I was reading a medical home advocacy group’s upbeat approach to a recent JAMA study that had found scant benefit in the concept when, suddenly, we tumbled into Alice in Wonderland territory.
The press release from the leadership of the Patient-Centered Primary Care Collaborative (PCPCC) started out reasonably enough. The three-year study of medical practices had concluded that the patient-centered medical home (PCMH) contributed little to better quality of care, lower cost and reduced utilization. This was an “important contribution,” said the PCPCC, because it showed “refinement” of the concept that was still necessary.
That was just the set up, though, to this challenge from Marci Nielsen, chief executive officer of the group. “It is fair,” said Nielsen, “to question whether these pilot practices (studied) had yet transformed to be true medical homes.”
Where might one find these true medical homes? The answer turns out to be as elusive as a white rabbit. Formal recognition as a medical home via accreditation “can help serve as an important roadmap for practices to transform.” However, accreditation as a PCMH “is not necessarily synonymous with being one.” Conversely, you can be a “true PCMH” without having received any recognition at all!
But maybe the true medical home does not yet exist, since, “the evidence base” for the model “is still being developed.”
In Through the Looking Glass, Humpty Dumpty scornfully informs Alice: “When I use a word, it means just what I choose it to mean – neither more nor less.” And so we learn that a true medical home means just what the PCPCC says it does.
It’s confusing. If the truly transformational medical home lies in the future, why does the PCPCC chide the JAMA researchers in this “otherwise well-conducted study” for failing to “reference the recent PCPCC annual report which analyzed 13 peer-reviewed and 7 industry studies and found cost savings and utilization reductions in over 60 percent of the evaluations”?
Continue reading “The Medical Home’s Humpty Dumpty Defense”
Filed Under: THCB
Tagged: health care delivery, Michael Millenson, patient centered medical homes (PCMH), patient centered primary care collaborative (PCPCC), Population Health, primary care
Mar 6, 2014
There’s scant disagreement that a key to transforming the U.S. health system is strengthening its primary care foundation. But there’s no consensus about how.
In last week’s new cycle, evidence of our dysfunction on this central issue was apparent:
Last Monday, the American Academy of Pediatrics fired a volley across the bow at retail clinics, calling them an “inappropriate source of primary care for pediatric patients (1).” Instead, the society that represents the nation’s 62,000 pediatricians encouraged an alternative—the patient centered medical home it originated in 1967.
In its policy statement, while acknowledging the growing popularity of retail clinics, the AAP affirmed its opposition to models that are not physician driven. Never mind that the 1600 retail clinics deliver comparable outcomes for treatment of a dozen uncomplicated medical problems, offer extended hours and cost less than half for a medical office visit. And their caregivers are nurse practitioners.
Then Tuesday, a robust Canadian study was released that cast doubt on the suitability of the patient centered medical home (PCMH) as the transformative model for primary care (2). The Canadian research team compared results from 32 medical home practices in Pennsylvania that had achieved certification from the National Committee on Quality Assurance’ medical home program to 29 non-medical home primary care practices in the same region from 2008-2011.
They concluded “a multi-payer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement (3).”
And the same day, the White House announced it would spend $5.2 billion over 10 years to train 13,000 additional primary care residents and $3.95 billion over 6 years to expand the Health Resources Services Administration (HRSA) program from 8900 primary care providers to 15,000.
Continue reading “Primary Care 2.0: A Vision for a Transformative Solution”
Filed Under: Physicians, THCB, The Business of Health Care
Tagged: American Academy of Pediatrics, NCQA, PCMH, primary care, Retail Clinics
Mar 3, 2014
The goal of the Affordable Care Act, also known as “Obamacare,” is to make affordable, quality health care coverage available to more Americans. But how many physicians will America need to satisfy this new demand?
The debate over doctor supply rages on with very little conclusive evidence to prove one case or the other.
Those experts who see a shortage point to America’s aging population – and their growing medical needs – as evidence of a looming dearth in doctors. Many suggest this shortage already exists, particularly in rural and inner city areas. And still others note America maintains a lower ratio of physicians compared to its European counterparts.
This combination of factors led the American Association of Medical Colleges to project a physician shortage of more than 90,000 by 2020.
