By ROB LAMBERTS, MD

Things have been busy in my absence.  A recent post on Kevin MD by Joseph Biundo, a rheumatologist, challenged my assertion that primary care doctors can save money:

(In reference to my claim) That may be true in theory, but I see patients in my rheumatology office every day who have been “worked up” by primary care physicians and come in with piles of lab tests, and x-ray and MRI reports but are diagnosed in my office by a simple history and physical exam.

Prior to that, an article in the NY times along with a post by Kevin Pho noted the fact that more solo practitioners are leaving private practice and joining hospital systems.  Why are they doing this?  Dr. Kevin suggests the following:

Lifestyle matters. More doctors are entering the workforce seeking part-time jobs in order to maintain a family balance. By removing the administrative hassles from their plate, they can go back to focusing solely on practicing medicine and coming home at a reasonable hour.

The NY Times article suggests possible benefits to patients:

In many ways, patients benefit from higher quality and better coordinated care, as doctors from various fields join a single organization. In such systems, patient records can pass seamlessly from doctor to specialist to hospital, helping avoid the kind of dangerous slip-ups that cost the lives of an estimated 100,000 people in this country each year.

So as a primary care doctor in private practice, am I soon to go the way of the dinosaur?  Is this simply a shift in the business model as demanded by the times, or should people be concerned?  Would the system function better with fewer primary care doctors or ones who are employed by large hospital systems?

Those who read my blog regularly (and those clever enough to read the title of this post) already know my answer: private primary care is essential for a healthy healthcare system.

Why Primary Care?

While I can’t disagree with Dr. Biundo on his point regarding the physical exam skills of PCP’s, I do disagree that this raises question of the cost-effectiveness of primary care.  In his case (the practice of rheumatology), there are few expensive procedures, the diseases are less common (compared to fields like cardiology and other high cost specialties), and the patients don’t spend a high number of days in the hospital.  One overnight stay for a cardiac catheterization will pay a large part of a rheumatologist’s salary for a year.

Like primary care, rheumatology is largely an outpatient practice, with success being measured by the ability of the practitioner to keep the patient out of the hospital and away from expensive procedures.  Lately, rheumatologists have started having biologic medications (like Enbrel) that are quite costly, but the number of people on this relative to the general public is still quite small.

Primary care, on the other hand, is the fountainhead of all healthcare costs.  A good PCP is also measured by patients staying out of the hospital and away from expensive procedures.  In general, a PCP is less likely to:

• order an x-ray compared to an orthopedist
• get an EKG compared to a cardiologist, or
• order an endoscopy compared to a gastroenterologist.

There are some high-consuming primary care doctors, but much of the blame for this can be placed on the payment system that encourages expensive procedures and the ordering of tests.  For example, one of the PCP groups in our area has their own stress-testing equipment and CT scanner.  I am 100% sure that the physicians in this group order many more CT scans and stress tests when compared the physicians in my practice.  I am also sure that the care quality in my practice does not suffer from our lack of test-ordering.  Why?  Because the physicians are financially motivated to order these tests, making the appropriate business decision clash with the appropriate medical decision.  As long as it’s not harmful to order the test, the doctor can justify it.

Even these physicians, however, are not going to do any of these tests as much as a specialist, who depends on the presence of chronic disease to make a living.  The only specialists I have seen who are slow to order tests and procedures are those who don’t financially profit from their ordering: academic specialists.

Why Private Practice?

This brings me to my second point, which is the necessity of having primary care physicians who are in private practice.

Why do hospitals have an interest in hiring primary care physicians?  The answer is twofold: first, they allow them to negotiate contracts with the insurance companies in a position of strength.  Primary care is a must for most insurance contracts.  Patients will change insurance plans if their PCP is not on the plan, but they won’t do so nearly as much for specialists (with the possible exception of OB/GYN, which often act as PCP’s) or hospitals.  Plus, most insurance plans do their care management by requiring referrals, denying or accepting them being their means of cost control.  Primary care physicians are the referring physicians, and without them the hospital’s negotiating power is greatly diminished.

