patients as individuals as opposed to care from large teams of strangers in institutional settings where patients are numbers
  • Comprehensive services: the time to address the bulk of the needs at hand rather than knee-jerk referrals to other doctors due to lack of time
  • Care coordination: a doctor/nurse who help nagivate the complexity of the larger health system when needs exceed the primary care office

Finding practices like this has gotten a lot easier with groups like Hello Health.

 

*Wasson, J. H., Johnson, D. J., Benjamin, R., Phillips, J., & MacKenzie, T. A. Patients report positive impacts of collaborative care. Journal of Ambulatory Care Management, July-September 2006 29(3), 199–206.

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Mon, 30 Aug 2010 08:01:00 -0700 How to link high deductible health plans with high performing primary care http://physicianfreethyself.com/how-to-link-high-deductible-health-plans-with http://physicianfreethyself.com/how-to-link-high-deductible-health-plans-with

2-3% annual rate increases compared to 10-12% is covincing employers that it is time to move to high deductible health plans (HDHPs).  As noted in the Agile Health blog the annual savings per employee makes it possible to fun employee health savings accounts.

Employers interested in the significant savings from HDHPs can help their employees make good health care choices by steering them to practices that lower the threshold of access with same day appointments and virtual visits. 

Medical practices differ on attributes that make it easy or hard for people to get the care they need when they need it.  These differences lead to outcomes important to the patients and employers alike:

Patients are much less likely to miss time from work, end up in the hospital, emergency room, or needing expensive specialist interventions, they are much more likely to be satified with their care and have preventive needs met when they receive their care in practices that have excellent:*

  • Access: same day appointments with their own doctor with the option for virtual visits (avoiding unnecessary trips to the doctor's office)
  • Relationship:  excellent communication and the ability to tailor interventions to patients as individuals as opposed to care from large teams of strangers in institutional settings where patients are numbers
  • Comprehensive services: the time to address the bulk of the needs at hand rather than knee-jerk referrals to other doctors due to lack of time
  • Care coordination: a doctor/nurse who help nagivate the complexity of the larger health system when needs exceed the primary care office

Finding practices like this has gotten a lot easier with groups like Hello Health.

 

* Normal.dotm 0 0 1 30 173 Ideal Medical Practices 1 1 212 12.0 0 false 18 pt 18 pt 0 0 false false false <!-- /* Font Definitions */ @font-face {font-family:Arial; panose-1:2 11 6 4 2 2 2 2 2 4; mso-font-charset:0; mso-generic-font-family:auto; mso-font-pitch:variable; mso-font-signature:3 0 0 0 1 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman";} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} --> Wasson, J. H., Johnson, D. J., Benjamin, R., Phillips, J., & MacKenzie, T. A. Patients report positive impacts of collaborative care. Journal of Ambulatory Care Management, July-September 2006 29(3), 199–206.

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Thu, 26 Aug 2010 09:01:30 -0700 Getting the time you need in the exam room: root cause and possible solutions http://physicianfreethyself.com/getting-the-time-you-need-in-the-exam-room-ro http://physicianfreethyself.com/getting-the-time-you-need-in-the-exam-room-ro Kevin Pho MD's blog post and all the follow up comments about time in the exam room got me thinking.

I'm not going to discuss here the value of time in the interaction between patient and clinician - it is so obviously important I don't think it requires reiteration.  Finding the time is the critical issue.  Where do we find the time to do what's right for our patients?

Maggie Mahar's comment (about half way down the comments list) suggests that overhead is the problem and HIT and forming large groups are key solutions.   Let's look at overhead and HIT.

Practice overhead is too high:

True.  The solution to the inexorable increase in administrative trivia driven by insurance company paperwork leads most practices to add staff.  Most practices have a 'referral' clerk whose job it is to contact insurance companies to ask permission for patients to see other doctors and/or have tests performed.  Practices all have billing staff or billing services who wrestle payment from insurance companies for services rendered.  Practices have front office staff who query patients on insurance information and transpose that information into billing systems.  The practice then hires a practice manager to manage the staff.

Proposed solution:  Adopt health information technology.

HIT can streamline work flow but leaves the fundamental drivers untouched.  Stop the crazy billing wars and I can give up the very costly armies that make up the bulk of the overhead!  Insurance companies live on this craziness - it is the very essence of their 'value add' and to give it up puts their very existence into question. This is why the 'Patient-Centered Medical Home' pilots fail to address fundamental drives of high cost and low quality - to do so is too threatening to the business model of health insurers (and hospitals, but let's leave that for another post).

