Thursday, February 21, 2013

Time is on My Side

Time very well may be on your side if you are Mick Jagger and Keith Richards (they‘re still rockin’ after all these years!) but not for doctors and patients. The pressure on physicians to spend less time with patients is part of an unrelenting assault on the patient-physician relationship, declared the American College of Physicians in a report released yesterday on the state of the U.S. health care.  ACP President David Bronson, MD, FACP described it this way at a press briefing announcing the reports, “System-wide efforts to improve the healthcare system won’t succeed on their own in improving access and quality if the physicians that the system is counting on to deliver care are over-hassled, over-stressed, harried, hushed and rushed.”

Or, as I put it in my remarks at the same briefing, “None of us want our doctors to spend more time on paperwork than listening to us, yet we have a system that buries physicians in administrative tasks to the exclusion of patient care. None of us want our physicians to be rushed from patient-to-patient, from task-to-task, but that often is the only kind of medicine that the system allows.”

Lack of time with patients was one of seven barriers to the patient-physician relationship identified by ACP:

“Lack of time with patients. Current payment, coding and relative value systems discourage physicians from spending time with patients. Also, as physicians spend more and more time each day complying with unnecessary administrative tasks and mandates (see below) imposed by payers and government, they have even less time to spend with their patients.

Excessive, Unnecessary and Unproductive Administrative Tasks. A recent study found that U.S. physicians spend $31 billion annually on interactions with health plans. More specifically, physicians reported spending almost a half-hour each day, three hours each week, and three weeks per year, interacting with health plans. Primary care physicians spend significantly more time (3.5 hours weekly) than other medical specialists (2.6 hours) or surgical specialists (2.1 hours).

Electronic Health Records that Do Not Meet Clinicians’ and Patients’ Needs. Electronic health records were intended to improve care but many physicians are frustrated that they lack the capabilities needed while adding more inefficiency to their daily workflow, compounded by well-intended government “meaningful use” standards that might make things even worse.

Performance measures that can result in unintended adverse patient care consequences. Performance measures can be difficult to report on, may measure the wrong things, and they do not always agree with each other. Physicians appropriately ask: who is measuring the value and effectiveness of the measures themselves?

Growing and excessive number of mandates on physicians enforced by penalties. Payers and government keep imposing more penalties on physicians: for not e-prescribing, for not converting to a complex ICD-10 diagnosis coding system, for not meaningfully using electronic health records, and for not successfully reporting on measures. Physicians wonder how they can even find the time to track all of these mandates, incentives, rules, and penalties, while keeping their practices open.

The adverse consequences of a dysfunctional medical liability system. Physicians feel continually exposed to the risk of medical liability lawsuits, and feel pressured to perform “defensive medicine” to reduce the risk of being sued. At the same time, patients who are truly harmed by medical errors often wait years for a court to decide on their compensation, if they receive compensation at all.

Direct government intrusion into the patient-physician relationship. The patient-physician relationship is undermined by laws that tell physicians what they can and cannot say to their patients or what tests or procedures they must compel their patients to obtain, without regard to the physician’s clinical judgment or the patient’s interests.

What can be done about it?  ACP offered the following nine proposals to reduce  such intrusions:

1. Public and private policymakers and payers must ensure that any payment reforms have, as an explicit goal, allowing physicians to spend more appropriate clinical time with their patients.

2. Payment and delivery reforms that hold physicians accountable for the outcomes of care (measurable performance on quality, cost, satisfaction and experience with care) should concurrently eliminate the layers of review and second-guessing of the clinical decisions made by physicians.

3. CMS should harmonize (and reduce to the extent possible) the measures used in the different reporting programs, work toward overall composite outcomes measures rather than a laundry-list of process measures.

4. CMS should provide more clinically relevant ways to satisfy the requirement that physicians must transition to using ICD-10 codes for billing and reporting purposes.

5. Congress and CMS should consider working with physicians to encourage participation in quality reporting programs by reducing administrative barriers, improving bonuses to incentivize ongoing quality improvements for all physicians, and broadening hardship exemptions. If necessary, Congress and CMS should consider delaying the penalties for not successfully participating in quality reporting programs, if it appears that the vast majority of physicians will be subject to penalties due to limitations in the programs themselves.

6. The government, the medical profession, and standard-setting organizations should work with EHR vendors to improve the functional capabilities of their systems, to improve the ability of those systems to report on quality measures and to ensure that those systems improve rather than adding to workflow inefficiency.

7. Medicare and private insurers should move toward standardizing claims administration requirements, pre-authorization, and other administrative simplification requirements even in advance of, and in addition to, the simplification rules included in the ACA.

8. Congress should enact meaningful medical liability reforms including health courts, early disclosure errors, and caps on non-economic damages.

