By KENNETH D. MANDL, MD; DAN GOTTLIEB MPA; JOSH C. MANDEL, MD
The opportunity has never been greater to, at long last, develop a flourishing health information economy based on apps which have full access to health system data–for both patients and populations–and liquid data that travels to where it is needed for care, management and population and public health. A provision in the 21st Century Cures Act could transform how patients and providers use health information technology. The 2016 law requires that certified health information technology products have an application programming interface (API) that allows health information to be accessed, exchanged, and used “without special effort” and that provides “access to all data elements of a patient’s electronic health record to the extent permissible under applicable privacy laws.”
After nearly two years of regulatory work, an important rule on this issue is now pending at the Office of Management and Budget (OMB), typically a late stop before a proposed rule is issued for public comment. It is our hope that this rule will contain provisions to create capabilities for patients to obtain complete copies of their EHR data and for providers and patients to easily integrate apps (web, iOS and Android) with EHRs and other clinical systems.
Modern software systems use APIs to interact with each other and exchange data. APIs are fundamental to software made familiar to all consumers by Google, Apple, Microsoft, Facebook, and Amazon. APIs could also offer turnkey access to population health data in a standard format, and interoperable approaches to exchange and aggregate data across sites of care.
In most other human activities there are two speeds, fast and slow. Usually, one dominates. Think firefighting versus bridge design. Healthcare spans from one extreme to the other. Think Code Blue versus diabetes care.
Primary Care was once a place where you treated things like earaches and unexplained weight loss in appointments of different length with documentation of different complexity. By doing both in the same clinic over the lifespan of patients, an aggregate picture of each patient was created and curated.
A patient with an earache used to be in and out in less than five minutes. That doesn’t happen anymore. Not that doctors and clinics wouldn’t love to work that way, but we are severely penalized for providing quick access and focused care for our well-established patients.
As policy experts cling to pay-for-performance (P4P) as an indicator of healthcare quality and shy away from fee-for-service, childhood immunization rates are being utilized as a benchmark.At first glance, vaccinating children on time seems like a reasonable method to gauge how well a primary care physician does their job.Unfortunately, the parental vaccine hesitancy trend is gaining in popularity.Studies have shown when pediatricians are specifically trained to counsel parents on the value of immunizations, hesitancy does not change statistically.
Washington State Law allows vaccine exemptions on the basis of religious, philosophical, or personal reasons; therefore, immunizations rates are considerably lower (85%) compared to states where exemptions rules are tighter.Immunization rates are directly proportional to the narrow scope of state vaccine exemptions laws.Immunization rates are used to rate the primary care physician despite the fact we have little influence on the outcome according to scientific studies.Physicians practicing in states with a broad vaccine exemption laws is left with two choices:refuse to see children who are not immunized in accordance with the CDC recommendations or accept low quality ratings when caring for children whose parents with beliefs that may differ from our own.
The integration of behavioral health into the primary care setting has resulted in a number of benefits. Traditionally, behavioral health and medical health operated separately, but in recent years, the integration of these two systems has improved access to care, ensured continuity of care, reduced stigma associated with seeking care and allowed for earlier detection and treatment of mental health and substance abuse issues. By bringing behavioral health specialists into primary care facilities, healthcare systems have streamlined care and brought down costs, working collaboratively and reducing the number of appointments and hospital visits.
At Carolinas HealthCare System, we use technology to take behavioral health integration one step further. A robust behavioral health integration project was developed through myStrength, using virtual and telehealth technology to ensure that every primary care practice has the capabilities for early detection of mental illness and substance abuse and upstream intervention, easing the connection between behavior health specialists and patients who might otherwise be averse to seeking professional help.
Mental illness touches each of us personally: one in five individuals struggles with mental health issues, yet access to care is one of the biggest issues facing North Carolina residents today.Continue reading…
No one ever asks if you get along with the cashier at the grocery store or the barista at your neighborhood coffee shop.For most folks choosing a doctor means finding someone in your area who’s taking new patients with your insurance, which usually isn’t too many.
Simply getting an appointment is hard enough, so expecting a pleasant experience and a good relationship with the doctor seems to be an unreasonable request, like asking for a unicorn who also speaks fluent Spanish. Many people don’t think patient-physician relationship is particularly important; they’re looking to the doctor for medical advice, not to be a friend.In these days of electronic medical records and 15 minute appointments, many physicians simply don’t have the time to get to know patients and find out their motivations, goals and fears.It’s even harder for patients with language and cultural barriers; for example, physicians talk more and listen less to black patients than to white patients.
Recently the New York Times published an article What Kids Wish Their Teachers Knew. As a pediatrician, I have spent a good part of my lifetime fighting for the health and welfare of our young people. They are the future. We owe our children a safe, caring, stable childhood whenever possible. Outside of a supportive family, a long-term family physician or pediatrician can be an important role model for impressionable youngsters.
For confidentiality reasons I have altered identifying details, but will give you some of the great things heard over the years and a few tragic ones as well.