The second reason hospitals want PCP’s under their wing is that they generate business by ordering radiology tests, lab tests, and sending patients to specialists who will do expensive procedures in their facilities.  Primary care is a loss-leader to hospitals.  Hospitals make no money off of their PCP practices directly but make a huge amount from the referrals and procedures they generate.

This shifts the mission of the PCP.  The “success” of the PCP in the eye of the hospital system is not to avoid referrals or costly procedures, but to order them.  It’s not bad in the eye of the hospital that the PCP has higher hospitalization rates, it is better.

The Answer

The solution from an overall cost standpoint is to give primary care physicians incentive to do what they should be doing in the first place: keep people healthy and away from hospitals.  Any system that places too much value on procedures is going to fail at this, as the institutions and individuals who profit off of the procedures are going to fight for control of PCP’s.  Independent PCP’s who profit from keeping people well are the best thing for a system.

I have lived in both worlds: as a private PCP and as a salaried physician from a hospital.  I left the latter because it was clear that they had no interest at running my practice well and really just wanted me to be a turnstile into their money-making procedures.  It would be a big mistake to take away the one specialty that restrains cost.  We need to do the opposite, and encourage good primary care medicine.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, 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.

By PAUL LEVY

Rob Weisman and Liz Kowalczyk report in today’s Boston Globe that the US Justice Department is investigating possible antitrust violations against Partners Healthcare System, the dominant hospital and physician provider group in Massachusetts.

The letter, obtained by the Globe, said the probe sought to determine whether the practices violated the Sherman Antitrust Act, which bars companies from using their market power to limit trade or artificially raise prices.Continue reading…

By BOB WACHTER

Until about 8 years ago, inspections by the Joint Commission (TJC) were predictable and fairly silly. Hospitals were given a couple of years’ notice of the week that “The Joint” would be visiting. Everybody scurried around preparing – waxing the floors, locking up all the medications, that sort of thing. (It always struck me as the most dangerous day to be in the hospital, since nobody could find any of the medications, and the floors were slippery as hell). After arriving, the inspectors spent most of their time sealed in a conference room, pouring through policy manuals (we dusted them off before the visit) and meeting with administrators, exposed to whatever reality the hospital wanted them to see. It was an ineffectual kabuki dance.

Last week, the Joint Commission visited UCSF Medical Center. Luckily, our director of regulatory affairs, Jolene Carnagey, is tasked with checking the TJC website every Monday at 7:30 am to see what hospitals they’ll visit that week. Because of this, we had advance notice of our inspection – by about 15 minutes! Once Jolene spotted UCSF on the TJC schedule, she sent stat alerts to our key people, like a parental phone tree on a school snow day.

By 7:45 am, there were half-a-dozen TJC accreditors in our hospital lobby.

As important as the unannounced visits (which are, of course, what you’d want if you were a patient), TJC has made other major improvements over the past decade. The inspectors spend far more time walking around on clinical units – talking to docs, nurses, hospital administrators, and patients – and less time wading through policies and procedures. Their agenda is a bit less focused on the nitpicky “Standards” and more on a series of National Patient Safety Goals that TJC began issuing in 2003 – things like the pre-operative time out and developing methods to analyze errors and use the results to improve safety. The important stuff.

Continue reading…

By Matthew Holt

Last week Indu and I were on the Patient Power show run by Andrew Schorr and Peter Frishauf (who is an old friend and founded Medscape). It’s a show aimed at consumers and we’re very interested in getting the word out about Health 2.0 direct to consumers. Here’s the show and it’s both well done by Andrew and Peter, and Indu (at least) sounds very intelligent!

In addition I and a team of cohorts will be starting a (brief) spot twice a week on KOMO 1000AM/97.7FM a news radio station in Seattle. I have also recorded my first spot about technology and policy for doctors for ReachMD—a radio channel exclusively for physicians with which THCB has a new agreement. So watch out for yet more radio stardom.

By the way, the full excerpt from Educating Rita is:

In reply to the question, “Suggest how you would resolve the staging difficulties inherent in a production of Ibsen’s Peer Gynt” you have written, quote, “Do it on the radio.”