On the other side of the argument are health policy experts who believe the answer isn’t in ratcheting up the nation’s physician count. It’s in eliminating unnecessary care while improving overall productivity.
The solution, they say, exists in the shift away from fee-for-service solo practices to more group practices, away from manually kept medical records to electronic medical records (EMR), and away from avoidable office visits to increased virtual visits through mobile and video technologies. Meanwhile, they note physicians could further increase productivity by using both licensed and unlicensed staff, as well as encouraging patient self-care where appropriate.
The Doctor Divide: Global And Domestic Insights
Among the 34 member countries of the Organization for Economic Co-operation and Development (OECD), the U.S. ranks 30th in total medical graduates and 20th in practicing physicians per 1,000 people.
Despite these pedestrian totals, there is one area where the U.S. dominates. It ranks first in the proportion of specialists to generalists – and there’s not a close second.
These figures don’t resolve the debate on America’s need for physicians but they do reveal an important rift in the ratio of U.S. specialists to primary care practitioners.
Continue reading “Too Many American Physicians Or Too Few?”
Filed Under: THCB, The Business of Health Care
Tagged: Physician Shortage, Physicians, primary care, Robert Pearl, specialists
Feb 7, 2014
Let’s get the disclaimer out of the way:
We love Uber.
As physicians with roots in the Bay Area, we use Uber all the time. The service is convenient, (usually) swift and consistently pleasant. With a few taps of a smartphone, we know where and when we’ll be picked up — and we can see the Uber driver coming to get us in real time.
When the vagaries of San Francisco public transit don’t accommodate our varying schedules, it’s Uber that’s the most reliable form of transportation. (It might be that we like having some immediate gratification.)
So when we caught wind of the news that Uber’s founding architect, Oscar Salazar, has taken on the challenge of applying the “Uber way” to health care delivery, there was quite a bit to immediately like. From our collective vantage point, Uber’s appeal is obvious. When you’re feeling sick, you want convenience and immediacy in your care — two things Uber has perfected.
And who wouldn’t be excited by the idea of keeping patients out of overcrowded emergency rooms and urgent care waiting rooms? The concept of returning those patients to their homes (where they can then be evaluated and receive basic care) seems so simple that it’s brilliant.
Continue reading “Uber for Health Care?? Not So Much.”
Filed Under: Tech, THCB
Tagged: Ali Ansary, Ali Khan, consumer driven health, Innovation, Iora Health, One Medical Group, primary care, Startups, Tasce Bongiovanni, Tech, Uber
Feb 6, 2014
Thank you, my patients for all you have done for me. Thank you for the encouragement and support. Thank you for believing in me enough to join me in this crazy new way to do health care. Thank you for giving me the honor of being the one you call “my doctor.”
Your trust motivates me to work harder to justify that faith in me – a faith I often don’t have and, one I certainly wouldn’t have without you. I hope and pray this holiday season is a blessing to you. May you find peace in this time of year so often without peace.
May you also have a happy and healthy new year. May you stay out of the ER, away from the hospital and, yes, away from doctors. May you have no need for lab tests, procedures, x-rays and medications (and if you must have medications may they be very cheap.)
If, however, you do get sick, remember that I am here to help you get well, feel better or avoid getting any worse. And if I cannot do any of these, I will still be there to stand by your side through the hard times, and to offer whatever comfort I can give. Doing these things is what it means to me when you call me “my doctor.” It is why that is such an honor.
Again, thank you for all you do for me. God bless you.
Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind),where an earlier version of this post first appeared.
Filed Under: Physicians, THCB
Tagged: Patients, Physicians, practice of medicine, primary care, Rob Lamberts
Dec 8, 2013
He seemed a bit grumpy when he came into the office. I am used to the picture: male in his early to mid-forties, with wife by his side leading him into the office to “finally get taken care of” by the doctor. Usually the woman has a disgusted expression on her face as he looks like a boy forced to spend his afternoon in a fabric store with his mother. My office is the last place he wants to be.
