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Tag: primary care

Doctors, Hospitals and the Yankees

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By ROB LAMBERTS, MD

Joe Boyd hated the Yankees.

“Those damn Yankees.  Why can’t we beat ‘em?”

Then he got the opportunity to save his beloved Washington Senators by making a deal with the devil – giving up his soul in exchange for being transformed into “Shoeless Joe” to propel his team to win the World Series.

Interesting.  I think a lot of doctors are making their deal with the devil.  They are looking for a small gain in comparison to a long-term of misery.  True, Joe Boyd made out in the end; but that will only happen if someone from Hollywood writes our script.

Here’s the problem: at the core of our problems with healthcare is the total lack of cohesive communication.  Doctors have no idea what other doctors have done with a patient.  Tests get ordered, medications get changed, procedures, hospitalizations, even surgeries are done without communication to other doctors who would benefit from this information.  The conduit of communication is this:

Doctor: “So, how have you been doing over the past few months?”

Patient: “Didn’t you get the notes from the hospital?  I was in for two weeks.  I had a heart attack and a stroke and now I am in rehab for both of these.”

Doctor: (checks chart uncomfortably) “No, I didn’t hear about it.  Why don’t you tell me about it….”

Situations like this happen daily at my office.  Patients are started on medications by specialists without my knowledge.  Lab tests are done that I have no access to.  Huge changes happen in the lives of the patients for whom I have cared for over a decade, and I get nothing.  Even consults I order are done without any communication back to me.  On the other side of things, my patients are hospitalized without any consideration of the care I have been giving over the past decade.  Patients are treated as if their care starts from scratch every time they enter a new venue.

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Care Coordination Metrics: One Can of Worms that NEEDS to be Opened

By VINCE KURAITIS Vince_Kuraitis

“Track who is on a care team — and share info with the patient.”

That’s just one of the summary recommendations coming from expert testimony given in a recent public hearing on how to improve care coordination through the use of health information technology. The Meaningful Use workgroup and Quality Measures workgroups are now wrestling with how to translate this recommendation into meaningful use criteria for HITECH Stages 2 and 3.

Seems like a good idea — simple, straightforward — perhaps even obvious. The EHR (electronic health record) could be a great tool for keeping care team members in the loop and on the same page about a patient’s care.

But then I thought about this for a few minutes, and the complexities started dawning. This seemingly simple recommendation — “Track who is on a care team and share info with the patient” — is the proverbial can of worms.

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Northwestern Memorial Hospital Faces a Brave New World

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By David Dranove Picture 3

If you have read my earlier blogs, you know that I am writing a book about the organization of healthcare delivery. A recent story in the Chicago Tribune reminds me that I need to keep my nose to the grindstone. The article told of changes underway at Northwestern Memorial Hospital. In order to prepare for new payment models, the medical staff and hospital want to create something along the lines of an Accountable Care Organization. The ACO will accept an “all-in” fee for treatment of specific conditions. The ACO makes money if it can keep costs under the fee and receives bonuses if quality objectives are met. The ACO model, or versions of it, have floated around for some time, and prepayment is certainly not new. What is new is that payers will now prepay for all costs associated with episodes of care, as opposed to prepaying hospitals for inpatient stays, or prepaying primary care physicians for a year of primary care.

The ACO model tries to better align the payment modality with the “product” that patients would naturally purchase. This should, in theory, lead to a matching of incentives with production. Hospital prepayment leads to a shift to outpatient care. Primary care physician prepayment leads to too much hospital care. Episode of illness prepayment should eliminate these gaming incentives.

Northwestern Memorial and its medical staff still face a dilemma. Should they create a new third legal entity to accept the prepayment, or should the prepayment go directly to the hospital or medical foundation? More importantly, should the hospital and medical foundation become partners in the new venture, or, more radically, unite into a single entity without creating the new entity? Healthcare executives have not always approached this question in the most thoughtful manner, as this short film painfully shows. (Painfully funny if you approach it with the right mindset.)

