By KEVIN WANG, MD
urgent-care-as-healthcare culture isn’t killing us, it’s certainly wasting our
time and resources.
Consider these facts highlighted by Advanced Medical Reviews, based on various studies:
- U.S. physicians report that more than 20 percent of overall medical
care is not needed.
- The Congressional Budget Office recently estimated that up to
30 percent of the costs of medical care delivered in the U.S. pay for tests,
procedures, doctor visits, hospital stays, and other services that may not
actually improve patient health.
- Unnecessary medical treatment impacts the healthcare industry through
decreased physician productivity, increased cost of medical care, and
additional work for front office staff and other healthcare professionals.
Most of today’s
primary care is, in retail terms, a loss leader — a well-oiled doorway to the
wildly expensive sick care system. For decades, practitioners have been forced
into production factories, seeing as many patients, ordering as many tests, and
sending as many referrals as possible to specialists. Patients, likewise, have
avoided going in for regular visits for fear of the price tag attached, often
waiting until they’re in such bad shape that urgent (and much more expensive)
care is necessary.
The system as it
stands isn’t delivering primary care in a way that serves patients, providers,
employers, or insurers as well as it could. To improve health at individual and
population levels, the system needs to be disrupted. Primary care needs to play a much larger role in healthcare, and it
needs to be delivered in a way that doesn’t make patients feel isolated,
neglected, or dismissed.
care is making a comeback — the kind that doesn’t just treat symptoms, but sees
trust, engagement, and behavior change as a path to health.
By HANS DUVEFELT, MD
The chest CT report was a bit worrisome. Henry had “pleural based masses” that had grown since his previous scan, which had been ordered by another doctor for unrelated reasons. But as Henry’s PCP, it had become my job to follow up on an emergency room doctor’s incidental finding. The radiologist recommended a PET scan to see if there was increased metabolic activity, which would mean the spots were likely cancerous.
So the head of radiology says this is needed. But I am the treating physician, so I have to put the order in. In my clunky EMR I search for an appropriate diagnostic code in situations like this. This software (Greenway) is not like Google; if you don’t search for exactly what the bureaucratic term is, but use clinical terms instead, it doesn’t suggest alternatives (unrelated everyday example – what a doctor calls a laceration is “open wound” in insurance speak but the computer doesn’t know they’re the same thing).
So here I am, trying to find the appropriate ICD-10 code to buy Henry a PET scan. Why can’t I find the diagnosis code I used to get the recent CT order in when I placed it, months ago? I cruise down the list of diagnoses in his EMR “chart”. There, I find every diagnosis that was ever entered. They are not listed alphabetically or chronologically. The list appears totally random, although perhaps the list is organized alphanumerically by ICD-10, although they are not not displayed in my search box, but that wouldn’t do me any good anyway since I don’t have more than five ICD-10 codes memorized.
By HANS DUVEFELT, MD
Imagine if your bank handled all your online transactions for free but charged you only when you visited your local branch – and then kept pestering you to come in, pay money and chat with them every three months or at least once a year if you wanted to keep your accounts active.
Of course that’s not how banks operate. There are small ongoing charges (or margins off the interest they pay you) for keeping your money and for making it possible to do almost everything from your iPhone these days. Yes, there may be additional charges for things that can’t be done without the bank’s personalized assistance, but those things happen at your request, not by the bank’s insistence.
Compare that with primary care. The bulk of our income is “patient revenue”, what patients and their insurance companies pay us for services we provide “face to face”. We may also have grants if we are Federally Qualified Health Centers, mostly meant to cover sliding fee discounts and what we call “enabling services” – care coordination, loosely speaking.
Only a small fraction of our income comes from meeting quality or compliance “targets”, and those monies only come to us after we have reached those goals – they don’t help us create the needed infrastructure to get there.
Then look at how medical providers are scheduled and paid. We all have productivity targets, RVUs (Relative Value Units – number and complexity of visits combined) if our employer is paid that way and usually just straight visit counts in FQHCs (because all visits are reimbursed at the same rate there). Sometimes we have quality bonuses or incentives, which truthfully may be the combined result of both our own AND other staff members’ efforts.