The Business of Health Care

Care On the Continuum

My change from a traditional practice to direct-care has caused me to challenge some of the basic assumptions of the care I’ve given up to this point.  Certainly, the nature of my documentation will radically change with my freedom from the tyranny of E/M coding requirements.

Perhaps the biggest change in my care comes courtesy of the way I get paid.  The traditional way to be paid is for service rendered (either at an office visit or procedures done).  This means that I am financially motivated to give the bulk of my attention to people when they are in the office.  They are paying for my attention, so I try to give them their money’s worth.  The corollary of this is that I tend to not think about people who are not in the office to be seen.  The end-result is an episodic approach to care that is entirely dependent on the patient paying for an encounter.

There is a huge problem with this approach to care: people live their lives between encounters.  Life does not go on hold between office visits for my patients, and the impact of my care is not dependent on what happens in the encounter, but what happens between visits.  My ability to help my patients depends on my ability to affect the continuum.  If I do a good enough sales pitch for a person taking their medications, and if I consider the life-circumstance which may affect their ability to take the medicine, then I am successful.  I don’t learn about the success until their next visit (usually), and I also don’t learn about problems until then.  People are reluctant to call with problems they are having with medications, new symptoms, or other important details, often waiting for many months to tell me things I really want to know.  Perhaps they don’t want to be “one of those patients who calls all the time,” perhaps they don’t understand what I said, or maybe they’re worried I will “force them to come in” to pay for another office visit.  Regardless of the reason, I get very limited interaction with my patients in this episodic care model.

My new practice model allows for, and even encourages interaction between face-to-face encounters.  I intend on spending a significant part of my day systematically reviewing records to make sure they are up-to-date, and initiating contact if need be.  I will also give them resources to be able to manage their care (or their wellness) without having to pay for each encounter.  One reader (of another blog to be left unnamed) suggested that under this system he would get his “money’s worth” by using my service as much as possible.  For him that meant coming to see me often, but in the model of care on the continuum it would involve going to the web site and updating records, sending me questions, or watching videos I’ve made on a particular subject.  My hope is that all my patients would “get their money’s worth” between visits, and that perhaps this will reduce the need for actual face-to-face encounters.  In fact, that is the whole point of what I am doing.

There are some specific types of care that the view on the continuum is significantly better than the traditional episodic approach:

  1. Pediatric/Well care – We traditionally see babies at 2 weeks of age, then at 2, 4, 6, and 9 months of age during the first year of life.  After that the care becomes less frequent, to the point that many pediatricians don’t see children in school-age and teenage years more than every 2 years for well care.  The reality is, however, that children grow between these visits, and much of the advice given during these visits (“anticipatory guidance”) is forgotten by parents.  Care on the continuum means parents have access to the information about a wide range of problems as well as having the ability to ask questions any time they want.  Things like “I can’t get my child to sleep in her own bed,” or “Jonny is still wetting his bed” are problems parents will hold off on asking until the scheduled visit.  Certainly there will still be scheduled visits for measuring, assessing development, and physical exam (not to mention that the pediatrician needs his baby fix), but these visits are enhanced by what happens between them, allowing problems to be addressed sooner.
  2. Psychiatric problems – Much of the follow-up care of anxiety, depression, or attention deficit disorder (which are the three staples of psych in primary care) involves assessment of interim symptoms and/or problems.  Care on the continuum can happen with monthly (or more frequent) reports of how things are going, how the child is doing in school, or if there are problems with medications.  Many people with these problems are reluctant to come to the office, much less talk about new problems.  I hope having direct access to my care will give them an easier avenue to give me the real view of how they are doing.
  3. Controlled drugs – Prescribing and refilling controlled drugs are a huge part of my work stress, and one I wanted to address in my new practice.  Traditionally I write refills of these medications and manage them with intermittent office visits.  On the continuum I can require a symptom questionnaire before refilling medications, allowing me to address increasing use as it is happening and moving people away from more addictive short-acting drugs to the more effective and safer long-acting drugs.
  4. Chronic disease – Diseases like asthma or diabetes are much better cared for on the continuum, as a regular log of blood sugars or peak flow readings can be sent to me on a regular basis.  I can see early, not waiting for the 3 months A1c, that the sugar is not coming down as expected.  I can hear about early symptoms of asthma, not waiting for the patient to come in with a full-blown attack.  Adjustments can be made much more frequently without the need for face-to-face care just to hear about symptoms or blood sugar readings.

