So we decided to have a family (family of origin as well as husb and kids) vaca to DC for mom's birthday. (She's 29, if anyone asks). We're staying with my brother Mike, and when we arrived last evening there was a small gathering of his friends. I really enjoy meeting people, seeing old faces too, and learning about what they do. And of course, leaping loudly onto my soapbox to anyone who will listen.
Since this is DC, the job options are slightly more varied than they are in Cape May County, and one of the people I met was a "Healthcare Policy Analyst". At the current phase in my life, that was about as exciting to me as it would be to meet the drummer for Van Halen or a pro baseball player. I'm embarrassed to say that I monopolized her attention for at least an hour after the other guests had left! But what a great conversation!
Here's what I learned: The Agency for Healthcare Research and Quality has a program called CAHPS: consumer assesment of healthcare providers and systems. https://www.cahps.ahrq.gov/default.asp
This group has developed patient surveys for hospitals that have been used for years in order for hospitals to get full medicare payment.
This group has also developed surveys for patients about the healthcare experience in outpatient primary and specialist settings. They are freely available, but I'd never heard of them.
There are people in this group who fear the development of the PCMH model as is stands. This particular individual who would prefer to remain anonymous (as if anyone reads this) could even remember about the time when we all embraced capitation and it didn't work out. She worried about the huge push for technology as the savior of healthcare, and realized that just having a computer and emr didn't make someone a better doctor. This sounds familiar.
So here is someone in Washington, who knows and advises people who make what amount to life changing decisions for me and my patients. (She gave me the example of Medicare D, she communicated with Senator Kennedy about the fact that it was and remains a Really Bad Idea.)
So here I've got this great opportunity, and I'm sure I looked like a total spaz! She is involved in the development of surveys for patients to evaluate healthcare quality, and hasn't heard of howsyourhealth. Correction, hadn't heard of it. I am a little lost on how to follow up on the conversation. I am again overwhelmed with information. I wonder how in this world of information overload, do people who share the same views combine their data and resources to influence policymakers. Or do we need to? Maybe it will all filter up. (Like salmon getting past the status quo of profit driven healthcare policy). And I wish I knew more about the system and how it works.
But mostly I'm just excited every time I meet someone that welcomes system-wide healthcare change.
Friday, April 17, 2009
Monday, March 9, 2009
The More Things Change
So I recently read the novel "Middlemarch" by George Eliot. (actually I listened to it, a free recording from librivox.org which is a fantastic resource for audiobooks that are in the public domain). Among many other things, there was a doctor in Middlemarch, Tertius Lydgate, that came into town with lots of new ideas about how things should be done. He felt that if doctors directly dispensed medications and charged for them, they had a conflict of interest and would, perhaps, overtreat. He volunteered in the a new "fever" hospital, designed in case the cholera spread to middlemarch. He spent time knowing his patients, analysing thier conditions, and recommending approprate pharmaceutical and non pharmaceutical interventions. Some patients liked him, some didn't. Sometimes they got better, sometimes they didn't. But one thing was universally true. The stodgy old doctors in town hated Lydgate.
*small spoiler* In the end, Lydgates wife couldn't handle his dedication to his profession, he couldn't make enough money to pay his debts, he left town and went to the city, and he died young. His spoiled brat of a wife went on to marry a rich "more traditional" old doctor.
I guess I was fairly taken by the fact that even in 1870 the economics and politics of medicine were deeply enmeshed with the "medical" part of medicine. (and of course, there was no health insurance or government funding then, the hospital for the poor was financed by rich benifactors). The citizens of Middlemarch (perhaps spurred on by the old doctors) after seeing the financial and political trouble Lydgate had, began to question his medical judgement.
So I ponder the current climate. I wonder if I should make less waves. (This is purely hypothetical, because making waves is so a part of my nature that I doubt I could stop if I tried.)
I read the descriptions of the old docs in Middlemarch and had no choice but to envision the graying, balding, slightly overweight men I see at hospital and board meetings. (If you're someone I go to meetings with and reading this, I likely don't mean you). I feel as though I jump up and down and wave my arms and scream "THERE HAS TO BE ANOTHER WAY! LOOK!! TRY SOMETHING DIFFERENT!!!" (although I don't think I actually do jump up, I'm pretty sure I raise my voice.) And they look at me and shake their heads and mutter "poor misguided Tac. She had so much promise." If they see me at all. How long before they run me out of town, and I die young, penniless, and unloved.
