Thursday, May 20, 2010

What can Edward Bear, tell us about Primary Care?

"Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it."

From: A.A. Milnes "Winnie the Pooh and the House at Pooh Corner"

Internists, I expect, will identify with Edward Bear.

Richard Baron's study in the NEJM on the amount of work he and his colleagues do outside of an office visit - the bump, bump, bump of a busy internal medicine practice - has resonated with many of his colleagues. Jay Larson, who often posts comments on this blog, did a similar analysis for his general IM practice in Montana, and found that for every one patient seen in the office, tasks are done for 6 other unscheduled patients. Jay writes "So really there [are] internists [who]are managing about 130 patients per day. Not much consolation when they only get paid for 18 per day."

The "bump, bump, bump" of everyday practice include:

- Prescription renewals and pharmacy call-backs

- Calls to family care-givers

- Return calls to worried patients

- Review of lab studies

- Follow ups with consultant physicians

- Pre-authorization requests from insurance companies

- 15 minute office visit on top of 15 minute office visit, all while dealing with the other bumps of a harried day.

And what do they get paid in return? $65 for a mid-level office visit (Medicare payment rate).

The good news is that people are beginning to think of ways to finance and organize primary care that - that at least in theory - would improve outcomes and reimbursement, lower costs, and increase patient and physician satisfaction. These include patient-centered medical homes and accountable care organizations. Common elements of these models include:

- Team-based care under a physician's supervision, so that some of the bump, bump, bump work of physicians might be managed by an advance practice nurse, physician assistant, or other qualified non-physician, allowing physicians to spend more time with the more complex patients who really need to be seen by them.

- Paying physicians for to the work outside of an office visit and for achieving better outcomes, efficiently, to reduce the bump, bump, bump of having to generate an office visit in order to get paid.

- Better care coordination, to reduce the bump, bump, bump of duplicate testing, unnecessary referrals and return visits, and incomplete information sharing between a patient's primary care physician and other specialists involved in their care.

The challenge with these models, though, is that internists are so busy taking care of their patients, in a system that undervalues their work and imposes way too many bumps to the back of their heads, to stop bumping for a moment and think of a better way.

Today's question: Is there another way to organize care that would involve fewer bumps to the back of internists' heads, if only we could stop bumping for a moment and think of it?


Arvind said...

While you portray this process in GIM practices, it is a similar story amongst the cognitive specialty practices. In my solo Endocrine practice, we do all this (except looking for referrals rather than sending out) plus a lot more uncompensated care such as uploading blood glucose meters to patient charts in our EMR or downloading enormous amounts of insulin pump data, etc.

The question is not how we can eliminate these processes, but rather how we get paid for these. Because these processes are intrinsic to providing continuous care to people with chronic diseases, we must persuade either third party payers or patients that such care processes are worth paying for. Similarly, Medicare must be convinced that balance billing must be allowed for such value-added services. Again, if we let free market principles into the health care field, people will make the right choices.Price fixing must end if we need to see appropriate value for our services.

Of course, we must fight to eliminate unnecessary administrative processes that don't enhance patient care. Interestingly, the brand new Law does nothing to improve any of these processes.

Robert J. Sobel, M.D. said...

Today, Bob, you ask an easy question. There is no reason to think Dr. Larson, Dr. Baron, or so many others, have failed to address the problems you cite that are supposed to be the advantages of PCMHs and ACOs. What is absent is fair reimbursement. My argument, all along, has been that there is a proportionality between the tasks of the office visits, ancillary services, the tasks of phone management, and the tasks of bureaucracy. The latter have grown inordinately, as the competition model has been thrown on its head.

There is no capitalist theorist who can really believe that the chaos of "bottom-line" blind is a worthy model for progress. The under-cutting theory of pharmacy-benefit companies, mid-level providers, and the private insurance industry, are not to be used as models for reform.

I said last July that it would not be real reform if drug prices are left unchecked. The price increases, the maneuvering, and the lawsuits, certainly bare me out. The Docfix should not be so difficult. Let us penalize the overdrive of the for-profit insurance industry and the bureaucratic waste inherent in the Hatch-Waxman fallout. I may be alone in this latter construct, but I remain un-impressed with any alternative notions to date.

The enjoyment of longitudinal, primary care, with periodic reassessment, predates the medical-industrial complex, and is not the source of the second trillion in growth that pushed the envelope on health care costs.

The failure to correctly diagnose the growth drivers is a lesson in political realities. I would argue that a whole bunch of primary care physicians could develop a fair approach that leaves us alone but fixes our pay. I don't see CMS asking any time soon.

W. Bond said...

Whether “under the name of Sanders,” or otherwise, I am skeptical that you, me, politicians, bureaucrats, or any one man or woman, no matter how intelligent, can design a fair system from the top down, devoid of unintended consequences, resulting in innovation, improved service, efficiency, and decreased cost.

I would indeed challenge you to show any economic example in the history of the world, modern or ancient, where more central planning, rather than less, reduced costs or improved productivity.