The Ideal Medical Practices project worked with more than 100 PCP volunteers from across the U.S.  Many of these volunteers used a low overhead approach, using much more technology to reduce staffing costs (71% of overhead in a typical practice is salary and benefits of staff according to a study by Ken Smithson MD of VHA Inc.)  We published results demonstrating very low overhead compared to national stats.  The sad news is that low overhead and health information technology alone cannot solve the problem.  

In some regions of the country the combination of high cost of living (NJ, Southern California, for instance) combined with very low insurance payments (NJ, Southern California, for instance) makes it impossible for primary care to survive without some kind of subsidy.  PCPs across the nation are finding it increasingly difficult to keep up with the rising tide of unfunded administrative trivia mandated by insurers.  We are spending the bulk of our time responding to demands from insurers rather than addressing the needs of our patients.  It is no surprise that these 'Dead Zones' turn out to be fertile environments for Hello Health.  Any help in creating a truly supportive environment is attractive in these dire times.

Failure to address these root causes is driving PCPs into the ranks of early retirement.  Those who still love the profession are desperate for a truly supportive environment.  An increasing number find it by going AWOL from the insane billing wars and figuring out how to work directly with their patients and local employers.  I would love it if the insurance industry would simultaneously fund the full scope of effective primary care while eliminating the bulk of the value-detracting administrative trivia game, but the middleman is killing primary care.  If they won't address root cause, they're not part of the solution.

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Tue, 10 Aug 2010 10:06:11 -0700 Extra fees or other subsidy is the only way for primary care to survive this toxic environment http://physicianfreethyself.com/extra-fees-or-other-subsidy-is-the-only-way-f http://physicianfreethyself.com/extra-fees-or-other-subsidy-is-the-only-way-f Primary care is embattled by a set of policies that simultaneously crush the offices with unfunded mandates (the 'billing wars') while paying for only a fraction of the work.  Because we in health care are used to the idea of cost-shifting (those who pay are charged more to cover those who can't pay), we use the technique to cover the losses of primary care.

Here is how subsidies support primary care in our current system:

Hospital owned primary care
The hospital accepts losses in primary care to ensure the pipeline of people who end up paying 8:1 on the losses by ending up in the emergency department or in a hospital bed.  If the hospital can manage the practices with little loss, so much the better.  The typical management approach is to crank up the hamster wheel so that each primary care physician has a very large panel of patients, sees as many patients as can be (in)humanly packed into waiting rooms and kept waiting in the sensory deprivation experiments we call exam rooms.

Community & Rural Health Centers
States and the Federal Government provide cost-based reimbursement as part of the social safety net.  While a private practice in NYC might receive $23 for an hour long workup of a complicated Medicaid patient, a community health center would receive $160 for the same work.  These centers would not survive without the huge subsidy.  The federal agency that oversees the program drives the docs onto the hamster wheel by defining work as "office visits" and setting the bar at a level that makes it difficult to address the full health care needs of these medically complex and fragile patients.

Independent/private practice
Any economist or small business owner can tell you what happens when a person is faced with fixed-fee price control and rising costs:  crank up the hamster wheel. When we reach the limits of endurance on that front we start looking for other lines of revenue to keep the business afloat.

New lines of revenue 
More and more primary care practices are testing new fees so that they can remain in business.  Some have purchased lasers and other devices to address the raging epidemic of body hair or unsightly spots.  Others are learning how to sell hormones and snake oil to baby boomers desperate to be forever young and buff.

Still others are offering extraordinary access through the use of new technology like the Hello Health platform. 

It would be wonderful if our nation provided these services as a natural extension of citizenship, but given the climate in Washington I don't expect it any time soon.  Many policy makers are betting on 'medical home' projects while ignoring or missing the obvious flaws: big increase in unfunded work, big expense in electronic systems that are designed as weapons for the billing wars, measurement that addresses tangential issues while missing the essence of the solutions.

I wish there were a better way.  I don't relish the idea of asking people to pay more, but I'm not in control of the policies that drive up insurance rates every year while strangling the system with a Byzantine set of rules and regulations.

If you're a struggling primary care physician you have a choice: jump onto an employer's hamster wheel, build your own hamster wheel, or use another subsidy to free yourself from the insane strictures of our broken system.

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Mon, 09 Aug 2010 09:05:12 -0700 We're supposed to buy health plans like this? Small business is getting creamed by insurance costs. http://physicianfreethyself.com/were-supposed-to-buy-health-plans-like-this-s http://physicianfreethyself.com/were-supposed-to-buy-health-plans-like-this-s I received a quote on health insurance for our medical practices in NYC.  We want to do the right thing by our employees and we'd like to cover the cost of their health insurance.  We know full well the benefits that come from good access to care - if you have good access you are more likely to be up to date on your preventive services, to care for your conditions well, and to be on top of new symptoms before they get out of hand. 

