I often leap onto my soapbox and forget to mention all the great things about my life and job. I must thank Joel Rose who did the NPR article for Day 2 Day, and did a fantastic job focusing on the positive aspects of my practice. I am so grateful for his spectacular interviewing and editing skills, I can't get over what a great job he did on the article.
And also, thanks to the many people who have sent encouraging replies or emails to the blog or the NPR piece. It always renews my spirit to hear other docs talk about the real priorities in family medicine, and to hear patients that appreciate docs who really do care, and are supportive.
And also thanks to my sister Kath, for sending the letter to npr in the first place.
And of course to Al, because I'd be nowhere without him.
And, I wouldn't want to leave out my friends and family, the support and stress relief are beyond measure.
Happy New Year.
Saturday, December 27, 2008
more proof that things really do need to change
It's not that I want people to have to pay. I sometimes feel somewhat hypocritical about charging people a hundred dollars for a doctor visit when in my heart of hearts that healthcare is an unalienable right and should be freely accessible to all. It even looks hypocritical here in print. But here's my argument: it's not just that everyone needs healthcare, its that everyone needs good healthcare. And right now, December 27, 2008, I can't deliver good healthcare for what I would be paid by insurance companies.
And another thing, I think that by continuing to work within a broken system, we are sending a mixed message. Every time I talk to family docs we talk about the unfair payment of insurance companies. Again, I reiterate, we are the ones agreeing to take the crappy pay!!!!! But we are also sending a message to our patients. We want our patients to be educated and empowered and proactive about their health, but then we all to often allow them to think that insurance company rules are more important than our recommendations. Three months ago a woman in her 50s was in my office for a check up, her mammogram was (my favorite) "probably benign" asymmetric density, (irregular lump) recommend 6 month recheck. Knowing her family history, and the fact that she had abnormal mammograms before, I decided that neither she nor I was comfortable with waiting to check out an abnormal, even if it is "probably" benign, so I recommended a breast MRI, something, I realize, that I probably wouldn't have been able to do in a land of "nationalized healthcare". Turns out I can't do it here either. Despite two appeals, it was denied by her insurance. So I explained to her that a lump is a lump, and she should see a surgeon to see if it should be biopsied. The surgeon agreed with me, and ordered an MRI, but never told me the outcome. Three months later she came to my office for "follow up" and I said, "I never heard from the surgeon, what were the results?" and to my shock and dismay she told me the insurance also denied the MRI request from the surgeon so she never followed up (and neither did the surgeon). I told her she must go for mammogram and ultrasound to evaluate for change now. She told me she was afraid the insurance company would deny that, too, since the radiologist recommended 6 month. It got approved, and unfortunately, the irregular lump is now bigger. Lots of things should have been done differently. I don't know how this will turn out, and I pray for a negative biopsy for her.
The fact is, our system was set up to make her feel like the insurance company had the last word, and we have let this happen. And we must stop. I realize that this is not directly related to my practice style, but indirectly it is. Because every day, when my patients make the choice to come "out of network", they are reminding themselves (and me) that good care trumps insurance policy.
And another thing, I think that by continuing to work within a broken system, we are sending a mixed message. Every time I talk to family docs we talk about the unfair payment of insurance companies. Again, I reiterate, we are the ones agreeing to take the crappy pay!!!!! But we are also sending a message to our patients. We want our patients to be educated and empowered and proactive about their health, but then we all to often allow them to think that insurance company rules are more important than our recommendations. Three months ago a woman in her 50s was in my office for a check up, her mammogram was (my favorite) "probably benign" asymmetric density, (irregular lump) recommend 6 month recheck. Knowing her family history, and the fact that she had abnormal mammograms before, I decided that neither she nor I was comfortable with waiting to check out an abnormal, even if it is "probably" benign, so I recommended a breast MRI, something, I realize, that I probably wouldn't have been able to do in a land of "nationalized healthcare". Turns out I can't do it here either. Despite two appeals, it was denied by her insurance. So I explained to her that a lump is a lump, and she should see a surgeon to see if it should be biopsied. The surgeon agreed with me, and ordered an MRI, but never told me the outcome. Three months later she came to my office for "follow up" and I said, "I never heard from the surgeon, what were the results?" and to my shock and dismay she told me the insurance also denied the MRI request from the surgeon so she never followed up (and neither did the surgeon). I told her she must go for mammogram and ultrasound to evaluate for change now. She told me she was afraid the insurance company would deny that, too, since the radiologist recommended 6 month. It got approved, and unfortunately, the irregular lump is now bigger. Lots of things should have been done differently. I don't know how this will turn out, and I pray for a negative biopsy for her.