I Wish My Doctor Knew… there is not enough food at home. Many years ago, I was seeing twins for a yearly checkup and giving them shots when one, older by 4 minutes, blurted out there was not enough foods to eat at night when she was hungriest. I contacted the school counselor to ensure both children were offered free breakfast and lunch at school. They were added to the program sending home a backpack full of food every weekend. At Thanksgiving, this family received one of the donated dinner baskets with turkey, mashed potatoes, and all the trimmings. The children grew better and crossed percentiles in the positive direction; their grades improved as an added bonus.
In 1978, the Institute of Medicine published A Manpower Policy for Primary Health Care: Report of a Study (IOM, 1978) where they defined primary care as “integrated, accessible services by clinicians accountable for addressing a majority of heath care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” The four main features of “good” primary care based on this definition are: 1. First-contact access for new medical issues, 2. Long-term and patient (not disease)-focused care, 3. Comprehensive in scope for most medical issues, and 4. Care coordination when specialty referral is required. These metrics ring as true today as they did many years ago.
Estimates suggest that a primary care physician would spend 21.7 hours per day to provide all recommended acute, chronic, and preventive care for a panel of 2,500 patients. An average workday of 8 hours extrapolates to an ideal panel of 909 patients; let us make it an even 1000 to simplify. A primary care physician could easily meet acute, chronic, and preventative needs of 1000 patients, thereby improving access. Our panels are much larger due to the shortage of available primary care physicians and poor reimbursement which keeps us enslaved. Pay us what we are worth and then utilize this “first-access” metric to judge our “quality.”
Strengthening primary care has been a core goal of health care payment reform over the past several years. Primary care physicians are the cornerstone of the health care delivery, directing billions of dollars of follow-on care. With better support, the models presume, primary care doctors could guide their patients toward a better health, direct them to the right care when needed, and in so doing, bring down unnecessary medical costs. Moreover, especially if coupled with payment reforms that can support better coordination with specialist practices, these reforms can provide an alternative to health system employment and health care consolidation, thus buoying competition in local markets.
The most recent effort toward this goal lies at the heart of the recently announced Comprehensive Primary Care Plus (CPC+) program. This program doubles down on the kinds of “medical home” payment and delivery reforms that were the hallmarks of previous Medicare initiatives, most notably the Comprehensive Primary Care Initiative, which in its first two years showed significant improvements in some dimensions of quality – but so far has generally failed to show reductions in overall costs significant enough to offset the per-member per-month (PMPM) payments to primary care practices to support their reforms. While some medical home payment reforms have shown both savings and outcome improvements, overall results have been mixed particularly in Medicare, with the result that the CMS actuaries have not yet “certified” any such medical home model as leading to overall spending reductions.
American healthcare has a customer service problem. No, customer service in the US is terrible when it comes to healthcare. No, the customer service in the US healthcare system is horrendous. No, healthcare has the worst customer service of any industry in the US.
There. That seems about right.
What makes me utter such a bold statement? Experience. I regularly hear the following from people when they come to my practice:
“You are the first doctor who has listened to me.”
“This office makes me feel comfortable.”
“I didn’t have to wait!”
“Where’s all the paperwork?”
“Your office staff is so helpful. They really care about my needs.”
“This is the first time I’ve been happy to come to the doctor.”
“It’s amazing to have a doctor who cares about how much things cost.”
About seven years ago, the California Healthcare Roundtable and HealthAffairs sat down to prepare a white paper on the emerging “phenomenon” of urgent care centers, and what it might mean for primary care. At the time the group couldn’t agree that urgent care was a “disruptive” innovation, but it seemed clear to all participants that it represented a threat to primary care: The rise of UC, the group noted, would lead to 1) less preventive care and 2) concentrate acuity in primary care clinics. They wrote: “[Urgent care] means fewer patients per day, a higher intensity environment for providers, and potentially lower reimbursement.”
In particular, the group couldn’t understand if patients were choosing to leave primary care because they didn’t value having a PCP, or if they were settling for the inherent limitations of UC because cost and convenience outweighed its disadvantages.
Seventy-five percent [of UC customers] are women ages 28 to 42 and their children. Some hypothesize that this consumer group thinks of its health care relationships differently than do people of the baby boomer generation and older. The younger cohort often has no “medical home,” while baby boomers and older people tend to view the primary care physician as the center of their medical care. Discussants concurred that what the data do not reveal, however, is whether the medical “homelessness” of this younger group and its high relative use of retail clinics reflect how these consumers want to receive their care or is instead merely their experience (or is a function of the fact that they have fewer chronic conditions and thus need less care and care coordination).
Since the roundtable in 2007, there has been a flood of urgent care centers with ongoing rapid growth. The American Academy of Urgent Care estimates that there are around 9300 UCs nationally. Across the country, clinics are sprouting like flowers, sometimes fueled by private equity investors, but often by hospitals and health systems who are reflexively installing UCsin repurposed strip malls, sometimes without a clear strategy other than “keeping market share” in an otherwise low margin business.
The reasons for growth, according to the American Academy of Urgent Care? Primarily extended hours (as compared to primary care) and better wait times and lower prices than the ED.
As the private-equity fueled urgent care bubble expands, here’s my prediction on how this all plays out: Don’t bet the farm on UCs being the final answer to the consumer’s search for value. For all of UC’s utility, it’s also possible that urgent care may just get out- maneuvered by the next generation of primary care.