Physicians

Dear Mr. Slavitt, Please Come Visit My Office

flying cadeucii

Andy, if you want to fix primary care you must do some field research.  Come spend one day, or even a week at my office or another small primary care physicians’ office.  You need to see what we do on a daily basis and actually understand the view from a small practice perspective. This knowledge deficit is at the core of CMS’s problem.  You cannot repair what you do not comprehend.

Once you understand what we are capable of doing, how we do it, and how it actually SAVES money in the long run, while still providing high quality, then you are ready to tackle Focusing on Primary Care for Better Health.  The bottom line:  you must pay us more for what we are doing if you want to increase our overhead expenses.  Tasking us with additional administrative burden in order to earn extra money is not actually paying us any more for our work.  We would be working harder, not smarter.  Do you understand that?

First and foremost, the largest stumbling block for reducing expenditures of a small practice is addressing the certified EHR. Why do you need all this data?  Your days at McKinsey & Company have hooked you on its necessity to make management decisions, but your background is in healthcare insurance and expenses is a far cry from the provision of primary health care or value-based care.

The EHR mandate has damaged our profession as a whole.  It has been destructive to the physician-patient relationship as well. Technology has not improved safety, efficiency, or patient satisfaction and has only served to increase physician dissatisfaction.  Physicians are overwhelmed, hopeless, and trying to get out of the practice of medicine altogether.  You do not belong between me (the physician) and my patient – move out of the way.  Please.

If you want me to collect mountains of data, then prove it actually increases quality, reduces cost, and decreases our workload before I get on board.  There is very little margin to work with in my office, and if I make a wrong decision, my practice (and many others) will be dead in the water.   Find technology that is useful to both physician and patient while being affordable at the same time.  Stop adding complicated algorithms and programs to increase reimbursement while expanding our administrative burdens.

Second, value will materialize if you pay us more for what we do.  Higher reimbursement allows us to slow down and talk longer with each individual patient.  Make our lifestyle something to which others want to aspire and you will find more primary care physicians wanting to work in smaller areas.  Primary care physicians, actually ALL physicians, deserve better.

Have you not realized small practices provide urgent and emergency care, acute and chronic care, plus everything in between?  Care coordination, we already do it!  Winging it when there is NO specialist to refer to at all, we already do! It is value, pure and simple.  You cannot get anything more out of us.  There is nothing more to give.  If primary care is rendered obsolete because we could not keep up with your overwhelming demands, access will be in jeopardy.  Access will be worse than it is right now.  What will you do then?

As to your Collaborative Care Model, supporting mental and behavioral health through a team-based, coordinated system involving a psychiatric consultant, behavioral health manager, and the primary care physician sounds like a dream come true.  My county with a population of 260,000 has NO psychiatrist.  Not one.  Many states all over are experiencing the same provider shortages.  Can you grow psychiatrists somewhere at an accelerated rate, like that clone army in Star Wars, and drop them randomly by plane throughout the United States?  That would be a good start.  They could be raised to believe indentured servitude is their destiny.  I think it could work if you put that on your task list.

CMS employees have not spent one day inside a small primary care practice.  It is necessary at this point in time that they do.  You talk about encouraging innovations to connect people with primary care.  Here is the thing Andy, primary care physicians do not need innovations to connect people.  We use phones, interact face-to-face with our patients, and chart to document the entire process.  If we were not good at connecting with people, we would not be successful primary care physicians.
There is a lot of talking as a primary care physician.  It is difficult to quantify the value of face-to-face interaction but it is a crucial part of health care.  If you are feeling socially awkward and experiencing difficulty connecting to people, again, please come visit me in my office.  I will rid you of your communication problems, pronto.  At the very least, please spend some time with one primary care physician in a small community.  It will show you all that can be good with health care.  It will also open your eyes to what you are about to destroy.

Niran Al-Agba is a physician in private practice in Washington State.

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Categories: Physicians, Uncategorized

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fixthebusmeltootsPeterPaul @ Pivot ConsultingLLCanish_koka Recent comment authors
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fixthebus
Member

Their regulations and tools to improve healthcare have nothing to do with quality but money. The ‘public good’ is a tool to implement a big-business approach to healthcare – to practice medicine by statistics – all the while collecting huge amounts of money for themselves and their buddies in corporate America. You are not going to beat these people in the political arena as they own the media and the candidates. You can only beat them in the private sector, and it may come down to a black market. Eventually, though, this ‘noble’ approach by big government and big business… Read more »

Niran Al-Agba
Member

This is fantastic news! If I could get Andy to visit a small rural practice in the Pacific Northwest we can really get the ball rolling.