The fact is, our system was set up to make her feel like the insurance company had the last word, and we have let this happen. And we must stop. I realize that this is not directly related to my practice style, but indirectly it is. Because every day, when my patients make the choice to come "out of network", they are reminding themselves (and me) that good care trumps insurance policy.
Wednesday, December 10, 2008
Home Improvement
So I've got some angst about the whole Patient Centered Medical Home agenda. The American Academy of Family Physicians explains it thus: "A patient-centered medical home is an approach to providing comprehensive primary care for people of all ages and medical conditions. It is a way for a physician-led medical practice, chosen by the patient, to integrate health care services for that patient who confronts a complex and confusing health care system." Key features include: ongoing relationship with a personal physician, comprehensive care, whole person orientation, coordination of care across all elements of the community and healthcare system, quality, safety, evidence based medicine, enhanced access, and physician accountablity. More details on the AAFP website's QandA. I have no problem with these ideals.
This program has support from the AMA as well as the American Academy of Pediatrics and several other groups, with the idea being if we come up with a good system, we can use this as a means to convince Them (the people who pay us) that we deserve to be paid for our work.
These groups, supporting the PCMH, and an organization called TransforMed, have come up with a "strategic transformation process combined with an integrated suite of practice transformation products and services— all derived from our experiences facilitating the NDP and designed to create a framework, a common language and an opportunity for practices to become Patient-Centered Medical Homes". Here is where I start to get a little twitchy. I get it, we have to have a common set of rules and guidelines, we have to be accountable to standards. But I am viscerally opposed to anything that makes our system of payment, reimbursement, and delivery of care ANY MORE COMPLICATED THAN IT ALREADY IS!
Then, people talk about one of the reimbursement improvements would be a set payment per patient. In December 1 AMA news article about the medical home it notes that in a North Carolina program a doctor receives $2.50 per Medicaid enrollee per month to manage their care. That is ludicrous. (Even assuming that medicaid pays per visit as well). Here's the deal, it takes time and resources to provide good medical care. Good systems can help that be more thorough and efficient, but over systemizing it and not giving the support needed to spend the time and resources only makes greater expectations and more frazzled, stressed out, and overburdened docs.
Now, I realize that part of my gut reaction is my inherent resistance to change of any kind, especially right now while my practice is in the midst of this transition. But I really really have a bad feeling about this. We've tried the "doctor manages and coordiates the care for a monthly fee per enrollee", we called it capitation and it was very appealing. But it feels to me like it promotes a system that encourages doctors to have lots of people on their panels and hope that they do not schedule appointments (free money). I sat at a hosptial staff meeting once where a good portion of the time was spent discussing what to do when HMOs remove people from your capitation list and stop paying you the monthly fee for these people, how to compare to prior lists to see who was removed. I asked if they could just check the lists as the patients schedule to see if the patient is on the list, and they explained that the people that were being "removed" were people they had never ever seen or even heard from, they were their assigned group. This is what we waste our time on, and I fear the new and improved system will promote the same attempts to "beat the system" in order to make enough money to stay afloat.
"But," I say to myself, "the new system will have requirements in place to make sure docs have the correct protocols". Well, I respond to myself, there's guidelines now for proper care and lots of docs for lots of reasons don't follow them.
So how to make it more fair then? We could just pay the docs that really and truly do the good job-pay for performance. One more thing to document and list and submit on my list of things to do. And if some docs are willing to upcode, downcode, and double bill now and risk the nightmare of a medicare audit, why wouldn't they be willing to fudge on the P4P submissions too.
Truly, I feel the only way to fix the payment problem is to minimize the red tape and infinite trees of denial and approval rules, and wipe the slate and implement a single payer system. Never will a group of payors (group = N>2) agree to a set of guidelines and payment structure. And the larger the N, the more loopholes they can make to make it confusing to doctor and patient alike.
