Small Practice

Small Practice

Will Independent Physicians Go Extinct?

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Richard Gunderman goodLife is tough for physicians in solo and small group practice.  The federally mandated introduction this fall of ICD-10 requires physicians and their staffs to learn a new system of coding diseases.  “Meaningful Use,” another federal program, requires physicians to install and use electronic health records systems, which are complex and expensive.  And PQRS, the Physician Quality Reporting System, is beginning to penalize physicians for failing to report individual data for up to 110 quality measures, such as patient immunizations, each of which takes time to collect and record.

Of course, such requirements are not being imposed solely on solo and small-group physicians.  In many ways, they affect all physicians alike.  Yet the burdens of complying are disproportionately high for small groups, which cannot spread out the costs of purchasing equipment, hiring employees and consultants, and training personnel over so large a number of colleagues.  Hospitals and large medical groups can afford to hire full-time specialists to meet these challenges, but such approaches are not economically feasible for a group that consists of only a few physicians.

Such challenges are not just raining down –  they are pouring down on the heads of physicians.  Some physicians fear they smell a conspiracy to drive solo and small-group practitioners out of business.  And the problem is not just the money.  It’s also the time.  Many physicians already work long hours and simply cannot afford to shop for such systems, negotiate contracts, and enter data.  We personally know physicians who report spending two hours each evening completing records that they did not have time to attend to while they were seeing patients.

ONC’s Interoperability Plan: a Day Late and $19bn Short

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Screen Shot 2015-10-21 at 8.40.34 AMEarlier this month, the Office of the National Coordinator for Health Information Technology released an update to Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap. The roadmap was first announced back in January, and the changes shared this month aren’t significant.

Ultimately, it calls for all healthcare providers nationwide to be able to send and receive electronic clinical information by the end of 2017.

This is a good plan on the surface, although it comes six years and millions of dollars late, and like other programs it may be more cumbersome that it first seems. Essentially, there are three facets:

1) Data standards to format and request/receive data

2) Incentives (again!)

3) Governance

Despite the intention to move data across the Union, each state will have the right to create its own unique rules on how to manage the exchange of information. This is a problem as we have seen before in the simple Case of e-prescription routing. A few states make it almost impossible to send e-scripts and layer on their own special form of bureaucracy. This inhibits the ultimate goal of reducing costs and errors and increasing Efficiency at the expense of both providers and patients.

A Radical Policy Proposal: Go Easy On Older Docs

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flying cadeuciiThrough Dec. 15, federal regulators will accept public comments on the next set of rules that will shape the future of medicine in the transition to a super information highway for
Electronic Health Records (EHRs).  For health providers, this is a time to speak out.

One idea:  Why not suggest options to give leniency to older doctors struggling with the shift to technology late in their careers?

By the government’s own estimate,in a report on A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure, a fully functioning EHR system, for the cross-sharing of health records among providers, will take until 2024 to materialize.The technology is simply a long way off.

Meanwhile, doctors are reporting data while the infrastructure for sharing it doesn’t exist.  Now, for the first time, physicians will be reporting to the federal government on progress toward uniform objectives for the meaningful use of electronic health records.  Those who meet requirements will be eligible for incentive payments from Medicare and Medicaid, while those who don’t may face penalties. In addition, audits are expected to begin in 2016.

How I Use P4 Medicine to Maximize Patient Engagement

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Molly MaloofThe healthcare industry is changing as new models of care and reimbursement emerge. One of these approaches is P4 Medicine. P4 Medicine stands for predictive, preventive, personalized, and participatory. This approach deeply resonates with me because the philosophy is aligned with how I have been developing my medical practice, which is focused on optimizing health and avoiding disease. In my opinion, P4 Medicine is one of the best models for maximizing patient engagement.

The earliest manifestation of P4 Medicine began eight years ago at the Institute of Systems Biology when Dr. Lee Hood, MD, PhD, a physician scientist and creator of the automated gene sequencer, recognized that the application of systems biology to medicine would fundamentally alter our understanding of health and disease. This model has merged three powerful aspects of science and technology:

Zen and the Quest For Quality

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Screen Shot 2014-08-21 at 11.45.17 AMCelebrating its 40 anniversary this year, Robert M. Pirsig’s Zen and the Art of Motorcycle Maintenance bears several distinctions.  It is listed in the Guinness Book of World Records as the eventual bestseller that was rejected by more publishers than any other, 121.  It went on to sell more than 5 million copies, making it the most popular philosophy book of the past 50 years.  And it focuses on a truly extraordinary topic, which its narrator refers to as a “metaphysics of quality.”