Then I realize that I am none of those things. I am slowly chipping away at my debt. I have good community support, and home support like none could expect. And, alas, I am no longer young. So maybe we have learned something in 139 years. Or maybe things will always be in a constant state of change...
*small spoiler* In the end, Lydgates wife couldn't handle his dedication to his profession, he couldn't make enough money to pay his debts, he left town and went to the city, and he died young. His spoiled brat of a wife went on to marry a rich "more traditional" old doctor.
I guess I was fairly taken by the fact that even in 1870 the economics and politics of medicine were deeply enmeshed with the "medical" part of medicine. (and of course, there was no health insurance or government funding then, the hospital for the poor was financed by rich benifactors). The citizens of Middlemarch (perhaps spurred on by the old doctors) after seeing the financial and political trouble Lydgate had, began to question his medical judgement.
So I ponder the current climate. I wonder if I should make less waves. (This is purely hypothetical, because making waves is so a part of my nature that I doubt I could stop if I tried.)
I read the descriptions of the old docs in Middlemarch and had no choice but to envision the graying, balding, slightly overweight men I see at hospital and board meetings. (If you're someone I go to meetings with and reading this, I likely don't mean you). I feel as though I jump up and down and wave my arms and scream "THERE HAS TO BE ANOTHER WAY! LOOK!! TRY SOMETHING DIFFERENT!!!" (although I don't think I actually do jump up, I'm pretty sure I raise my voice.) And they look at me and shake their heads and mutter "poor misguided Tac. She had so much promise." If they see me at all. How long before they run me out of town, and I die young, penniless, and unloved.
Then I realize that I am none of those things. I am slowly chipping away at my debt. I have good community support, and home support like none could expect. And, alas, I am no longer young. So maybe we have learned something in 139 years. Or maybe things will always be in a constant state of change...
Tuesday, February 10, 2009
Moving Day is a very Dangerous Day
Ok, nothing quite like moving to make you realize how much stuff you have that you really, really don't need. Unfortunately, the stuff you really do need is mixed all in with it, so you can't just dump it all. But it's been an exciting few weeks despite it all.
Packing: I had these great plans of taking the opportunity to go through all my file cabinets and folders and get rid of the outdated guidelines, and organize the useful ones into something in some sort of order, downsize, computerize, and declutter. You can go ahead and stick that one on the list right after "find cure to common cold" and "world peace". I did manage to thin out the patient chart room down from 5 cabinets to 3, and put an additional 40 boxes into my storage (attic), adding to the over 30 that were already there. Someday I'm going to have to deal with all of these, but not right now. (and we are painstakingly starting to scan the charts of transferring patients, so storage of them will be on disc, not in actual space, eventually).
I also took 380 pounds of paper to the Giant Shredding Truck. Mostly old billing paperwork that I realized it wasn't worth saving when I admitted to myself that even if I needed the EOB from my 3rd patient on June 7 2004, I wasn't going to be able to find it in the boxes. It was great to be rid of all that stuff, but shredding really gives me anxiety.
By last saturday afternoon, my packing/storage plans became more of a "sweep the entire contents of your desk into a large box and deal with it later" . That large box is now under my desk, to be rummaged through when I need something. Not exactly as I had planned, but it works.
Choosing: I was fortunate to be able to make some minor changes in the new place, including having a hole cut in the wall between the receptionist office and the waiting room, and a sink into the exam room, and paint. I was also fortunate enough to have an absolutely fantastic contractor do this work for me. Most of the choices were easy, (went to home depot, picked out the least expensive reasonable looking sink and cabinet, etc), but choosing paint was hard. I'm not the most visually perceptive person, but I've made some unusual paint choices in my life, and since I look at the office walls all day every day, I wanted to to be right. Most paint stores will sell you small "sample" jars of paint (the local one by me they are $5) to test on the wall. If I can give one bit of advice GET THE SAMPLES. Even if you need to try 10 different ones, it is worth $50 not to screw up the paint color. I picked out the one I liked, it was a sortof greenish aqua, but the lighting in the room made it look like baby blue. I would have been so annoyed with my little baby boy nursery walls all day. I ended up picking one that on the little square looked way too dark, but on the walls looks peaceful and calm and deep.