Giving ourselves and our employees access to good care like this is not just a nice thing that gets better results for our employees - it reduces the risk that our people end up in the emergency room or hospital, makes it less likely that people miss days from work or work at less than full capacity due to illness.  Call it enlightened self-interest.

The problem is the cost of the premiums.
Family plan with no deductible and typical ($30-50) co-payment costs more than $19,500 annually.
Family plan with $2000 individual/$4000 family annual deductible & typical co-pay ($10-50) is a mere $15,800 annually.

I have to say that I'm attracted to the high deductible health plan (HDHP).
Family plan with annual deductible of $5800 per individual/$11,600 per family is a lot more attractive at $8,400 annually, or the Family Plan $10,000 individual/$20,000 family annual deductible with annual premium of $5,856.

We could take the tens of thousands of dollars in annual savings and fund a good portion of the deductible through a health savings account (HSA).  The HSA money is a benefit to the employee since they can roll it over to the next year.  

We need cheaper plans like these HDHPs with linked HSA so that we can break away from the unbelievably high premiums of typical insurance, especially as the high premium insurance doesn't seem to cover that much any more and comes with a boatload of hassle and denials.

The other thing I like about the HDHPs and linked HSA is that we or the employee can guarantee access to high performing primary care by purchasing membership in a Hello Health practice.  People who get care in practices like this are more likely to achieve good health outcomes, be up to date on prevention, take care of wellness, and therefore are less likely to ever approach their deductible limits - a good thing all around.

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Thu, 05 Aug 2010 08:22:32 -0700 2009: jump in uninsured and 47% of individually insured people average $2500 annual deductible http://physicianfreethyself.com/2009-jump-in-uninsured-and-47-of-individually http://physicianfreethyself.com/2009-jump-in-uninsured-and-47-of-individually We live in interesting times.  There's so much promise in the air around health reform and everyone having health insurance by 2014.  Some of that promise is tarnished by the reality faced by many Americans in the here-and-now.  

  • USA Today reports that 3 million more Americans joined the ranks of the uninsured in 2009.
  • In Kaiser Family Foundation survey they found that individuals purchasing health insurance (part of the mandate that is coming in 2014) faced the steepest increase in health premiums in 2009 (20%) and had an average deductible of $2,500.

These two groups have something in common: they have to navigate the obscure and hidden fees of health care and hope that a visit to a doctor's office doesn't blow their budget.

"..healthcare is like fine dining...if you have the money, you get it, and if you don't, you won't."  Professor Uwe Reinhardt on Oprah 

Too many people will probably let symptoms go up until they get serious enough to force them in for care.  This results in hugely expensive care and misses the opportunity for early intervention.  If a person had good access to primary care they could get on top of things before they got out of hand and became difficult to treat.  If they had good access to primary care they could keep their conditions under control and prevention up to date so they'd be healthier in the long run. 

Good primary care sharply lowers the chances of ending up in emergency or a hospital bed.  Employers and individuals who want to live long and be healthy invest in good primary care because that investment pays off in both the short and long term.

There is a growing cadre of clinicians doing what they can to help.  Hello Health practices reduce their own overhead so that they can make care more affordable and accessible to their patients and publish their fees openly so people know what to expect.  Like many of the other Hello Health practices, Agile Health Partners in NYC offers a membership plan that can help keep people healthy and provides access to treatment before a person has to run through their entire deductible.  

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Wed, 04 Aug 2010 15:53:01 -0700 Can you hear me now? Hello? Why are quality results falling on deaf ears? http://physicianfreethyself.com/can-you-hear-me-now-hello-why-are-quality-res http://physicianfreethyself.com/can-you-hear-me-now-hello-why-are-quality-res A colleague of mine told me the other day that she hasn't taken home a paycheck in about four months. Since she's a primary care physician I guess I shouldn't be all that surprised. Current policies aimed at managing health care costs fall disproportionately on primary care practices with a toxic mix of unfunded reporting and administrative mandates coupled with fixed fee-for-service payments that cover only a fraction of the work of primary care.

What's really pathetic about this particular case is that this particular doc is phenomenally good. Her practice is an exemplar of primary care. She provides really good access, she takes time to build good relationships, she and her practice group have invested heavily in information technology so that they can better manage the oceans of data in which she swims every day. This doc has brought in external professionals to help turn her office staff into a true high performing multi-disciplinary team. Her results are terrific. People who really know quality point to her and say "There is a doc who really does it right."