9. State and federal authorities should avoid enactment of mandates that interfere with physician free speech and the patient-physician relationship.

ACP’s report didn’t just focus on policies to reduce intrusions on the patient-physician relationship; it also proposed ways to improve the health care system overall—by building on the progress in expanding coverage and lower costs, by creating incentives for primary care, but putting a stop to across-the-board budget cuts to vital health programs, by eliminating the Medicare SGR, and by preventing deaths and injuries from firearms.  ACP doesn’t buy into the argument that one has to choose between expanding coverage to the uninsured and reducing hassles for physicians and patients—we need to do both. 

Dr. Bob Centor, chair-elect of the ACP Board of Regents, puts it this way in his DB’s Medical Rants post on ACP’s proposals:

“Often readers of this [DB’s Medical Rants] blog impugn the ACP and other national organizations. They charge that we are not in sync with practicing physicians.  I challenge you to read these positions and say that here. You may disagree with parts of the ACA, but most of you do want to see broader coverage for patients.  I know that you care about payment and making primary care a more desirable option. You have told me often that government is intruding into our practices, and I contend that the ACP's positions should be most agreeable.

We are proud of our agenda.  We believe that most internists will agree with the majority of our positions.  We wish the Congress and their staffs, the White House and state legislatures would pay attention.  We can improve health care AND spend less money.  We can decrease physician burnout without harming quality. And please note my favorite point – one that readers of this blog will recognize: Payment reforms must allow physicians to spend more appropriate clinical time with their patients.”

The need to change the things that drive physicians and patients crazy is a theme I blogged about last fall, and it is good to see ACP give such prominent attention to the issue in its new report (Disclosure: I was the principal staff author of the report).

Putting time back on the side of patients and their physicians won’t be easy—harried and rushed medicine is deeply engrained in our system---but it is essential if we are to have the kind of health care that patients want and deserve. Let’s rock n’ roll to make it happen.

Today’s questions: What do you think about ACP’s description of the “unrelenting assault on the patient-physician relationship”, and its policy proposal to end it?


Steve Lucas said...

We have institutionalized the shortening of patient doctor interactions through the use of financial incentive:

“In addition to Pharma, psychiatrists are also raking in money from expensive drugs that adults and children may not even need. A psychiatrist working eight hours a day doing talk therapy "earns approximately $940 a day, $4,700 a week and $225,000 per year," notes an article called, "The Industrialized, New-Deal Age of Psychiatry," by psychiatrist Ronald Ricker. That is "chump change" compared with 15-minute, once-a-month med checks that net from $85 to $100 dollars, says Ricker. By seeing 38 to 42 patients each day at $100 a visit plus extra fees averaging $30 per appointment, a psychiatrist can make "roughly $104,000 a month, and $1,248,000 per year," he computes. The pill bonanza is abetted by the phony disease and patient groups Pharma funds.”

Following drug companies for nearly 40 years my personal belief is that they are using psychiatry as a business model for control of the entire medical system. In a system where there is a drug for every person, and every person is taking a drug, we have seen drug companies set standards and then move those standards to encompass an ever growing population.

One way to assure doctor compliance is through financial incentives designed to eliminate meaningful patient doctor interaction. A doctor that spends an appropriate amount of time with a patient may be less inclined to prescribe a drug as they lean more about their patient.

We can also not discount government’s involvement that is driven in part by pharma:

“ …even if one looks back in time, and artificially combines legacy Schering-Plough total spend -- together with legacy Merck, pre-merger. For so long as such disclosures have been available (since the early 2000s), the lobbyist spending has never been more than $10 million in a year. Until now.

By way of comparison, I'll note that Apple (the second largest company worldwide, by market cap) spent $2 million in 2012 -- on lobbying. “

This perfect storm of financial incentive, government intervention, all driven in part by a drug industry whose only desire is to make profit, study 329 and the current Zoloft suit come to mind, are creating pressures that will be hard for the average physician to fight to retain control of their time with patients.

Reports, impossible standards, etc. all tie into a system that has a very corporate base, but does little for the patient and only drives cost and the use of drugs and testing. There are so many players who benefit from this financially that it will be difficult to reduce these barriers to doctors returning to being doctors, and not data entry clerks.

Steve Lucas

William M. Fogarty, Jr., MD said...

Bob: The part about EHR is correct but incomplete. I believe that they are a serious impediment to good patient care. I have recently resigned from the indigent clinic where I have served for 12 years because it is impossible to access prior notes or data in a timely fashion while seeing a patient. Mistakes are being made and patients potentially harmed because important information is not available.
Until a clinician oriented system is developed that really delivers the potential advantages of an EHR it is detrimental to good care to continue forcing the present systems on physicians and patients.
William Fogarty, MD, FACP