He let himself down on the couch across from my desk with a wince, belying the back pain that brought him here. He looks around at my office, which is not only a place he didn’t expect to be, but not what he expects a doctor’s office to look like. First there’s the sofa he is sitting on, which is where my patients spend most of their time during their visits. Then there is my guitar just behind me. He and his wife comment on how their daughter would love the fact that I have a guitar, as she is into acoustic guitar music. Then there’s me, wearing jeans and an untucked button-up shirt, sitting back in my chair and chatting like an ordinary person. He seems intrigued.
He owns a business, which is a service type business like mine. Like me, he and his wife choose to do things differently, charging less for folks who can’t afford it. I chat with him about the stress and strain of owning and running a small business, pointing out how his choice is similar to mine.
He had actually suggested coming to me after he had seen me on television, but obviously had initial doubts as to the accuracy of the report. Spin happens. But as we talk, there is much to find in common, and he warms up. His shoulders relax, he sits back on the couch, and forgets he’s in the doctor’s office.
Continue reading “Target Demographic”
Filed Under: Physicians
Tagged: direct primary care, doctor/ patient relationship, Patient-centered care, Patients, practice management, primary care, Rob Lamberts, Small Business
Oct 11, 2013
So, the question has been raised: why am I doing this? Why re-invent the EMR wheel? What is so different about what I am doing that makes it necessary to go through such a painful venture? I ask myself this same question, actually.
Here’s my answer to that question:
What medical records offer:
High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.
What I need:
No focus on billing codes, instead a focus on work-flow.
What medical records offer:
Complex documentation to satisfy the E/M coding rules put forth by CMS.This assures physicians are not at risk of fraud allegation should there be an audit. It results in massive over-documentation and obfuscation of pertinent information.
What I need:
Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.
What medical records offer:
Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)
What I need:
Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not. My goal is to keep them out of the office because they are healthy.
What medical records offer:
Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.
Continue reading “What I Need”
Filed Under: Tech, THCB
Tagged: direct primary care, EHR, practice management, primary care, Rob Lamberts
Aug 29, 2013
While hard at work at building a new practice and (in the eyes of some) on my insanely misguided effort to build a medical record, I’ve been thinking. Dangerous thing to do, you know. It can lead to scary things like ideas, creativity, and change. I know, I should be satisfied with the usual mental vacuum state, but I’ve found it a very hard habit to kick. Perhaps there’s a 12-step group for folks with ideas they can’t suppress.
Anyway, my thoughts have centered around explaining what I am doing with all of the my time and energy, and, more importantly, why I am doing all that stuff that keeps me from writing about important things like body odor, accordions, and toddlers with flame-throwers. I’ve really strayed from the good ol’ days, haven’t I? The problem is, I’ve grown so accustomed to my nerd persona that I end up giving explanations that are harder to understand. To combat this, I’ve decided to employ a technique I learned from my formative years: stories with pictures. My hope is that, through the use of my incredible drawing talent I will not only explain things faster (saving 1000 words per picture), but prevent my readers from falling, as they often do, into a confused slumber.
So, here goes.
Adventures in Health Care: Part 1 – The Participants
This is a patient. Let’s call him “Chuck.” Chuck is not really a “patient,” he’s a person. Many doctors believe that people like Chuck don’t exist outside of their role as “patients,” but this has been proven false (thanks to the tireless work of Oprah and ePatient Dave). But since this story is about Chuck’s wacky adventures in health care, we will mainly think of Chuck in his role of “patient.”
Why are people like Chuck called “patients?” Some people think it’s to put them in their necessary subservient place in the system. I think it’s just to be ironic.
Chuck is a generally healthy guy, but occasionally he does get sick. He also worries about getting sick in the future, and want’s to keep himself as healthy as possible. This is when he uses the health care system, and when he is forced to be “patient.”
Continue reading “Adventures in Medicine”
Filed Under: THCB
Tagged: Patients, practice management, primary care, Rob Lamberts
Aug 20, 2013
My mom is great.