Moving: There is always, always, more than you think. Saturday morning I went to the office to make sure all of Fridays "real work" medical patient stuff, was done (friday ended up being a super busy day after a really slow week). Then came the joy of moving all that stuff that was so caringly packed (10% of the contents of the office) and the stuff that was haphazardly thrown into boxes (the other 90%). It turns out that most of what doctors do is not actually hands on medical care, we actually fabricate paper. It comes out of our machines in every shape and size and fills boxes and files and drawers and covers every flat surface until none remains. (Mind you, not much of it is the small green kind that you can exchange for goods). It is really scary.
The wonderful contractor I mentioned also was saintly enough to offer us his truck and trailer, and he and his wife spent the day with us saturday. I think I would still be sitting in the back of my old office looking around wondering how to move everything if not for them. We were able to get chart file shelves onto the truck with the charts still on them, alas, we could not get them through the new foyer without tiliting them onto their sides, so thus had to remove the charts while they were in the foyer. That was a bit of a drag, but aside from little stuff like that, it was super smooth. By saturday night, the old place was empty, and the new one overflowed.
Unpacking:
I went from four small rooms to two large rooms, deciding to minimize on unneeded space and duplication of stuff and work, so I have a room that is my office and exam room, and it's great. It has all my exam stuff (table, ekg, supplies), but also my desk, computer, bookshelf, phone etc. I really really like having a centralized work area. But unpacking my crammed office, and my cluttered exam room into a useable space was not exactly easy. Ditto for the front staff area-chart room, reception desk, copy area, and storage are all in one now. I think it would have been easy to start a new practice with this very efficient layout, but cramming my old style into this new one is going to take some work. I just keep on saying to myself "I don't need more space, I need less stuff."
The first week:
I've moved about one mile from my previous place, into an office building owned by two psychiatrists. It's been years since I've shared office space with other doctors, one forgets that not everyone does things the same way. They haven't thrown me out yet, so I think it's going to be ok tho. There's still a few kinks to work out (thermostat, door locks, and psychiatrists with overly sensitive noses who smell curry when it's not really there and try to blame you for making a smelly lunch). But all in all, I am so very glad to be in my new place. The new exam room/office is comfortable and roomy (if not yet perfectly organized and arranged). I can have 3 extra chairs now for patients and family, and there is plenty of breathing space. And breathing is good, right?
Packing: I had these great plans of taking the opportunity to go through all my file cabinets and folders and get rid of the outdated guidelines, and organize the useful ones into something in some sort of order, downsize, computerize, and declutter. You can go ahead and stick that one on the list right after "find cure to common cold" and "world peace". I did manage to thin out the patient chart room down from 5 cabinets to 3, and put an additional 40 boxes into my storage (attic), adding to the over 30 that were already there. Someday I'm going to have to deal with all of these, but not right now. (and we are painstakingly starting to scan the charts of transferring patients, so storage of them will be on disc, not in actual space, eventually).
I also took 380 pounds of paper to the Giant Shredding Truck. Mostly old billing paperwork that I realized it wasn't worth saving when I admitted to myself that even if I needed the EOB from my 3rd patient on June 7 2004, I wasn't going to be able to find it in the boxes. It was great to be rid of all that stuff, but shredding really gives me anxiety.
By last saturday afternoon, my packing/storage plans became more of a "sweep the entire contents of your desk into a large box and deal with it later" . That large box is now under my desk, to be rummaged through when I need something. Not exactly as I had planned, but it works.
Choosing: I was fortunate to be able to make some minor changes in the new place, including having a hole cut in the wall between the receptionist office and the waiting room, and a sink into the exam room, and paint. I was also fortunate enough to have an absolutely fantastic contractor do this work for me. Most of the choices were easy, (went to home depot, picked out the least expensive reasonable looking sink and cabinet, etc), but choosing paint was hard. I'm not the most visually perceptive person, but I've made some unusual paint choices in my life, and since I look at the office walls all day every day, I wanted to to be right. Most paint stores will sell you small "sample" jars of paint (the local one by me they are $5) to test on the wall. If I can give one bit of advice GET THE SAMPLES. Even if you need to try 10 different ones, it is worth $50 not to screw up the paint color. I picked out the one I liked, it was a sortof greenish aqua, but the lighting in the room made it look like baby blue. I would have been so annoyed with my little baby boy nursery walls all day. I ended up picking one that on the little square looked way too dark, but on the walls looks peaceful and calm and deep.