So what's wrong with this picture? The entities that pay for health care in her region appear to be deaf to quality. Without referring to her specifically, some say "well, if this doc is already doing so well we don't need to put any more money into the system to support her, she should just keep doing what she's doing." A sound argument if we didn't know that the supply of primary care docs is drying up as medical students choose other more lucrative specialties. It might be a sound argument if we didn't know that an increasing tide of primary care docs are dropping out of the system by going part time (just so they can have a life beyond work). It might be a sound argument if we didn't find a growing corps of physicians waking up to the reality that the measurement and payment paradigm is broken beyond fixing.

It's time to move on. If the insurers and other monied stakeholders in the status quo are deaf to quality it is time to exit this dysfunctional relationship and figure out better ways to re-engage with our patients. If insurers stonewall quality and patient care it is time to move beyond their toxic reach and find other ways of financing health care - financing paradigms that align the interest of patients with the ethics of our profession.

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Tue, 27 Jul 2010 11:02:00 -0700 ER wait times rise, putting people at risk. Primary care access is key to solution http://physicianfreethyself.com/er-wait-times-rise-putting-people-at-risk-pri http://physicianfreethyself.com/er-wait-times-rise-putting-people-at-risk-pri

In a report just released documents increased waiting times in emergency rooms across the US.  This does not bode well for the average person, for employers or even for health care premiums.   ER visits are an incredibly expensive way to deliver care.  A young woman told us that a sore throat visit to a NYC ER cost her $2000.  (see a 30 second YouTube interview)

Policymakers and the public should also have no illusions that the recently passed health care legislation is going to decrease ER use.  Massachusetts, which enacted health care reform in 2006, has seen an increase in emergency department visits, with no decrease in patient acuity.  It proves that health care coverage is no guarantee of health care access. American College of Emergency Physicians press release

When people have very good access to primary care they end up needing the emergency room much less.  The woman with the sore throat wishes she'd known of our office (AgileHealthPartners) at the time as she would never have ended up in the ER, and Jaclyn would have saved $1840.

Why is primary care access a problem?  In large part due to the payment policies of health plans.  Independent primary care practices are crushed by the administrative burden of fighting the billing wars with health plans.  Many are selling themselves to hospital systems that are financially better off with the $2000 ER visit than the  $160 office visit - why should the hospital system slaughter the cash cow?

An increasing number of practices are choosing instead to call out the irreparably broken system by leaving it behind.  By charging directly for our services we are able to divest the huge expense of the billing wars.  This allows us to reduce our charges while improving our access.  Getting out of the insurance wars we are able to offer care 24/7 via phone, secure email & video, and spend more time with our patients.  The winners in this new paradigm are the patients, the people paying for health care, and the primary care workforce.  The losers are those who profit from the billing wars.

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Mon, 26 Jul 2010 08:58:44 -0700 The keys to successful management of chronic conditions: you and the support you receive http://physicianfreethyself.com/the-keys-to-successful-management-of-chronic http://physicianfreethyself.com/the-keys-to-successful-management-of-chronic There is a nice article in the NYT:  For Chronic Care, Try Turning to Your Employer

Dealing with a chronic condition involves climbing a steep learning curve and doing a lot of work.  Successful management of a chronic condition rests on doing that work reliably and well.  The mistake most health care people make is that they believe that - aside from the routine follow up visits - the bulk of the work ends with the eduction phase.  

"Hey, I told the patient what to do.  If they don't do it, they're non-compliant."

The problem stems from reductionist linear thinking:  Patient has condition X.  Treatment for X is Y. Just do it. With rare exception, people usually prefer to live long and be healthy.  The source of their difficulty is the complexity of life.  Condition X is only one of many many things happening in the person's life.  Sometimes X has to take a back seat to things like "I just lost my job" or "I think my daughter is doing drugs" or "I have a make-or-break project."

There are a wealth of published studies describing how best to support people in their management of their conditions.  Effective support of people in self-management is rooted in supporting people in their own context.  A diet recommendation ignoring ethnic or cultural food choices is mis-informed and unlikely to be followed.  Writing that person off as "non-compliant" adds insult to injury.

Disease management programs - from employers, health plans or doctor groups - often fail to ascend beyond linear thinking and thus fail to address the complexity of human existence.  Successful programs focus on the person and not just the disease.  Read the literature and you'll find a common thread in the successful programs:  an external agent (nurse, health coach, caregiver, etc) helps the individual learn to successfully navigate lifestyle change.  The intervention is usually no more complicated than helping the person understand the nature of their choices, helping them make small successful steps in a healthier direction, and following up.

This is the work of effective primary care.  