I keep getting new ideas of how to handle problems differently in this new model of care, but all of them benefit from the fact that it looks at patients before problems pop up, or at least at the time of the problem instead of after a potentially dangerous delay.  The waste in our system is, as has been noted often, huge.  But the assumption that episodic care is the proper model could be the most costly mistake of all.  People are afraid to engage our system because of the cost, and that fear ends up costing everyone by not dealing problems until they are “bad enough.”  Care on the continuum seems to accomplish the main goal of my care: keeping people away from the rest of the health care system unless it’s absolutely necessary.

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 this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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JakeWinstonMikeSCindyDave Chase (@chasedave) Recent comment authors
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Jake
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Jake

Great post, understanding the continuum and how care providers interact with it is vital to what I do. Can you elaborate more about how you have reorganized your practice and what tools you use to accomplish this research and communication effectively? I was unable to find other pre-cursor blog posts; maybe you can just point me in that direction.

Winston
Guest
Winston

Not long ago you did a post on email explaining that you don’t accept emails from patients because they are a distraction and eat up a lot of time for no pay. Given that you are now going to be able to focus more on patient relationship building than the administrative burden of getting reimbursement, have you views on using email changed?

Dave Chase (@chasedave)
Guest

Talking with DPC MDs, there aren’t major differences with specialist referrals (i.e., if there’s a situation requiring specialists, they refer) but there are a few… 1)in DPC, PCPs aren’t “loss leaders” that have a practice model that maximizes the potential for referrals — after all, if your “productivity” #’s force 8 minute encounters there’s a high likelihood that you’re inclined to get the person in & out as quick as possible by referring out or prescribing drugs. 2)DPC MDs have more time so they can discuss the pros/cons of various treatment options. One gave the example of a patient with… Read more »

BobbyG
Guest

“In the aforementioned DPC paper, the evidence suggests a significant decrease in ED visits, surgeries, hospitalizations and specialist visits. That may be good for the patient and whoever is picking up healthcare costs but obviously one person’s cost savings is another’s revenue. It’s clear why some orgs won’t embrace DPC if they see it harming their bottomline.” ___ This has long been the reform conundrum. “Every misspent dollar in the health care system is part of someone’s paycheck.” – Brent James, MD, M.Stat, IHC, 1995, during our CQI training sessions in SLC Brent also noted (paraphrasing here) “Let’s not kid… Read more »

Rob
Guest

This is why the solution to out-of-control spending must come from outside of the system, with a disruption rather than an inside change. Those with the most to lose will do what they can to preserve their jobs. This is what finally convinced me to step outside of the system and change it for my little corner of it. My goal, by the way, is to get all of my patients old, but to keep things as simple as possible. It is far easier to focus on quality of life for someone in their 80’s and 90’s, avoiding unnecessary treatments… Read more »

Winston
Guest
Winston

How will you coordinate referrals to other specialist doctors? This business model sounds like a good idea for PCPs, but do you think it is adaptable to specialists?

Also, do you lock your patients in with contracts? If there’s a rift between you and a patient, can the patient cancel the subscription at any time?

Rob
Guest

My plan is to not do referrals through my “referral specialist” but instead email directly to specialists that are willing (securely, of course). I would like to take a hand in making sure the referrals are done in a way that the specialist knows what I’ve done and what I am asking. Not being required to keep a full office allows me to do these out-of-the-office tasks that are critical and not worry about revenue. I’ve got lots of specialist friends who will cooperate, and those who choose not to may not get referrals. I don’t think I’ll have a… Read more »

MikeS
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MikeS

Rob –
If I was in your area, I would run, not walk, to sign up with your new practice. I predict a happy healthy practice.