BobbyGvegas
Member

BREAKING: Slavitt suggests MACRA could be delayed
By Shannon Muchmore | July 13, 2016

CMS Acting Administrator Andy Slavitt told lawmakers Wednesday the agency is considering delaying the start date for Medicare payment reform which is set to go into effect Jan 1.

Testifying before the Senate Finance Committee, Slavitt said the CMS is concerned that some physicians, particularly at small practices, may not be ready for the changes under Medicare Access and CHIP Reauthorization Act that replaced the much maligned sustainable growth rate formula…

http://www.modernhealthcare.com/article/20160713/NEWS/160719961?utm_source=modernhealthcare&utm_medium=email&utm_content=20160713-NEWS-160719961&utm_campaign=mh-alert

anish_koka
Editor

While I appreciate the difficulty of Mr. Slavitt’s job and I do note the ‘listening’ in the recent chronic care management payment increases as well as the reduced reporting requirements, this is all still ensconced in a regulatory structure that sees physicians as cogs in a data collectors/population health machine. The higher reimbursement promised for the ‘weekend call’ does come along with reporting requirements, and are not promised in perpetuity. Mollifying the good physicians struggling to provide care in this framework will take more than a change of tone but a different language. While I am sure the policy folks… Read more »

Niran Al-Agba
Member

Thank you. We must emphasize intent to improve is not the same as true “outcome-based” improvement. Apples and oranges.

Hayward Zwerling
Member

As part of the Massachusetts Medical Society’s efforts to improve the HIT situation, Mr. Slavitt had been invited to visit one of the MMS member’s office, where, I believe Epic is used. Mr. Slavitt did make that visit and it is my understanding that it provided him with important insights into our current HIT dilemma.

Niran Al-Agba
Member

That is great to hear. Again, I would love it if he would read this and join me for a day.

mbushkin
Member

Niran, I don’t know Andy Slavitt personally but from what I’ve read I think it grossly unfair to use him as a “whipping boy” to make your point. In the course of trying to make the government programs more useful and effective, he and Karen DeSalvo, MD have spoken with literally hundreds of doctors—probably more than you or most other physicians have done. Whether you agree with their conclusions, of course, is another matter — and you clearly don’t. Your basic point, however, raises serious questions about what can be done to help you do more of what you really… Read more »

BobbyGvegas
Member

“Niran, I don’t know Andy Slavitt personally but from what I’ve read I think it grossly unfair to use him as a “whipping boy” to make your point. In the course of trying to make the government programs more useful and effective, he and Karen DeSalvo, MD have spoken with literally hundreds of doctors—probably more than you or most other physicians have done.”
__

Imputations of ill will and ulterior motives are the norm here of late.

mbushkin
Member

Bobby, sorry you misunderstand my comment. I am not imputing anything. I merely object to a literary style that makes its point at the expense of others.

BobbyGvegas
Member

You misunderstood MY remark. Wasn’t accusing YOU of anything. I tire of the recurrent casting of aspersions toward people like Slavitt by others, both here at THCB and elsewhere.

Niran Al-Agba
Member

“Aspersions” is a little dramatic don’t you think? I neither attacked Mr. Slavitt’s reputation nor his integrity. This is a true heartfelt invitation to spend time at my office. He would enjoy the experience, and would be able to develop more perspective on what an old fashioned medical practice looks like — very efficient and able to keep costs under control.
Bobby, if you wish to critique my literary style in the future, you will probably have to be less subtle. I missed it, as did Merle. Thank you for your comments.

Paul @ Pivot ConsultingLLC
Member

Bobby, these are critical issues, and the central powers are imposing changes….usually with no pilot tests or research…..that dramatically alter doctors’ careers as well as patient health….and almost always in a negative way that is degrading a noble profession (despite what are most likely good intentions). Passion about these issues is called for and helpful in my opinion.