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Sun, 25 Jul 2010 08:51:00 -0700 Physicians owned by hospitals: the good, the bad, the ugly http://physicianfreethyself.com/physicians-owned-by-hospitals-the-good-the-ba http://physicianfreethyself.com/physicians-owned-by-hospitals-the-good-the-ba

One summer a few years ago, an MBA student and I worked through a big block of (de-identified) claims data.  We found that for every dollar the insurer spent on primary care, they spent an additional $8 on 'ancillary services.' labs, xrays, hospital based procedures, hospital based specialist visits, hospital based 'facility fees.'

I found out that when a patient has a consultation with a hospital based physician, the insurer is billed not only by the physician, but an additional bill is generated by the hospital as a 'facility fee.'  If the patient sees a non hospital based physician, no such 'facility fee' is generated.

Hospitals don't love owning primary care physicians and their practices - they tend to lose money on them.  Even 11 years ago this was obvious.  So why do hospitals continue to buy up physician practices?  If you count the eight-to-one return on the ancillaries the hospital comes out way ahead.  Hospitals tend to own physicians so that they can dictate where those $8 are spent.

'Once, my administrator announced that I was in breach of contract if I ever referred a patient to a system outside mine. “But don’t worry, he said, I wouldn’t dream of suing you … Unless your ancillaries dropped below the mean.”' From blog KevinMD

Fighting in the claims war is exhausting and I don't for a second doubt the integrity of my debilitated colleagues who explore the seemingly secure grounds of hospital employment, but be sure to consider underlying motivations of your potential employer.

Getting a salary check with 401k contributions every two weeks is good.  This keeps some primary care physicians from leaving the workforce entirely and that is also good.  Selling yourself to a hospital system expecting you'll get off the hamster wheel is bad thinking.  Trading your freedom to focus on your patients for indenture to a system rewarding productivity over quality is ugly.

Hospitals are not the font of all evil. They didn't set up a revenue model that rewards them every time a person gets sick enough to fill a bed and provides bonus dollars every time the person has complications and needs the ICU.  There are some very good hospital systems that have learned to do well with primary care while managing their revenue model.

It is important that physicians assess the underlying motivations and understand the revenue model: the more we do in primary care to keep people healthy and out of the hospital, the more we harm the hospital revenue model.  

This is not a system designed for optional function and does not bode well for the relationship and it makes me wonder about the future of Accountable Care Organizations organized by hospital systems.

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Tue, 20 Jul 2010 10:42:00 -0700 What the doctor is really thinking: transparency = better communication = better outcomes http://physicianfreethyself.com/what-the-doctor-is-really-thinking-transparen http://physicianfreethyself.com/what-the-doctor-is-really-thinking-transparen Medical providers have been stepping up efforts to improve doctor-patient communication, in part because studies show it can result in better patient outcomes. The introduction of electronic medical records in recent years has allowed patients to contact their doctors by email, log on to secure websites to get lab results and get links to health information recommended by their doctors.

A quotation from a WSJ article: What the doctor is really thinking

I remember the first time I talked with other doctors about sharing my notes with patients - a doctor-in-training (a.k.a. 'resident') got quite upset and suggested that I must be a liar because there was no way I could be honest in my notes. 

"If you think the patient is fat or an alcoholic you wouldn't be able to write that, so you'd be lying."
"Why would I not write that I thought that the patient had a problem with weight or alcohol? Is that not important health information I should share with them?"
"Because it would offend them."

This is a classic mistake of trying to please patients rather than provide expert advice and treatment.   People may not always like the truth, especially when the truth is ambiguity and uncertainty, but our professional obligation to serve our patients dictates that at times we delivery hard truths.  Respect for our patients dictates that we do this with compassion and dignity.

I've used electronic health records since 2001 with an openness to share as much as possible.  I learned from studies at Kaiser Permanente the power of providing a patient with a written 'after-visit summary' - this not only improves patient and caregiver retention of the plan, but cuts down on the number of follow up 'can the doctor/nurse explain something I missed' phone calls.

Some doctors say that this extra communication is just too much on top of an already over-stressed day.  I have to gently suggest that these doctors may be working in environments that do not support high quality care if they are forced to trade effective communication for some other goal (productivity maybe?).

Communication is central to our work.  People remember more when provided access to the information.  Once we can get past the incessant noise of EMR as dressed up billing engine we can evaluate the field for technology that supports seamless and secure communication.  Once we choose to stop supporting environments that offer the false choice of finance versus patient outcomes we will have the time to attend to our patient's needs.  I'm using the Hello Health platform for just this reason.