Moving: There is always, always, more than you think. Saturday morning I went to the office to make sure all of Fridays "real work" medical patient stuff, was done (friday ended up being a super busy day after a really slow week). Then came the joy of moving all that stuff that was so caringly packed (10% of the contents of the office) and the stuff that was haphazardly thrown into boxes (the other 90%). It turns out that most of what doctors do is not actually hands on medical care, we actually fabricate paper. It comes out of our machines in every shape and size and fills boxes and files and drawers and covers every flat surface until none remains. (Mind you, not much of it is the small green kind that you can exchange for goods). It is really scary.
The wonderful contractor I mentioned also was saintly enough to offer us his truck and trailer, and he and his wife spent the day with us saturday. I think I would still be sitting in the back of my old office looking around wondering how to move everything if not for them. We were able to get chart file shelves onto the truck with the charts still on them, alas, we could not get them through the new foyer without tiliting them onto their sides, so thus had to remove the charts while they were in the foyer. That was a bit of a drag, but aside from little stuff like that, it was super smooth. By saturday night, the old place was empty, and the new one overflowed.
Unpacking:
I went from four small rooms to two large rooms, deciding to minimize on unneeded space and duplication of stuff and work, so I have a room that is my office and exam room, and it's great. It has all my exam stuff (table, ekg, supplies), but also my desk, computer, bookshelf, phone etc. I really really like having a centralized work area. But unpacking my crammed office, and my cluttered exam room into a useable space was not exactly easy. Ditto for the front staff area-chart room, reception desk, copy area, and storage are all in one now. I think it would have been easy to start a new practice with this very efficient layout, but cramming my old style into this new one is going to take some work. I just keep on saying to myself "I don't need more space, I need less stuff."
The first week:
I've moved about one mile from my previous place, into an office building owned by two psychiatrists. It's been years since I've shared office space with other doctors, one forgets that not everyone does things the same way. They haven't thrown me out yet, so I think it's going to be ok tho. There's still a few kinks to work out (thermostat, door locks, and psychiatrists with overly sensitive noses who smell curry when it's not really there and try to blame you for making a smelly lunch). But all in all, I am so very glad to be in my new place. The new exam room/office is comfortable and roomy (if not yet perfectly organized and arranged). I can have 3 extra chairs now for patients and family, and there is plenty of breathing space. And breathing is good, right?
Wednesday, January 21, 2009
Change is good.
So I'm sure blogs all over the great wide world are talking about Obama and his great speech and how the world is changing right now, so why should I be any different?
Let me start by saying I am so so so so so so very glad to see Barack Obama as president. I just feel like his attitude aligns with mine on so many economic and foreign policies, and he's got great plans and he's not afraid to point out things that screwed us up. He's going to to a lot of good, I think. Except, of course, for healthcare.
He said two things in his (beautiful) inaugaral speech that touched on The Healthcare Issue, and I'm not going back to look at the exact quote or I'll never get anything done so I'll paraphrase. He said we will use technology to improve healthcare delivery. I got the impression, probably from other talk I've heard about budget allotment and planning, that he means that by pushing for an Electronic Medical Record (EMR) we will be able to give more organized, coordinated care. Sounds great, but the reality is computers can't make medical decisions. Computers, as we all know, are good when used correctly, and can make life much more complicated if not. I know too many doctors that have saved lots of time with thier EMRs (I hope) that now are incapable of writing a coherent note or summary of care. They click the template for the visit, add in if indicated, and off it goes to the pcp with an electronic signature, and I get a letter that makes no sense at all. (e.g. the "routine post op check, wound healing nicely, pt recovering well and can resume her normal activites", by the time i got the letter a week later, the patient was dead, I called the surgeon to ask why he thought she took such a sudden decline, he said that she was in fact very ill at her routine post op check, and not even walking without assistance, he was not at all surprised at her death, but her wound had healed well so he sent the standard note). So my point is, getting an EMR might help make good doctors more efficient (maybe), but they can also make bad doctors faster at being bad.