Integration has many positive connotations, and executives who create new integrated organizations can usually keep their boards at bay. This may explain why so many executives are eager to integrate. But integration comes with numerous challenges. It will take an entire book to make this argument clear, but consider the following two questions. First, what happens when physicians switch from being entrepreneurs to being employees? Second, accepting all-in capitated payments turns the ACO into a de facto insurance company. Will the ACO have the capabilities to be an effective insurer? I hope that Northwestern Memorial does not face the future with its eyes wide shut. Many hospitals have fared quite poorly by jumping on the integration bandwagon without understanding the risks.

David Dranove is the Walter McNerney Distinguished Professor of Health Industry Management at Northwestern University's Kellogg Graduate School of Management, where he is also Professor of Management and Strategy and Director of the Health Enterprise Management Program. He has published over 80 research articles and book chapters and written five books, including "The Economic Evolution of American Healthcare and Code Red". He has a Ph.D. in Economics from Stanford University.

Letting the Data Flow, Part One

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By JOHN MOORE John Moore

Making clinical data liquid permeated a series of events I attended last week during Health Innovation Week in San Francisco.  Monday and Tuesday found me at the HIE/REC conference. Wednesday was HealthCamp at Kaiser-Permanente’s Garfield Research Center (KP was extremely gracious in hosting this event and the opportunity to get a tour of the facilities prior to event kick-off was great). The week concluded with the annual and well-orchestrated Health 2.0 conference.

This first post will focus on the HIE/REC event as it was quite distinct from the other events: smaller audience, more staid, dominated by government officials and tied at the hip, for good and bad, to the existing healthcare system infrastructure.

The HIE/REC conference was an odd event with attendance hovering around 200 or so attendees.  The event was focused almost entirely on what the States are doing with the federal funds coming their way to establish Regional Extension Centers (RECs) whose main objective is to get priority primary care physicians (PPCPs) to adopt and meaningfully use a certified EHR. Now, having been to this event and heard many of the State REC initiatives that are now underway via this program, sad to say that my original opinion has not changed. Rather than picking preferred EHRs and assisting with deployment, these RECs may be better off just helping to these PPCPs understand exactly what the HITECH Act is, what are their options, what questions to ask of a vendor or service provider and leave it to EHR consultants and vendors to take it from there.

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What is a Patient?

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By ROB LAMBERTS, MD Rob Lamberts

What is a patient?  What do they do?  What’s their role in the doctor’s office?  Are they chassis on a conveyor belt?  Are they puzzles for doctors to solve?  Are they diseases?  Are they demographics?  Are they a repository for applied science?

Or are they consumers?  Are they paying customers?  Are they the ones in charge?  Are they employing physicians for their own needs?

It depends.  It depends on the situation.  It depends on perspective.

Some physicians are very offended when the “consumer” and “customer” labels are applied to patients.  They see this as the industrialization of healthcare.  We are no longer professionals, we are made into “providers” – a sort of smart vending-machine made out of flesh.

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Sickening People

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ROB LAMBERTS, MDLamberts

I found the discussion around my recent post about treating colds very interesting.  Sick people come to the office to find out how sick they are.  Most people don’t want to be sick, and when they are sick they want doctors to make them better.

Most people.

Some people want to be sick, and some doctors want to make people sick.  I am not talking about hypochondriacs – people who worry that they may have disease and become fixated on being sick.  I am not talking about malingerers – people who pretend to be sick so they can get medications.  I am talking about the slippery slope of defining disease.

“I lost my job and have felt depressed ever since.”

“My son won’t obey me.”

“I’m just tired and have no motivation.”

“My daughter’s having trouble in school.”

The definition of disease versus normal has become a big issue recently.  A recent study found that over 50% of Americans are taking regular medications.  In the eye of the hurricane of this controversy is the DSM-5, the new manual for the definition of mental illness.  John Gever, of MedPage Today explained in a recent article on KevinMD that the criteria seem, in the eyes of many, to shrink the definition of a “normal” person.  The motivation to put a label on normal people, he explains, has various motivating forces:

It’s true that drug companies often do little to discourage off-label use of psychiatric drugs and sometimes encourage it. It’s also true that many doctors throw medications at patients who might do better with other treatments or no treatments. (That’s true for many somatic conditions too, let’s not forget.)Continue reading…

Primary Care is Not a Panacea: It Takes a Team

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By MAGGIE MAHAR

The emphasis on primary care as the “key” to lifting the quality of U.S. healthcare may be exaggerated according to a report, released today, by Dartmouth’s Institute for Health Policy & Clinical Practice.