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Mon, 19 Jul 2010 12:12:18 -0700 Physician burnout hurts patients while @kevinmd misses the elephant in the room http://physicianfreethyself.com/physician-burnout-hurts-patients-while-kevinm http://physicianfreethyself.com/physician-burnout-hurts-patients-while-kevinm Dr. Pho's nice op-ed piece in today's USA Today points out the problem of physician burnout and how it hurts doctors and patients.  He cites some of the literature that explains burnout:
  • Too much work to do in too little time
  • Heavy administrative burden

Peeling the onion we unmask a fixed fee payment system that funds only a fraction of the work while piling on unfunded administrative work that pulls us away from our patients to play mother-may-I for our patient care.   Most doctors are run ragged on a 'productivity' hamster wheel that rolls inexorably over the bodies of quality, compassion, and the dignity of our patients.

Dr. Pho suggests we learn coping mechanisms like mindfulness and meditation - both wonderful practices that deserve our attention once we topple this insane system of policies that systematically erode our ability to serve our patients well.  

The arcane rites of coding by the numbers and playing the billing game dictate the terms of engagement for armies of clerks in doctor offices, insurance companies, and hospitals. The conventions of this warfare create untold cost and pain throughout our land through the collateral damage of denials, delays in care, and as Kevin points out: the continued erosion of the primary care work force due to increasing professional malaise and burnout.

This system of policies does not deserve our support and meditation will not lead me to accept the continued harm it brings to patients.  Until those in charge of these policies are willing to move beyond tweaks to the system we will see more physicians exiting the system through burnout or by discovering other modes of financing that support effective care without mixed incentives.

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Sun, 18 Jul 2010 09:18:00 -0700 Insurers Push Plans Limiting Patient Choice of Doctors http://physicianfreethyself.com/insurers-push-plans-limiting-patient-choice-o-0 http://physicianfreethyself.com/insurers-push-plans-limiting-patient-choice-o-0 Many things get better and cheaper over time.  Not so for health insurance.  Today's NY Times describes the health insurance industry's latest bid to limit benefits.

A $1000 computer today comes with more memory and processing speed than a $1000 computer from five years ago.  Health insurance goes the opposite way.  Ten years ago $400 per month would likely have gotten you and your family a no-deductible plan covering any doctor or hospital, a relatively unrestricted pharmaceutical formulary, and a $10 co-payment at time of service.  

Today $400 per month might get you an individual plan that covers any non-pre-existing condition, a $2500 annual deductible, a long list of 'non-benefits' for which you will pay out-of-pocket.  This is on top of having to play 'mother-may-I' with insurance companies for benefits they do cover, a very restricted formulary, and starting now, a restricted list of doctors and hospitals.

I have to admit that I'm not really opposed to the idea of restricting access to certain parts of the health delivery system.  There is very good evidence that some doctors and hospitals crank up charges several times more than others while adding absolutely no discernible value or incremental quality.

What I'd like to point out is a very interesting quote from the article, from a company that makes bicycles: 

“There wasn’t any pushback,” Mr. Skoda said. Haro’s employees are generally young and healthy, he said, and they rarely go to the doctor. Instead, they want to make sure they have adequate coverage if they go to the emergency room.

Why not go for a high-deductible health plan or HSA and cover primary care through a direct pay association?  HDHPs and HSAs cover the big ticket items like emergency room & hospital and other things that we fear and cost much less than the moth-eaten sieve of "full" coverage.  In NYC we checked individual prices for a 28 year old woman on full HMO/PPO insurance and it was between $840-$3300 per month.  A catastrophic plan that covers hospitalization would cost $175 per month.  

Insurance companies don't want to pitch these plans because they call into question the value of the HMO/PPO plans.  Haro would do better to push United Health Care, Aetna and others to strip away the huge costs associated with administering the HMO/PPO plans and provide true low cost catastrophic plans.  Haro could then fund effective primary care through a direct pay association. 

Primary care is more like road maintenance: paying for ongoing maintenance is less expensive in the long run than infrastructure collapse.  We insure against the collapse, we pay up front for the maintenance. 

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Sat, 17 Jul 2010 08:01:30 -0700 EMR: your ticket to better billing & the broken paradigm of payment policies http://physicianfreethyself.com/emr-your-ticket-to-better-billing-the-broken http://physicianfreethyself.com/emr-your-ticket-to-better-billing-the-broken We spend too much on health care and have too little to show for the money we spend when comparing US per capita expenditures to other more (health care) developed countries.
Out of the ocean of suggested solutions rises the vision of the Electronic Medical Record (EMR): if doctors would only use these electronic systems we would part the bloody seas of inefficiency and ascend to the promised land of high quality and low costs.  

The problem with this thinking is that it misses the point of most EMR - they are designed primarily as a means to enhance the doctor's ability to manage the insanely complex and costly tasks of responding to insurance company billing policies.  Once we get past the public posturing over EMR and duck into the medical lounge we find the Billing Centered Medical Home-Run.

