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Tag: primary care

The Most Powerful Health Care Group You’ve Never Heard Of

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By Brian Klepper and Paul Fischer

Excessive health care spending is overwhelming America’s economy, but the subtler truth is that this excess has been largely facilitated by subjugating primary care. A wealth of evidence shows that empowered primary care results in better outcomes at lower cost. Other developed nations have heeded this truth. But US payment policy has undervalued primary care while favoring specialists. The result has been spotty health quality, with costs that are double those in other industrialized countries. How did this happen, and what can we do about it.

American primary care physicians make about half what the average specialist takes home, so only the most idealistic medical students now choose primary care. Over a 30 year career, the average specialist will earn about $3.5 million more. Orthopedic surgeons will make $10 million more. Despite this pay difference, the volume, complexity and risk of primary care work has increased over time. Primary care office visits have, on average, shrunk from 20 minutes to 10 or less, and the next patient could have any disease, presenting in any way.

By contrast, specialists’ work most often has a narrower, repetitive focus, but with richer financial rewards. Ophthalmologists may line up 25 cataract operations at a time, earning 12.5 times a primary care doctor’s hourly rate for what may be less challenging or risky work.

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Lessons from MinuteClinic

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By John Goodman

After entering the clinic a thought occurred to me: why do we need doctors? Then a second thought: why do we need nurses?

Ah, but I’m getting ahead of myself.

About a decade before the Obama administration started touting electronic medical records and evidence-based protocols there was MinuteClinic. The entity came into existence primarily to cater to patients paying out of pocket.

There was no need for a law requiring price transparency. In every market where the dominant buyers are patients spending their own money, prices are always transparent. MinuteClinic posts its prices on a computer screen and on readily available pamphlets. Clearly, the organization is competing on price. Entities that compete for patients based on price usually compete on quality as well. One study found that MinuteClinic nurses following computerized protocols follow best practice medicine more consistently than conventional primary care physicians. They also do a pretty good job of knowing what kind of medical problems they are competent to handle and which problems need referral to a physician.

Wherever you find price competition you usually also find that providers are respectful of your time. As the name “MinuteClinic” implies, this is an organization that knows you value your time as well as your pocketbook. I couldn’t help but wonder if the entire health care system might be this user friendly, if only the third-party payers weren’t around.

For the first 15 minutes of my 20 minute visit, the nurse barely looked at me. She was sitting in front of a computer screen typing in my answers to her questions, as she went through the required decision tree. I didn’t mind. Mine was a minor problem and I did not want to pay for more sophisticated service.

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‘Help Wanted’ For Medicaid Expansion

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By John H. Schumann, MD

Despite its complexities and its politics, I support the Affordable Care Act (aka “Obamacare”).  As I’ve written elsewhere, I think it would be both morally and economically wrong for Governor Fallin and the Oklahoma legislature to opt out of the ACA’s vast Medicaid expansion – a position shared by Oklahoma Policy Institute.  So if Oklahoma does the right thing and opts to expand Medicaid for adults with incomes at or below 133 percent of the federal poverty level, what will happen?

Oklahoma faces a serious shortage of primary care access. The Oklahoma Health Care Authority, the agency in charge of administering Medicaid, recently compiled county-by-county maps, color-coded to classify areas of severe physician shortage based on presumptive levels of Medicaid expansion.  At a glance, these maps reveal something we already know: rural areas are hurting for physicians and populous counties seem to have more capacity.  In my opinion, however, the maps don’t paint a full picture of the eventual shortfall.Continue reading…

Your Doctor’s Brain

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By Rob Lamberts, MD

I have a split medical personality.  On one hand, I am a pediatrician;  I light up around babies and love to mess around with little kids.  On the other hand, I am an Internist; I love complex problems and love talking to the elderly.  But the one part of internal medicine which gives me perhaps the most joy is the opportunity to solve medical puzzles.  Yes, pediatrics has puzzles in it too, but they are far more common in adults.