Medicine may be a unique good and service, but that it remains. Until there is a movement to let price reflect perceived value we will continue to have increasingly worse medical service at a higher price.

Perhaps ACP could start with a small but radical step - by proposing that internists be allowed to charge patients above (or below) Medicare prices – and with the caveat that all pricing be transparent to patients. Patients could then make the same micro-economic decisions we all make everyday (e.g. he costs $20 more/visit but the visits are longer vs. he is closer to my home and open later but is rushed vs. his reputation is better, etc.). This simple move could hold down Federal costs while solving primary care access problems and might result in general internal medicine being a more appealing specialty.

Let a thousand flowers bloom. Let hundreds of models of care develop and compete.

But when tempted instead to constantly tinker with central planning, keep in mind Hayek’s wise words:

“The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design.”
- F.A. Hayek, The Fatal Conceit

Cheers, Wbond

Steve Lucas said...

From the other side of the desk let me once again beat the drum for a retainer style medical practice. Direct payments from a patient to a doctor create a relationship not found in a third party payment system. Additionally, insurance is no longer insurance but a pre-paid medical service. With no direct connection to cost patients will demand ever increasing amounts of this free care.

Doctors would also be able to break the pharma hold on their practices by being able to choose medications based on the patients ability to pay, or their now altered insurance policies.

Insurance would now be pricing their product based on a more limited number of events in the population, heart attacks, cancer, auto accidents. Based on this, rates should come down, protecting people from the ravages of large medical bills.

I want a doctor whose sole relationship is with me, not the insurance companies, not the drug reps, not anyone else. I personally believe doctors want this same type of relationship with a smaller patient panel. Add a stable income and more reasonable working hours and I think there will be a draw to IM and general medicine.

While I would limit the panel size, and there would be few other criteria for this model, the lifestyle changes would get our current practicing physicians off the treadmill they have been on for far too long.

Steve Lucas

DrJHO7 said...

Our medical system needs to improve the care it provides to patients in many ways. Many opportunities in the ambulatory care realm exist, including better medication reconciliation practices, electronic prescribing to reduce errors, processes that ensure patients don't miss scheduled appointments for chronic disease management, test order/result tracking and referral tracking, improving transitions of care from the in-patient to the out-patient settings with attention to med changes, test result followup and coordination of outpatient home care services, etc.

The above noted important processes, even if implemented however, are not going to draw young physicians to careers in the medical specialties that encompass primary care. Salaries for primary physicians remain the lowest of physician salaries, hassle factors (including, but not limited to paperwork and preauthorization of anything that costs an insurer money) are more prevalent in this mode of practice, after hours non-reimbursable work burden is high and perceived respect from colleagues, non-physician personnel, insurers, and to some extent patients, is at an all time low. The emerging generation of general internists is more likely to select the substantially better income and more definable work hours of the hospitalist physician in favor of a better life-style. Disturbingly, there is a trend away from entering careers where the physician is committed to a panel of patients 24/7, longitudinally.

PCMH's and/or ACO's will likely improve care for patients and physicians that are part of these may be more satisfied with their work, but they will cost the medical system more up front, and whether they will save more than they cost down the road is still an unknown. Whether physicians who are employed by PCMH's or ACO's will make any higher salaries is also an unknown. It is certainly possible that those who own them will. But, will these entities draw physicians back to primary care specialties? Also unknown, but probably not, unless they address the fundamental reasons for avoidance of these specialties, some of which are listed above.

Medical education needs to re-think its approach to educating young physicians with regard to emphasis of and exposure to the primary care specialties, early on (this is one area where the Osteopathic medical profession excels). Primary care specialties need to receive substantially better payment for the services they provide, hassle factor intrusions need to be substantially eliminated by insurers and government. Minus such changes, the drought of primary care specialists is likely to continue for the forseeable future.

Harrison said...

I don't exactly know how to stop bouncing on my head.
It is what I do.

I am intrigued however by the notion that small local innovations are what will work.
It is a romantic notion.
But it is coupled with the idea that private business entities can do medicine (or really anything) better than government.

That is a misleading thought process.

Kaiser is a non governmental agency.
But it is huge and overbearing.
Any practitioner working in the system and any patient receiving those services knows that there are rules and that the organization gets those rules in a top down fashion.
And it is a successful model.

There is no reason to believe that a government organization cannot do much the same things.

Evidence based guidelines and rules about what will and what won't be covered can happen in both the public and private sector.

What makes it a bit harder for me to bounce on my head every day is that these rules change from organization to organization and from month to month.

I would like some top down order to help structure my local head bouncing.


W. Bond said...

Harrison, I agree that your preference for top-down central-planning is an important aspect of the issue.

I would like to politely disagree, however, that the opposite is Romantic. It is, in fact, the reverse, or very nearly so. Romanticism was an anti-(classic)liberal movement, and represents one of the many related responses in politics and thought to the Anglo/Scottish/American enlightenment.

I will only also suggest that your counter example of a very large HMO model practice operating within the milieu of centrally-set Medicare pricing does not lead to as compelling an argument - on careful reflection - as perhaps you had intended.