The good journal Family Practice Management - an arm of the American Academy of Family Physicians - has been conducting a user survey of EMRs. Their most recent analysis unmasked some disconcerting results:

Simpler EHR products designed for small practices have consistently scored better than functionally more sophisticated products designed for practices of 21 doctors or more. In fact, at face value, an almost inverse linear relationship between practice size and user satisfaction has shown up in our surveys; as practice size increases, EHR satisfaction decreases. Nevertheless, many of these products designed for larger practices have won industry awards for their functionality.  
FPM Article

The author's analysis points to a number of factors influencing satisfaction:  size of physician group is inversely related to satisfaction, physician involvement in selection is directly correlated, etc.  The bit I find fascinating is the direct correlation between 'productivity based compensation' and satisfaction.

If a physician's income relies on their ability to generate bills, they are more likely to be satisfied with an EMR.  Salaried physicians were less satisfied.

I can't say that productivity based compensation causes satisfaction with EMR, but the circumstantial evidence linking billing emphasis to EMR satisfaction is compelling.  Payment policies are driven by the Cartesian notion that the more refined our analysis of the parts - the more we delve into details of the data - the better our understanding of the big picture.  Anyone practicing medicine today will be happy to abuse you of this notion, but the combined chorus of the entire primary care workforce in our nation falls on deaf ears of those who dictate policy.  The solutions proffered by insurance companies and government alike drive more complexity into billing.  If your income depends on success in the billing game, a better billing engine is just the ticket.

That the entire paradigm of billing and "quality reporting" is so far from solving the problem is evident to most doctors in practice, hence the steady tide of those who are choosing to exit the maze seeking paradigms that align payment policy with their professional intent to serve their patients.

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]]> http://files.posterous.com/user_profile_pics/342458/LGM2_2.jpg http://posterous.com/users/3sDxxuh5EtIl L Gordon Moore lgordonmoore L Gordon Moore Tue, 13 Jul 2010 14:12:49 -0700 Matthew Holt from THCB Interviews Dr. Blumenthal on final MU Regs http://physicianfreethyself.com/matthew-holt-from-thcb-interviews-dr-blumenth http://physicianfreethyself.com/matthew-holt-from-thcb-interviews-dr-blumenth

Interview: Blumenthal talks meaningful use

July 13, 2010,  By Matthew Holt

Absolutely hot off the recorder, here's my interview with David Blumenthal, the Obama administration's National Coordinator for Health IT.

Listen to recording HERE

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]]> Tue, 13 Jul 2010 11:50:59 -0700 From Texting To Apps, Using Cell Phones For Health http://physicianfreethyself.com/from-texting-to-apps-using-cell-phones-for-he http://physicianfreethyself.com/from-texting-to-apps-using-cell-phones-for-he

HEALTHBEAT: From Texting To Two-way Feedback, Testing Cell Phones As Tool To Fight Disease

(AP)  WASHINGTON (AP) – “What if my blood sugar's too high today? Is it time for my blood pressure pill? With nagging text messages or more customized two-way interactions, researchers are trying to harness the power of cell phones to help fight chronic diseases. "I call it medical minutes," says Dr. Richard Katz of George Washington University Hospital in the nation's capital. He's testing whether inner-city diabetics, an especially hard-to-treat population, might better control their blood sugar - and thus save Medicaid dollars - by tracking their disease using Internet-connected cell phones, provided with reduced monthly rates as long as they regularly comply.

Consider Tyrone Harvey, 43, who learned he had diabetes seven years ago only after getting so sick he was hospitalized for a week, and who has struggled to lower his blood sugar ever since. In May, through a study Katz began with nearby Howard University Hospital's diabetes clinic, Harvey received a Web-based personal health record that he clicks onto using his cell phone, to record his daily blood sugar measurements. If Harvey enters a reading higher or lower than preset danger thresholds, a text message automatically pings a warning, telling him what to do. And at checkups, doctors will use the personal health record, created by Indiana-based NoMoreClipboard.com, to track all his fluctuations and decide what next steps to advise….

….The trend is called mobile health or, to use tech-speak, mHealth. If you're a savvy smartphone user, you've probably seen lots of apps that claim to help your health or fitness goals - using your phone like a pedometer or an alarm clock to signal when it's time to take your medicine.

Katz and other researchers are going a step further, scientifically testing whether more personalized cell phone-based programs can link patients' own care with their doctors' disease-management efforts in ways that might provide lasting health improvement.”