The term used for a medical puzzle-solver is diagnostician.  It is always a great compliment to a physician to be called a great diagnostician.  It means you are a good thinker, have a good store of facts, know how to organize your thoughts properly, and can see patterns in things you otherwise would never have found.  It is the Sherlock Holmes, Lord Peter Whimsey, or Harry Dresden side of medicine.  The diagnostician searches for clues, but especially searches where they are most often missed: right out in the open.

I am not sure anyone has called me a good diagnostician, but there are few things that give as much satisfaction in my job.  It calls on my creativity, my memory, my mental organization, my ability to ask questions, my power of observation, and my ability to put all the disparate pieces together to form a cohesive whole.  It’s not just coming up with an answer; it’s coming up with a plan.Continue reading…

A Call For a New Primary Care Society

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By Brian Klepper

The dream of reason did not take power into account – modern medicine is one of those extraordinary works of reason – but medicine is also a world of power.

Paul Starr, The Social Transformation of American Medicine, 1984

How can primary care’s position be reasserted as a policy leader rather than follower? Even though it is a linchpin discipline within America’s health system and its larger economy – a mass of evidence compellingly demonstrates that empowered primary care is associated with better health outcomes and lower costs – primary care has been overwhelmed and outmaneuvered by a health care industry intent on freeing access to lucrative downstream services and revenues. That compromise has produced a cascade of undesirable impacts that reach far beyond health care. Bringing American health care back into homeostasis will require a approach that appreciates and leverages power in ways that are different than in the past.

But primary care also has complicity in its own decline. It has been largely ineffective in communicating and advocating for its value, and in recruiting allies who share its interests. Equally important, it has failed to appreciate and protect primary care’s foundational role in US health care and the larger economy, as well as the advocacy demands of competing in a power-based policy environment.

The consequences have been withering constraints that have diminished primary care’s value, and that have thwarted its roles as first line manager of most medical conditions, and as patient-advocate and guide for downstream services. Combined with fee-for-service reimbursement and a lack of cost/quality transparency, primary care’s waning influence has precipitated a cascade of impacts, allowing health industry revenues to grow at more than four times the general inflation rate for more than a decade, with unnecessary utilization and cost that credible estimates suggest is half or more of all health care spending.Continue reading…

Zen and the Art of Not Thinking Magically

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By Rob Lamberts, MD

Don’t assume anything.

Assumptions can kill.  

Assuming something regarding your own health care can cost you money, cause you pain, and yes, even kill you.  Here’s my list of potentially harmful assumptions:

1.  No news is good news

If you have a test done and don’t hear anything about the result, do not assume it is fine.  This assumption kills people.  I have too many patients with too much information flying at me every day for me to catch every important detail.  Sometimes things are missed, but sometimes the results don’t come to our office.   We have trained our patients to expect an email or letter with their results within a certain amount of time, so they sometimes call when the test results don’t come in.  I tell them to do so in the clinical summary sheet I hand out at the end of each visit, but the assumption remains.

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Are Female Physicians Underpaid?

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By Peter Ubel, MD

In a new study published in JAMA, my colleagues and I found that even after accounting for productivity, women working as physician researchers at American Medical Schools are paid $13,000 less per year than their male colleagues, a difference that amounts to hundreds of thousands of dollars over the course of their careers.

But does this difference stand as evidence of discrimination?

Many claims of gender inequity in pay have suffered from an apples vs. oranges problem.  For example, consider gender disparities across different careers.  Many traditional male careers, like construction work, pay better than traditionally female careers, like nursing and teaching.  It’s plausible that these disparities result, at least in part, from societal bias about how relatively important it is for men and women to make enough money to provide for their families.  However, these disparities could also result from more justifiable factors.  Maybe the physical demands of the work differ in important ways, or perhaps the marketplace is simply responding to supply and demand.

Medical experts have long noticed gender disparities in physician pay.  Traditionally male fields like neurosurgery pay substantially more than fields preferred by more women, such as general pediatrics.  If women are voluntarily choosing lower paying fields—perhaps for lifestyle reasons or maybe because they don’t value money as much as men do—then it’s arguable that we should not fret over pay disparities.  It’s America, after all, where people have the right to choose.

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A Funny Thing Happened on the Way to Meaningful Use

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By Rob Lamberts, MD

This July will mark the 16th anniversary of the installation of our electronic medical record.