The other thing that gets me about the Transformation To A Patient Centered Medical Home Model, is that when you transform into something, it implies that you are something different now. Back in med school, I picked Family Med because of the comprehensive, whole patient in the context of family and community approach. That is what I was trained to do. I'm not denying room for "home improvement", there's lots of things I look forward to implementing as advances in medical knowledge and technology explode. But I do not need the headache of managing a team of providers, nurses, social workers, dietitians, and educators in order to be a good Family Doc. I don't feel like I should have to justify myself to anyone except my patients and the medical board. I do not believe that I need to Transform My Practice into a different entity to make my patients feel that my number (or email) is the one they need to call when they have a health problem, issue or question. They will (and do) call me first when they know that I will (and do) give my best effort to provide them the best care.
This program has support from the AMA as well as the American Academy of Pediatrics and several other groups, with the idea being if we come up with a good system, we can use this as a means to convince Them (the people who pay us) that we deserve to be paid for our work.
These groups, supporting the PCMH, and an organization called TransforMed, have come up with a "strategic transformation process combined with an integrated suite of practice transformation products and services— all derived from our experiences facilitating the NDP and designed to create a framework, a common language and an opportunity for practices to become Patient-Centered Medical Homes". Here is where I start to get a little twitchy. I get it, we have to have a common set of rules and guidelines, we have to be accountable to standards. But I am viscerally opposed to anything that makes our system of payment, reimbursement, and delivery of care ANY MORE COMPLICATED THAN IT ALREADY IS!
Then, people talk about one of the reimbursement improvements would be a set payment per patient. In December 1 AMA news article about the medical home it notes that in a North Carolina program a doctor receives $2.50 per Medicaid enrollee per month to manage their care. That is ludicrous. (Even assuming that medicaid pays per visit as well). Here's the deal, it takes time and resources to provide good medical care. Good systems can help that be more thorough and efficient, but over systemizing it and not giving the support needed to spend the time and resources only makes greater expectations and more frazzled, stressed out, and overburdened docs.
Now, I realize that part of my gut reaction is my inherent resistance to change of any kind, especially right now while my practice is in the midst of this transition. But I really really have a bad feeling about this. We've tried the "doctor manages and coordiates the care for a monthly fee per enrollee", we called it capitation and it was very appealing. But it feels to me like it promotes a system that encourages doctors to have lots of people on their panels and hope that they do not schedule appointments (free money). I sat at a hosptial staff meeting once where a good portion of the time was spent discussing what to do when HMOs remove people from your capitation list and stop paying you the monthly fee for these people, how to compare to prior lists to see who was removed. I asked if they could just check the lists as the patients schedule to see if the patient is on the list, and they explained that the people that were being "removed" were people they had never ever seen or even heard from, they were their assigned group. This is what we waste our time on, and I fear the new and improved system will promote the same attempts to "beat the system" in order to make enough money to stay afloat.
"But," I say to myself, "the new system will have requirements in place to make sure docs have the correct protocols". Well, I respond to myself, there's guidelines now for proper care and lots of docs for lots of reasons don't follow them.
So how to make it more fair then? We could just pay the docs that really and truly do the good job-pay for performance. One more thing to document and list and submit on my list of things to do. And if some docs are willing to upcode, downcode, and double bill now and risk the nightmare of a medicare audit, why wouldn't they be willing to fudge on the P4P submissions too.
Truly, I feel the only way to fix the payment problem is to minimize the red tape and infinite trees of denial and approval rules, and wipe the slate and implement a single payer system. Never will a group of payors (group = N>2) agree to a set of guidelines and payment structure. And the larger the N, the more loopholes they can make to make it confusing to doctor and patient alike.
The other thing that gets me about the Transformation To A Patient Centered Medical Home Model, is that when you transform into something, it implies that you are something different now. Back in med school, I picked Family Med because of the comprehensive, whole patient in the context of family and community approach. That is what I was trained to do. I'm not denying room for "home improvement", there's lots of things I look forward to implementing as advances in medical knowledge and technology explode. But I do not need the headache of managing a team of providers, nurses, social workers, dietitians, and educators in order to be a good Family Doc. I don't feel like I should have to justify myself to anyone except my patients and the medical board. I do not believe that I need to Transform My Practice into a different entity to make my patients feel that my number (or email) is the one they need to call when they have a health problem, issue or question. They will (and do) call me first when they know that I will (and do) give my best effort to provide them the best care.
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