Allan
Member
Allan

Paul, you are correct about passion. Healthcare is a life and death matter so passion is naturally a part of the debate which should be held, but to do so requires two parties. I wish Andy would have responded to some of the doctors concerns. It is his agency and him that are trying to change human nature and creating havoc while doing so.

meltoots
Member
meltoots

This is a perfect example of Mr Slavitt denigrating what physicians do and disrespecting us…his latest twitter post: “We need to get out of the mode of paying physicians just to run tests and prescribe medicines. We need to pay for conversations.” I mean, really, is that what medicare is currently paying for, just prescriptions and running tests? Come on. That is a total insult to me as a front line physician. It strikes right at the heart of the problem with CMS. THEY think they know how to practice medicine and what needs to be done, and they have… Read more »

Niran Al-Agba
Member

Believe me, I feel your pain. This quote “we need to pay physicians for conversations” is mine. It has been my crusade and is the reason I keep writing. I am thrilled Mr. Slavitt heard me. It is the first step. Now that he realizes the most important part of medicine IS NOT running tests and prescribing medicine, the second step is to show us what he will do about it. Front line physicians have to keep fighting together until we are heard. Of course counting and clicking do not have anything to do with improving care or reducing costs,… Read more »

Niran Al-Agba
Member

You may not like me or my opinion, but I LOVE this idea! You had me at free! Absolutely Brilliant. A small cost to patients or insurance company, and it does not change how I care for my patients in my office. I do not know Mr. Slavitt personally either and am certainly not whipping him. Pointing out deficits in his knowledge base is known by most of us as constructive criticism. Physicians experience this frequently and we are humbled when we receive suggestions as to how we can do better. Mr. Slavitt’s post gave me hope that he is… Read more »

mbushkin
Member

I admire your passion and open expression of how you feel. You are truly refreshing.

My objection was that you made your point by criticizing/challenging someone who I believe shares many of your goals and may even be your natural ally.

And as you surmised, the alternative patient-focused system I described isn’t hypothetical. It’s very real and exists today.

I greatly appreciate your comments about it will be delighted to have you try it with your patients. We would love to hear from other providers who wish to try it, too!

Niran Al-Agba
Member

Mr. Slavitt may share my goals and be a natural ally but I cannot help him unless he contacts me. There are so many easy ways to make care more efficient. Our phones and all technology are out today due to construction nearby. (Just another typical small town problem) Hopefully he calls tomorrow. I will absolutely test run your device. You might not think I’m so refreshing after you work with me. I’m fairly opinionated and passionate when it comes to quality care of children.

Niran Al-Agba
Member

Thank you all for the kind words. I am glad I have been able to put how many of us in primary care are feeling down on paper . John, I hope you are right and I hear from Mr. Slavitt. A few days with me will change him one way or the other. I will be honest, wanting to dislike Mr. Slavitt is easy. His background, both educationally and experientially, was not proper preparation for the job with which he is tasked. After reading his post about focusing on primary care, however, I appreciate his efforts and have softened… Read more »

Allan
Member
Allan

Niran, thank you for this most wonderful post. Andy won’t visit normal physician offices because he is unwilling to explain himself or the position of CMS. We see that unwillingness with his lack of responsiveness to physicians that have written about the problems they face. He can’t. CMS has a dream that CMS wishes to become a reality. Dreams are for ideologues. Reality is for those that actually live in the trenches. Saving money isn’t the issue either. It is the ideology that counts. If money were the issue we wouldn’t see Medicare paying more for colonoscopies in the hospital… Read more »

William Palmer MD
Member
William Palmer MD

Good, Allan. I agree this is a superb post.

They own the VA system. It is theirs. They should want to show us exactly what they desire for the rest of us by perfecting this as a model for the entire country.

Yet, they are mum about this–what they are accountable for–because ???

Peter
Member
Peter

“They own the VA system. It is theirs. They should want to show us exactly what they desire for the rest of us by perfecting this as a model for the entire country.

Yet, they are mum about this–what they are accountable for–because ???”

This from an earlier article on THCB that shows how the VA does it – BETTER. They are not “mum” by any means. They also get to negotiate drug prices, unlike Medicare.

https://thehealthcareblog.com/blog/2014/06/10/how-does-the-vas-technology-rate-against-other-emr-vendors/

Allan
Member
Allan

Though you seem to assume the EHR=healthcare it doesn’t. How has their EHR corrected the VA’s problems that are quality related and would lead to lawsuits in the healthcare sector?