Quality is a hot topic in healthcare today.  Hospitals and healthcare systems are abuzz with the rhetoric of QA and QI (quality assessment and quality improvement), and healthcare payers including the federal government are boldly touting new initiatives intended to replace quantity with quality as the basis for rewarding providers.  Yet as Pirsig’s narrator, Phaedrus (see Plato’s dialogue of the same name), comes to realize, quality is very difficult to define.

In fact, giving an account of quality is so difficult that it drove Zen’s author mad.  And this is a man whose IQ, 170, would make him one of the most intelligent people in any health system.  The problem, of course, is that there is a big difference between intelligence and wisdom, and in the quest for wisdom, mere intelligence often leads us dangerously astray.  Something similar is happening in healthcare today, where schemes to improve quality often precede sufficient efforts to understand it.

For example, we seek to gain greater control over healthcare outcomes through measurement, only to discover, to our chagrin, that people are massaging the data to meet their numbers.  We create new programs intended to increase patient throughput, only to discover unintended perverse effects on the quality of relationships between patients and physicians.  Initiatives intended to reduce error rates turn out again and again to stifle innovation.

Calcium Scan and Subtractive Medicine

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Being a radiologist, I rarely speak to patients, but I was asked to counsel Mrs. Patel (not her real name, so calm down HIPAA totalitarians), who was worried about the risks of radiation from cardiac calcium CT scan. Because of her risk factors for atherosclerosis, her cardiologist wanted her to take statins for primary prevention, but she was reluctant to start statins. They eventually reached a truce. If she had even a speck of calcium in her coronary arteries she would take statins. If her calcium score was zero she wouldn’t. This type of shared decision making is the most frequent reason why cardiologists order calcium scans at my institution.

The Doctor- Patient Relationship and the Outcomes Movement

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Screen Shot 2015-10-01 at 9.46.12 AMIn a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”

In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:

With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”

In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.

But in describing these successes, do the authors undermine their own argument?  For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third.  In other words…outcomes

Patients are NOT Customers

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Screen Shot 2015-03-21 at 4.26.26 PMRecently I wrote about the problems with Maintenance of Certification requirements.  One of the phrases I read repeatedly when I was researching the piece was “the patient as customer.”  Here’s a quote from the online journal produced by Accenture, the management consulting company:

Patients are less forgiving of poor service than they once were, and the bar keeps being raised higher because of the continually improving service quality offered by other kinds of companies with whom patients interact—overnight delivery services, online retailers, luxury auto dealerships and more. With these kinds of cross-sector comparisons now the norm, hospitals will have to venture beyond the traditional realm of merely providing world-class medical care. They must put in place the operations and processes to satisfy patients through differentiated experiences that engender greater loyalty. The key is to approach patients as customers, and to design the end-to-end patient experience accordingly.

Except for one thing.  Patients are NOT customers.

The definition of a “customer” is a person or entity that obtains a service or product from another person or entity in exchange for money.  Customers can buy either goods or services.  Health care is classified by the government as a service industry because it provides an intangible thing rather than an actual thing.  If you buy a good, like a car, you voluntarily decide to shop around and get the best car you can for the price.  Even a vacation, especially a vacation package or a cruise, is a good.  A nice dinner, while a good in the sense of the food, is also a service.  You buy the services of the cook and servers.

Here is why the patient shouldn’t be considered a customer, at least not in the business sense.

1. Patients are not on vacation.  They are not in the mindset that they are sitting in the doctors office or the hospital to have a good time.  They are not relaxed, they have not left their troubles temporarily behind them.  They have not bought room service and a massage. They are not in the mood to be happy.  They would rather not be requiring the service they are requesting.  Which leads to number 2:

2. Patients have not chosen to buy the service.  Patients have been forced to seek the service, in most cases.

3. Patients are not paying for the service.  At least not directly.  And they have no idea what the price is anyway.

4. Patients are not buying a product from which they can demand a positive outcome.  Sometimes the result of the service is still illness and/or death.  This does not mean the service provided was not a good one.

5. The patient is not always right.  A patient cannot, or should not, go to a doctor demanding certain things.  They should demand good care, but that care might mean denying the patient what the patient thinks he or she needs.  The doctor is not a servant; she does not have to do everything the patient wants.  She is obligated to do everything the patient needs.

6. Patient satisfaction does not always correlate with the quality of the product.A patient who is given antibiotics for a cold is very satisfied but has gotten poor quality care.  A patient who gets a knee scope for knee pain might also be very satisfied, despite the fact that such surgery has been shown to have little actual benefit in many types of knee pain.