Yup.  I am that weird.

Over the first 10-14 years of my run as doctor uber-nerd, I believed that widespread adoption of EHR would be one of main things to drive efficiency in health care.  I told anyone I could corner about our drive to improve the quality of our care, while keeping our cash-flow out of the red.  I preached the fact that it is possible for a small, privately owned practice to successfully adopt EHR while increasing revenue.  I heard people say it was only possible within a large hospital system, but saw many of those installations decrease office efficiency and quality of care.  I heard people say primary care doctors couldn’t afford EHR, while we had not only done well with our installation, but did so with one of the more expensive products at the time.  To me, it was just a matter of time before everyone finally saw that I was right.

The passage of the EHR incentive program (aka “meaningful use” criteria) was a huge validation for me: EHR was so good that the government would pay doctors to adopt it.  I figured that once docs finally could implement an EHR without threatening their financial solvency, they would all become believers like me.

But something funny happened on the way to meaningful use: I changed my mind.  No, I didn’t stop thinking that EHR was a very powerful tool that could transform care.  I didn’t pine for the days of paper charts (whatever they are).  I certainly didn’t mind it when I got the check from the government for doing something I had already done without any incentive.  What changed was my belief that government incentives could make things better. They haven’t.  In fact, they’ve made things much worse.

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Why Doctors Interrupt

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By Juliet Mavromatis

A few weeks ago I called a neurosurgeon to discuss a patient’s recent headaches.  My patient had been seen in the emergency room several days prior with the worst headache of his life. A complete work-up had not revealed a cause for the headache.  Although he was found to have a small aneurysm on CT angiogram, there was no evidence of bleeding by lumbar puncture.  The story, however, was slightly more complex than this. There had been several other findings that remained unexplained.  One of the findings led me to discuss the patient’s case with a cardiologist.  My patient had also undergone cervical spine decompression surgery several months prior to treat cervical myelopathy.  I wanted to engage the neurosurgeon and get his professional opinion about my patient’s headache, which had now recurred several days after his ER visit.

The surgeon was cordial, but about 5 seconds into my story he seemed inpatient and interrupted me.  “I heard about this guy,” he said, “What he needs is to be seen by one of our neurovascular specialists.”  I had more I wanted to say, but the doctor did not seem to want to listen.  I raised my voice slightly, interrupted him before he had a chance to end the conversation, and bulldozed through, telling the rest of the story in about two minutes.  “Now we’re talking,” he said, as I explained further about a family history of clotting and my concern about a dural thrombus as a potential etiology.  Together we formulated a plan that I was satisfied with–though the interaction left me with a feeling of unease.

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Patient Power

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By Barbra Rabson

What happens when consumers are able to compare the performance of primary care physicians in their state using Consumer Reports, the magazine that’s so highly regarded for its ratings of thousands of products and services we all use every day? Well, for the first time ever, we’re about to find out.

A special Massachusetts version of July’s Consumer Reports magazine will feature a report entitled “How Does Your Doctor Compare?” along with a 24-page insert that includes ratings of nearly 500 primary care physician practices from across the state. The ratings are based on data from a comprehensive patient experience survey conducted by Massachusetts Health Quality Partners (MHQP), a coalition of consumers, physicians, hospitals, insurers, employers, government agencies, and researchers. The physician ratings report is also available online at www.mhqp.org.

In recent years, there’s been a lot of talk in the health care community about the importance of consumer empowerment and patient-centered care. This experimental collaboration between MHQP and Consumer Reports, funded by the Robert Wood Johnson Foundation’s Aligning Forces for Quality program, helps move theory into practice, and will test some key assumptions about the value of transparency in the effort to improve the health care system. In many respects, ratings of primary care physicians are not new to Massachusetts. We at MHQP have been reporting the results of patient surveys and clinical quality data since 2006 and these reports have had a positive effect on health care in our state. But let’s face it, Consumer Reports adds a whole new dimension to the notion of transparency. Not surprisingly, their involvement has been met with both excitement and some trepidation in the physician community.Continue reading…

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