Cindy
Guest
Cindy

As an administrator for a small primary care practice (15 clinicians) I see the PCMH movement as great job security for administrators, but alot of fundamentally unnecessary waste/ overhead from a health policy and tax payer perspective. Insurance is for high cost, high risk events – not low cost, fairly predictable services like primary care. We don’t use our auto insurance for oil changes and tune ups – why do we do it in health care? All it does is drive up the cost and contributes nothing to the quality of care. BTW – direct primary care is specifically allowed… Read more »

BobbyG
Guest

“We don’t use our auto insurance for oil changes and tune ups – why do we do it in health care?”
__

See JD Kleinke (and, plenty of others have addressed that issue as well).

It’s not properly “insurance.” It’s (poorly structured) pooled “pre-payment.”

Dave Chase (@chasedave)
Guest

If you are interested in learning more about the DPC clause in the ACA, I’ve done an indepth study of it over the last year. I call this clause the “David Clause” (as in David & Goliath) in the ACA as it has the potential to slay the healthcare cost beast. I call DPC the “Triple Aim Champ” as it exceeds anything I’ve seen on the Triple Aim objectives by a wide margin. If you want a pre-release draft of the DPC paper (it’s about 40 pages but needs to be tightened up to <30 pages so having a fresh… Read more »

southern doc
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southern doc

“I see the PCMH being a bridge to the DPC”

Disagree. The PCMH ties the doctors even tighter to the insurers. Practices are required to make enormous up-front investments in staff and infrastructure,such that they become hooked on something as small as $1 PMPM. It doesn’t come close to covering their expenses, but any little bit helps. Patients do not pick up any more of the cost. From a financial point of view, it’s a terrible way to run a practice.

Dave Chase (@chasedave)
Guest

I’m talking about altering the care delivery side (i.e., a more proactive model vs. strictly the reactive model that is pervasive today)…not financial. I agree with you on the financial side. Dr. Rushika Fernandopulle stated the PCMH payment model as “putting wings on cars and calling them airplanes” (meaning his model is an “airplane”). As an outside observer, I’m glad primary care is being recognized for the value it brings. However, the simplicity of DPC makes much more sense to me as a patient and as an employer.

Barry Carol
Guest
Barry Carol

Rob – I would be interested in your estimate of how many hours of your practice day or week is currently devoted to documentation needed to get paid, especially with respect to Medicare patients that would disappear under your new practice model. Conversely, to what extent might you need additional staff to keep track of a continuing stream of data from patients regarding their BP, weight, glucose level and the like? Also, it seems that at least your more educated patients might be able to learn about some of the potential concerns you talked about from websites run by Mayo… Read more »

Rob
Guest

I think it is reasonable to say that I spend 50% of my time doing documenting beyond what is absolutely necessary for care or searching for information that is hidden in the “packing material” of E/M coded notes, etc. that is required by Medicare. We’ve streamlined things with the EHR we use (I am obsessed with streamlining processes), but often that results in time taken to work on the process improvements and over documentation with the EHR templates. My hope is (and I can’t say beyond that except that other direct-care doctors have experienced it) that the time I am… Read more »

RUCertain
Guest
RUCertain

Great post. Please continue to update challenges and success…and I hope for much success. Regarding JS Walker, MD: ” All things told, it would likely be less frustrating on the whole to become a PCMH (which certainly requires a team, not just one provider), than to try to invent something completely de novo.” This encapsulates the two main approaches to solving system problems: inside out and outside in. To be pejorative, the PCMH model seems to be the tail wagging the dog. It doesn’t fit Dr. Lambert’s practice style perfectly, like a custom tailored Italian suit but you can find… Read more »

southern doc
Guest
southern doc

The classicists among us would describe it as a Procrustean bed.

BobbyG
Guest

LOL. See Taleb, “The Bed of Procrustes”

Delightful book.

Rob
Guest

I consider my day worthwhile having learned that phrase. Most excellent.