By ROBERT ROWLEY, MD

Adoption of Electronic Medical Records (EMRs) by physicians – particularly by primary care physicians – has been a challenge, for a number of reasons. The Office of the National Coordinator for Health IT (ONC) has been charged with encouraging physicians to adopt Electronic Health Record (EHR) technology, as envisioned in the American Reinvestment and Recovery Act of 2009 (ARRA).

The ONC vision is that a transformed healthcare delivery system which is able to reduce medical errors, implement best-practices standards as they emerge, reduce disparities in care delivery, involve patients in their care, and encourage the coordinated delivery of health care – all of this needs, as a base, the widespread adoption of EHR technology by physicians in all settings of care, across the country. Getting there is the challenge before us all.

EHR adoption has been seen mainly in hospitals, clinics and other large institutions – the costs of traditional EHR systems (both the direct costs, and the indirect costs of needing to build and maintain a local network system in order to make it work) have been prohibitive to smaller practice settings. However, it is precisely those smaller practice setting where the majority of healthcare is delivered in this country.

Fortunately, newer technologies – like secure web hosting, which removes the need to install anything locally – and new business models – like having alternative revenue sources subsidize the web-based EMR so that the system can be offered for free to physician end-users (e.g. Practice Fusion’s free EMR) – have overcome many of the barriers to adoption that have prevented smaller practices from adopting EHR technology.

In light of the recent Health 2.0 in the Doctor’s Office conference, with its focus on newer technologies, we wanted to review some EMR adoption strategies that might help clinicians move from paper-based offices to electronic ones. As a practicing family physician, and relatively early adopter of EMR technology – we have not had paper charts in our practice since 2004.

Hardware recommendations

Regardless of the cost of the EMR system in the first place, a certain investment in hardware will need to be made. With a web-based EMR, this can be pretty minimal. I would discourage the use of fixed, in-exam-room computer equipment (risk of damage when unsupervised, need to close and then log back in when you leave the room in order to keep HIPAA privacy). Instead, I would recommend a wireless laptop or notebook (costs of these are now in the $400-$800 range) – one per clinician – which can be used to carry around the office. Nurses might want to have a fixed desktop computer at their nursing station (these are about $100-$200 less than a notebook these days). Front desk personnel should have a fixed desktop computer – this has been the tradition for some time.

If a locally-installed EMR system is chosen, then there is the whole burden of housing a server, with hardware redundancy to guard against failure, and software costs for that server – operating system, anti-virus, firewall, possibly license fees for the database system used. In addition, there will be the need to do data backup. Such local systems have a vulnerability of theft of Protected Health Information (PHI), which can expose the clinician to a HIPAA breach. Web-hosted EMRs avoid this whole back-end burden.

With a web-based system, internet connectivity is critical. I would recommend a good broadband connection (T1 lines run about $400/month, though DSL services for about half that may be sufficient as well). For safety, a 3G cell phone fail-over backup is also advisable, in the event of breakdown of the internet connection (a rare event these days).

Workflow redesign

Apart from cost, workflow disruption is another barrier to adoption. This is especially true in primary care practices, which function very close to the margin in the first place – any dip in productivity can cause the practice to dip below profitability for a while. Therefore, an intuitive, easy-to-use and flexible EMR design is critical. All the workflows encountered by physicians in an ordinary day need to be facilitated, not disrupted, by the EMR.

There are 7 workflows in an ambulatory practice, which need to be addressed in order to fully abandon paper charts: (1) billing and accounts receivable; (2) scheduling; (3) in-house messaging; (4) documentation of patient interactions; (5) processing refill requests; (6) reviewing and acting on lab results; and (7) managing external correspondence about patients. A way of dealing with each of these items needs to be addressed in order to successfully embrace EHR technology and abandon paper.

Small medical practices have faced challenges in their path toward adopting EHR technology – cost and workflow disruption are the main ones. Newer technologies and business models have overcome many of those barriers. Achieving the “meaningful use of certified EHR technology,” which qualifies a clinician to access ARRA/HITECH incentive payments beginning in 2011, can be achieved through these newer technologies. The old paradigm of massive, burdensome, and stand-alone systems is giving way to novel approaches which can result in widespread EHR adoption, as we have seen from our experience to date.

ROBERT ROWLEY, MD, is the chief medical officer at Practice Fusion, a San Francisco based company.