Unfortunately, like most mothers, she relishes telling funny (usually embarrassing) stories about us kids. I, unfortunately, seem to be the subject of the vast majority of those stories. But my big brother gets the leading role in one I will now tell. I guess it’s a small way to get back at him for…well, for lots of stuff. One day he came home from school all excited (unusual for my half-vulcan brother). ”Mom! Mom! I learned how to swim today!” he said. ”Oh?” my mother answered, not sure how and where he learned this new skill. Bill got a very pleased expression as he explained, “Steven V. taught me on the bus!” This is where my mother guffaws and my father chuckles and we kids look at each other with the well-worn “when will this story get old?” expression. He’s probably making that expression at his computer right now.
But the naïveté expressed by my brother at the nature of learning how to swim is similar to my confidence going into this project. Certainly it helps to know you can’t breathe underwater, and that swimming in a suit of armor is a bad idea, but this knowledge does not substitute for the first-hand experience of keeping afloat while the water seems to be trying to drown you. Similarly, I could read books, make a business plan, and impress people with my thought and insights, but that does not substitute for the first-hand experience of building a new business from scratch. It does nothing to keep me financially afloat while unseen forces try to pull me under.
Which brings me to my current situation. Would I have taken the plunge had I known what it’s taken up until now? It has been hard.
I hesitate to write about this, because:
- I hate to sound whiney.
- I don’t want people to worry that things are worse than they are. Especially my patients.
- I don’t want to get a lot of advice from well-meaning people who don’t know the details of my situation.
But I want to give a realistic picture of what this journey is like, not just throw you the vaporware version. Besides, my world right now has significant stress and pressures that I didn’t anticipate.
The first sign of trouble came very early, in the renovation of my office. My goal was to start seeing patients in mid-December, and officially opening around the first of the year. Unfortunately, the office wasn’t ready until February 6th, and the construction cost twice what I expected. For those who can’t see the implication: I spent more money and lost a month of earning it. More money out, less money in. Maybe swimming’s a little harder than Steven said it was.
Then came the EMR debacle.
Of the areas I was most sure of, my ability to use computers to improve care was at the top. After all, I had won national awards and much acclaim for my use of electronic records to improve care. Two months and five EMR products later, I was beginning to see just how far the health IT industry had moved away from patient care. I din’t know what to do; I was at an impasse. Each system I tried either lacked some basic element of organization I required (such as management of outside documents) or was unable to generate anything but the voluminous documentation which succeeds only in two areas: getting physicians paid and hiding useful clinical information.
Continue reading “The Good Doctor Calls For Backup”
Filed Under: THCB
Tagged: practice management, primary care, Rob Lamberts, the business of health care
Aug 15, 2013
A patient calls or emails me with a problem. I talk with them over the course of a few days, using whatever form of communication works best. Eventually, they need to come to the office to be seen – either for something needing to be done in-person (examination, procedure, or lab test), or because of the advantages of face-to-face communication. At the visit, I not only deal with one problem, but there are other issues needing to be addressed. Finally, after the visit, follow-up on the problem continues until it is either resolved, or at least is not causing much trouble.
So how do I document that?
In the past I would’ve had a clear structure for the “office visit” and separate “encounters” for the documentation of the communication done outside of the office. The latter would be done largely with narrative of the conversation, and some direct quotes from the patient. The former, the “office visit” would include:
- A re-telling of the story of the “chief complaint” and what’s been happening that caused this encounter to be necessary.
- A sifting through other symptoms and past-problems to see if there is any information hidden there that may be useful.
- A documentation of past problems (already in the record) to support the thought process documented later in the visit.
- An overview of the physical exam, again to support the decisions made as a result of the visit.
- A discussion of my thoughts on what I think is going on.
- A telling of my plan on how to deal with this.
- A list of any advice given, tests ordered, medications changed, prescriptions written, and follow-up as the details of that plan.
- A signature at the end, attesting to the validity of what is contained in the note.
But here’s the problem: it’s not real. I don’t make all of my decisions based on the visit, and the patient’s story is not limited to what they tell me. Details may be left out because they are forgotten, questions aren’t asked, or things just haven’t happened yet. This signed and sealed unit of care, represented as a full story, actually represents only fragments of the story, of many stories actually, and only as a moment on the continuum of the patient’s care.
Continue reading “The Office Visit Revisited”
Filed Under: Tech, THCB
Tagged: EHR, Patients, practice management, primary care, Rob Lamberts
Jul 21, 2013