The next point of concern I had with President Obamba (which still sounds beatiful to say) is when discussing things that will change for the better, he said "we will lower healthcare costs". I wish people would stop saying we need to do that. It's not the care costs that need to be cut, it's the adminitration cost. (Ok, some care costs too). I feel somewhat threatened when people say that healthcare is too expensive. Health Insurance is too expensive, and some parts of health care costs are expensive, but it is unfair to lump them. I fear that "lowering healthcare costs" means lowering reimbursement for docs, and tradtitionally, the primaries lose out first. We need to reduce the administrative costs of healthcare, the wasted time spent on useless hassles, the unnecessary paperwork and multiple faxes and phone calls. We need to reduce healthcare waste by having a strong primary care system so studies and procedures and meds aren't duplicated. We need to reign in pharmaceutical costs somehow. And at some point we need to buy in to the fact that we as physicians have a moral, ethical, and economic responsibility to not administer care that we know is futile. Then, if we haven't saved any money, we can talk again.
Small scale change is good too. I'm getting ready to move into a different office, about a mile from my current one. I usually hate the stress of moving, but right now its not so bad. I like the opportunity to clean out the cobwebs, and get rid of the excess. (which is why there are 16 boxes of charts in my bedroom and hallway right now). I like chosing paint colors and deciding where furniture will go. Its just fun to step out of the grind, look at processes, and how they can be better. I might not feel this good about it in two weeks, when its time to be done and i'm not even packed, but right now, it's all ok.
Let me start by saying I am so so so so so so very glad to see Barack Obama as president. I just feel like his attitude aligns with mine on so many economic and foreign policies, and he's got great plans and he's not afraid to point out things that screwed us up. He's going to to a lot of good, I think. Except, of course, for healthcare.
He said two things in his (beautiful) inaugaral speech that touched on The Healthcare Issue, and I'm not going back to look at the exact quote or I'll never get anything done so I'll paraphrase. He said we will use technology to improve healthcare delivery. I got the impression, probably from other talk I've heard about budget allotment and planning, that he means that by pushing for an Electronic Medical Record (EMR) we will be able to give more organized, coordinated care. Sounds great, but the reality is computers can't make medical decisions. Computers, as we all know, are good when used correctly, and can make life much more complicated if not. I know too many doctors that have saved lots of time with thier EMRs (I hope) that now are incapable of writing a coherent note or summary of care. They click the template for the visit, add in if indicated, and off it goes to the pcp with an electronic signature, and I get a letter that makes no sense at all. (e.g. the "routine post op check, wound healing nicely, pt recovering well and can resume her normal activites", by the time i got the letter a week later, the patient was dead, I called the surgeon to ask why he thought she took such a sudden decline, he said that she was in fact very ill at her routine post op check, and not even walking without assistance, he was not at all surprised at her death, but her wound had healed well so he sent the standard note). So my point is, getting an EMR might help make good doctors more efficient (maybe), but they can also make bad doctors faster at being bad.
The next point of concern I had with President Obamba (which still sounds beatiful to say) is when discussing things that will change for the better, he said "we will lower healthcare costs". I wish people would stop saying we need to do that. It's not the care costs that need to be cut, it's the adminitration cost. (Ok, some care costs too). I feel somewhat threatened when people say that healthcare is too expensive. Health Insurance is too expensive, and some parts of health care costs are expensive, but it is unfair to lump them. I fear that "lowering healthcare costs" means lowering reimbursement for docs, and tradtitionally, the primaries lose out first. We need to reduce the administrative costs of healthcare, the wasted time spent on useless hassles, the unnecessary paperwork and multiple faxes and phone calls. We need to reduce healthcare waste by having a strong primary care system so studies and procedures and meds aren't duplicated. We need to reign in pharmaceutical costs somehow. And at some point we need to buy in to the fact that we as physicians have a moral, ethical, and economic responsibility to not administer care that we know is futile. Then, if we haven't saved any money, we can talk again.
Small scale change is good too. I'm getting ready to move into a different office, about a mile from my current one. I usually hate the stress of moving, but right now its not so bad. I like the opportunity to clean out the cobwebs, and get rid of the excess. (which is why there are 16 boxes of charts in my bedroom and hallway right now). I like chosing paint colors and deciding where furniture will go. Its just fun to step out of the grind, look at processes, and how they can be better. I might not feel this good about it in two weeks, when its time to be done and i'm not even packed, but right now, it's all ok.
Saturday, December 27, 2008
Many Thanks
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.
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.
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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