“Primary care forms the bedrock of a well-functioning, effective health care system,” the researchers observe. But– and this is an important caveat- “simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage, may not be enough to improve the quality of care or lead to better outcomes.”

Wait a minute. In past reports, didn’t Dartmouth’s researchers tell us that patients fare better if they see fewer specialists and more internists?

No. Dartmouth’s earlier studies have shown that when patients see more specialists, care is more aggressive and more expensive, but, on average, outcomes are no better—and sometimes they are worse. This, however, doesn’t mean that primary care, by itself, ensures better care, even if a patient sees her PCP on a regular basis.

As the report points out: “Primary care is most effective when it is embedded in a high-functioning system, where care is coordinated, where physicians communicate with one another about their patients, and where feedback is available about performance that allows physicians and local hospitals to continually improve.”

Policy should “focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals,” says Dr. David C. Goodman, lead author and co-principal investigator for the Dartmouth Atlas Project.

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To Med Students Considering Primary Care

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By ROB LAMBERTS, MD

Dear Student:

Thank you for your consideration of my profession for your career. I am a primary care physician and have practiced for the past 16 years in a privately-owned practice. (At some point I intend to stop practicing and start doing the real thing. It amazes me at how many patients let me practice on them.)

Anyhow, I thought I’d give you some advice as you go through what is perhaps your biggest decision regarding your career. Like me, you probably once thought that choosing to become a doctor was the biggest decision, but within medicine there are many options, giving a very wide range of career choices. It is the final choice that is, well, final. What are you going to do with your life? ”Being a doctor” covers so much range, that it really has little meaning. Dr. Oz is a doctor, and he has a very different life from mine (for one, he’s not the target of Oprah’s contempt like I am – but that’s a whole other story).

Here are the things to consider when thinking about primary care:

1. Do you like talking to people who are not like you?

Primary care doctors spend time with humans – normal humans. This is both good and bad, as you see all sides of people, the good, bad , crazy, annoying, funny, and vulnerable sides. If you see mental challenge as the main reason to do something, and would simply put up with the human interaction in primary care, don’t do it. The single most important thing I have with my patients that most non-pcp’s don’t have is relationship. I see people over their lifetime, and that gives me a unique perspective.

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Why I Don’t Accept E-mail From Patients

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By ROB LAMBERTS, MD
Rob Lamberts

Dr. Wes (a cardiology blogger who all should read) wrote a very compelling post about technology and the bondage it can create for doctors.:

The devaluation of doctors’ time continues unabated.

As we move into our new era of health care delivery with millions more needing physician time (and other health care provider’s time, for that matter) – we’re seeing a powerful force emerge – a subtle marketing of limitless physician availability facilitated by the advance of the electronic medical record, social media, and smart phones.

Doctors, you see, must be always present, always available, always giving

This sounds like dire words, but the degree to which it has resonated around the web among doctors is telling.  He continues:

Increasingly the question becomes – if we choose future doctors on their willingness to sacrifice for others without expectation of appropriate boundaries and compensation – will we be drawing from the same pool of people as the ones who will make the best technically-skilled clinicians? What type of person will enter medicine if they know that their personal life will always take second place to patient care?

Dr. Brian V (long last name, but another one who you all should read) adds his voice to this:Continue reading…

“I Like (Political) Science and I Want to Help People”

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By BOB WACHTER, MD

I thought I was an oddball in college. I’ve only recently learned that I was avant-garde.

Right before beginning college in 1975, I decided I wanted to be a doctor. Being the first-born son – with decent SATs – of an upwardly mobile Long Island Jewish family, I had relatively little choice in the matter. Notwithstanding this predestiny, I felt confident that medicine was a good fit for my interests and skills.

But on my med school interviews four years later, I stumbled when the time came to answer the ubiquitous, “Why do you want to be a doctor?” question. The correct (but hackneyed) response, of course, is “I like science and I want to help people.” You’ll be comforted to know that I had no problem with the helping people part. It was the science thing that threw me for a loop.

It wasn’t that I didn’t like science, mind you. I found biology interesting, and organic chem was kind of cool, in the same way that Scrabble is. But I barely tolerated Chem 101, and disliked physics.Continue reading…