Read full article HERE

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]]> Mon, 12 Jul 2010 11:17:00 -0700 Patients who e-mail with doctors see health improvements http://physicianfreethyself.com/patients-who-e-mail-with-doctors-see-health-i http://physicianfreethyself.com/patients-who-e-mail-with-doctors-see-health-i By Amanda Gardner, HealthDay, 7/11/10

“Patients with diabetes or hypertension or both who communicated with their doctors via e-mail got better care and better health outcomes, new California research contends.The improvements as a result of the e-mail exchanges included such measures as blood sugar and blood pressure control, according to a report appearing in Health Affairs.

The American Recovery and Reinvestment Act of 2009 has called for implementing "secure patient-physician messaging" as part of electronic health records by 2013.

Kaiser Permanente health system started phasing in secure e-mail communication nationwide in 2004. In southern California, some three million patients as well as all primary and specialty care Kaiser doctors signed up for it and, by the end of 2008, 35,423 adult patients (7.8% of members in that geographical area) and 3,092 primary care physicians had actually used it. The study authors, from Kaiser Permanente, analyzed 630,807 e-mail messages between patients and doctors from March 2006 to December 2008, then compared them to baseline data from the previous year. The vast majority of the e-mails (85%) were initiated by the patients.

Those who emailed their doctors saw improvements of 2.4% to 6.5% in blood sugar control and screening, cholesterol screening and control as well as screening for retinopathy and nephropathy (kidney disease). Also, more patients with diabetes or hypertension alone achieved blood pressure levels under 140/90. And the more frequently emails were exchanged, the greater the improvements.

According to prior studies, patients most often e-mailed to report some kind of change in their condition, to talk about lab results and to discuss medication issues.

Patients also tended to respect the doctor's time, with three-quarters sending messages on actual medical issues as opposed to "their mother's favorite meatloaf recipe," said Terhilda Garrido, vice president for health information technology transformation and analytics at Kaiser Permanente and senior author of the study. "It sounds a little cliche. .. but the hypothesis (about why this works) is that putting the information in the patient's hands makes them feel empowered and, therefore, in control of their condition," Garrido added.”

Read article HERE

 

 

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]]> Fri, 02 Jul 2010 10:01:00 -0700 Additions to CMS coverage of telehealth services to be posted July 13 http://physicianfreethyself.com/additions-to-cms-coverage-of-telehealth-servi http://physicianfreethyself.com/additions-to-cms-coverage-of-telehealth-servi

The U.S. Centers for Medicare and Medicaid Services will officially post several proposed new additions to Medicare’s coverage of telehealth services in the Federal Register on July 13.  These additions were proposed by ATA and a number of other entities last December. While not all of ATA’s requests were approved in their entirety the proposed changes represent a significant victory for telemedicine and for patients. This is another clear sign that the use of remote health services has entered the mainstream.  


The changes address remote clinical services and patient education and intervention. They do not cover remote monitoring, except for prescribed cardiac monitoring.  Several of the proposed changes require that patients must first be diagnosed and treated in-person before subsequently being seen by a physician via telehealth. 
 The following new coverage areas for telehealth services are proposed to take effect on January 1, 2011:
 

  • Subsequent nursing facility care services using CPT codes 99307-99310:  CMS is proposing coverage for these codes, with the limitation on the patient's admitting practitioner of one telehealth visit every 30 days. However, these are in addition to the minimum number of physician visits for skilled nursing home patients that are mandated by federal rules. Although not all of the additions requested by ATA were adopted, this is an important new coverage that can greatly benefit high acuity, complex patients requiring multiple on-going physician consultations.
  • Subsequent hospital care services provided after initial treatment and admission, using CPT codes 99231 and 99232:  CMS is proposing coverage for these codes and code 99233, with a limit for the patient's admitting practitioner of one telehealth visit every 3 days. This will benefit patients that require ongoing care by the admitting physician within an institutional setting such as patients with a psychiatric diagnosis or those treated in a psychiatric hospital or licensed psychiatric bed.
  • Codes for health and behavior assessment and intervention using CPT code 96153 - Group and 96154 - Family-with-Patient:
  • Group medical nutrition services using CPT code 97804:
  • Individual and group services related to kidney disease education using HCPCS codes G0420 and G0421:
  • Individual and group diabetes self management training, not including at least 1 hour of in-person injection training, using HCPCS codes G0108 and G0109:

 

In another important area, CMS proposes to make changes to cardiac remote monitoring codes that require technical and professional components of the fee to align with an overall cap. In addition, changes were discussed in the proposed rules at length relating to the provision of continuous, 24/7, cardiac monitoring but there is little change in current policy.  
 
An excerpt of the telehealth section and the cover page for the proposed federal rulemaking is available on the ATA website at www.americantelemed.org

The full CMS proposal (in the current 1250 page format) is available HERE

 

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