DeterminedMD
Guest
DeterminedMD

“Psychiatric problems – Much of the follow-up care of anxiety, depression, or attention deficit disorder (which are the three staples of psych in primary care) involves assessment of interim symptoms and/or problems.  Care on the continuum can happen with monthly (or more frequent) reports of how things are going, how the child is doing in school, or if there are problems with medications.  Many people with these problems are reluctant to come to the office, much less talk about new problems.  I hope having direct access to my care will give them an easier avenue to give me the real view… Read more »

Rob
Guest

You read too much into this. Certainly the vast majority of pscyh problems are handled in a PCP setting, just as hypertension is handled there instead of by a cardiologist. Most of the time I “treat” people I talk about a holistic view on things (I hate that word, but it’s true in this case) that considers medicines as an optional adjunct to be used to assist with the relational, psychological, and even spiritual issues that have led to this problem. In the traditional practice I am often reduced to throwing pills at things (which is one of the reasons… Read more »

DeterminedMD
Guest
DeterminedMD

Hope patients will not force you to do more of the same.

Rob
Guest

Early in practice I may have been “forced” to give Rx, but now I am pretty good at saying no when it’s appropriate and (even in the lousy paradigm of care we have now) make sure they understand the bigger picture. That’s the difference between doing a job and being a clinician.

Margalit Gur-Arie
Guest

The original PCMH concept has been severely distorted lately, and a year ago, while commenting on a new study, I actually called it Process Centered Medical Home, because that’s what it became, and it is now used to further discredit small practice in spite of all the “study” results pointing to the contrary….
http://onhealthtech.blogspot.com/2011/07/process-centered-medical-home.html

southern doc
Guest
southern doc

I do an informal survey with my patients:

1. Do you want your medical care from me or from a team?

2. Do you want me to “transform” my practice or run it as I always have?

The answers I receive certainly indicate that the “P” In “PCMH” doesn’t stand for patient. Yes, “process,” but more and more “payor.”

Margalit Gur-Arie
Guest

The word “team” has also been co-opted for policy use. Unless you are a micropractice, there has always been a team. There is the lady helping you with appointments and referral appointments, and there is the lady who shows you in and takes your blood pressure, maybe even gives you a shot… and there is the doctor who treats you… Now “team” means that other people treat you and the doctor “leads” the team by reading reports on how things go and if you’re ready to keel over and drop dead may come in to see what’s going on. As… Read more »

southern doc
Guest
southern doc

I would describe it as a new paradigm.

Margalit Gur-Arie
Guest

Yes. Perfect. I’ll add that to my Verbal Wizardry Dictionary (seriously… 🙂 )

southern doc
Guest
southern doc

Checked out your link above. Perfect example of measuring what we can measure, not what is important. I think “Rapid Cycle Quality Improvement Strategy” was an option on my new Bosch dishwasher.

pcb
Guest
pcb

Interestingly, there is no team medical license. So if physicians simply said, “I’ll take responsibility for the medical decisions made under my license”, a lot of this team based care would have trouble functioning.

We can say No when asked to extend our liability and license beyond our own medical decision making.

pcb
Guest
pcb

“The ones who have to sign the death certificates, who have to look at the patient and agree to be ‘their doctor’, must be allowed to wear the pants in the family. This does not negate a team approach, or demean the vital roles of business, nursing, or other roles; but when the real leadership is not carried by those with the real ultimate responsibility, the system (whichever system) falters” This is an essential point. Unfortunately, it has been largely ignored. I would like to add that having an MD behind your name does not necessariliy mean you carry the… Read more »

Rob
Guest

I agree, and do think that clinicians should always lead should be the ones leading the reform, as we are the ones who see the real effects of a broken system

J. Stefan Walker, M.D.
Guest
J. Stefan Walker, M.D.

Rob, thanks for the intro summary to the principles of the new practice. It strikes me that your core values are not at all dissimilar to the PCMH model; and also strikes me as a loss to our profession if good docs like yourself exit the mainstream rather than remain as necessary agents of change within it. Could you not remain within the traditional payment system, but re-boot your practice as a certified PCMH? The funding streams may not be yet ready at present for a subscription model, but I foresee something like that (? grants from payers per annum)… Read more »

Rob
Guest

The question is: can substantial change come from within a system, when that change would require significant downsizing of that same system? I think the system doesn’t change itself because it would cause it too much harm to do so, and perhaps the only way to truly change the system is to offer a different and better alternative. This goes along the “disruptive innovation” concept which has wrecked many entrenched industries. The PCMH, which my practice was working on, became the DCMH (data-centered medical home), and was taking a lot of the attention off of the patient and on to… Read more »

J. Stefan Walker, M.D.
Guest
J. Stefan Walker, M.D.

Indeed, points taken. Key questions for reform-minded doctors: what is my overall goal? and equally important: can I realistically achieve that goal? If the goal is to reform the system, I have concluded that the train has left the station: health reform is one of the top domestic issues of the US political and economic discussion, for going on 4 years now; and the PCMH movement is growing exponentially, and as you note, is a ‘good idea’. How much could (should) one doctor do against massive forces like that, in developing a whole new approach – is it worth it… Read more »

Rob
Guest

For me there were two considerations: first was the little-picture of the people I care for. They are being hurt by the system and I see much of the immediate damage it causes. This cost me enough emotional energy that I was pushed to this choice. I am (and always have been) the kind of person who, when I see a problem I think I can solve, is compulsively drawn to solve that problem. That is what makes me a good clinician, to some extent, and why our practice adopted EMR 16 years ago. I can’t sit on my hands… Read more »

J. Stefan Walker, M.D.
Guest
J. Stefan Walker, M.D.

I understand the clarification. I would further push however that, happily perhaps for you and your patients, your own proposed new system most likely could be fit fairly easily into a PCMH model that would allow you to continue to take insurance; save even more patients money, perhaps; allow you proper autonomy to manage and innovate; and likely qualify you for future cooperation with payers in terms of grants for level 3 homes. I’m not saying stay in your original mainstream clinic construct; I’m proposing you do almost exactly what you were planning to do – just within parameters that… Read more »

southern doc
Guest
southern doc

I honestly don’t see how the PCMH model addresses any of the issues that motivated Dr. Lamberts to make this change. Meaningless MU, insurance interence, low fee schedules are still there, with a truly mind-numbing level of bureaucratic chores that come with certification.

southern doc
Guest
southern doc

How can you keep overhead low, but use the services of an entire team as opposed to one doctor?

The finances of the PCMH are disastrous without huge external financial support: it’s a very expensive way of delivering primary care.

J. Stefan Walker, M.D.
Guest
J. Stefan Walker, M.D.

There are a lot of ways to skin the PCMH cat. A small staff can do so by proper organization; a reasonable but usable EMR; and the small staff each wearing several hats within the construct. It’s the concept and the results that matter, not the size of the team. It can be done.

southern doc
Guest
southern doc

Don’t get it. Case in point: in our office, we run on one doc, two staff members with in-house billing. We’re extremely well-organized, and there is NO give to do the DCMH chores that Dr. Lamberts describes. For example: we’ve always done same day access, our patients know we do same day access. What is the advantage to me, my staff, my patients, or the system for me to pay someone time and a half to come in on weekends to document per NCQA guidelines what we’ve always done? Dr. Lamberts wants a less administrative-heavy practice, and you’re recommending what… Read more »

BobbyG
Guest

Very thought-provoking post. Thank you. This is perhaps a weak analogy, but, nonetheless: I used to work in Risk Management in a subprime credit card bank. I was the principal “portfolio management” officer/analyst. It was a big part of my job to monitor ongoing the shaky financial “health” of our financially halt and lame cardholders (we used to joke that it was like giving whiskey to alcoholics, granting credit lines to subbies). We had effective data mining pxs and predictive models for everything. Once we booked these people, he had to try to keep them profitably “healthy.” I was a… Read more »