Physician Free Thyself

Physician Free Thyself

hellohealth  //  Doctors get to spend about 18% of their time on patient care. We think that's wrong.

 
Aug 30 / 8:01am

How to link high deductible health plans with high performing primary care

by L Gordon Moore

2-3% annual rate increases compared to 10-12% is covincing employers that it is time to move to high deductible health plans (HDHPs).  As noted in the Agile Health blog the annual savings per employee makes it possible to fun employee health savings accounts.

Employers interested in the significant savings from HDHPs can help their employees make good health care choices by steering them to practices that lower the threshold of access with same day appointments and virtual visits. 

Medical practices differ on attributes that make it easy or hard for people to get the care they need when they need it.  These differences lead to outcomes important to the patients and employers alike:

Patients are much less likely to miss time from work, end up in the hospital, emergency room, or needing expensive specialist interventions, they are much more likely to be satified with their care and have preventive needs met when they receive their care in practices that have excellent:*

  • Access: same day appointments with their own doctor with the option for virtual visits (avoiding unnecessary trips to the doctor's office)
  • Relationship:  excellent communication and the ability to tailor interventions to patients as individuals as opposed to care from large teams of strangers in institutional settings where patients are numbers
  • Comprehensive services: the time to address the bulk of the needs at hand rather than knee-jerk referrals to other doctors due to lack of time
  • Care coordination: a doctor/nurse who help nagivate the complexity of the larger health system when needs exceed the primary care office

Finding practices like this has gotten a lot easier with groups like Hello Health.

 

*Wasson, J. H., Johnson, D. J., Benjamin, R., Phillips, J., & MacKenzie, T. A. Patients report positive impacts of collaborative care. Journal of Ambulatory Care Management, July-September 2006 29(3), 199–206.

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Aug 30 / 8:01am

How to link high deductible health plans with high performing primary care

by L Gordon Moore

2-3% annual rate increases compared to 10-12% is covincing employers that it is time to move to high deductible health plans (HDHPs).  As noted in the Agile Health blog the annual savings per employee makes it possible to fun employee health savings accounts.

Employers interested in the significant savings from HDHPs can help their employees make good health care choices by steering them to practices that lower the threshold of access with same day appointments and virtual visits. 

Medical practices differ on attributes that make it easy or hard for people to get the care they need when they need it.  These differences lead to outcomes important to the patients and employers alike:

Patients are much less likely to miss time from work, end up in the hospital, emergency room, or needing expensive specialist interventions, they are much more likely to be satified with their care and have preventive needs met when they receive their care in practices that have excellent:*

  • Access: same day appointments with their own doctor with the option for virtual visits (avoiding unnecessary trips to the doctor's office)
  • Relationship:  excellent communication and the ability to tailor interventions to patients as individuals as opposed to care from large teams of strangers in institutional settings where patients are numbers
  • Comprehensive services: the time to address the bulk of the needs at hand rather than knee-jerk referrals to other doctors due to lack of time
  • Care coordination: a doctor/nurse who help nagivate the complexity of the larger health system when needs exceed the primary care office

Finding practices like this has gotten a lot easier with groups like Hello Health.

 

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Aug 26 / 9:01am

Getting the time you need in the exam room: root cause and possible solutions

by L Gordon Moore
Kevin Pho MD's blog post and all the follow up comments about time in the exam room got me thinking.

I'm not going to discuss here the value of time in the interaction between patient and clinician - it is so obviously important I don't think it requires reiteration.  Finding the time is the critical issue.  Where do we find the time to do what's right for our patients?

Maggie Mahar's comment (about half way down the comments list) suggests that overhead is the problem and HIT and forming large groups are key solutions.   Let's look at overhead and HIT.

Practice overhead is too high:

True.  The solution to the inexorable increase in administrative trivia driven by insurance company paperwork leads most practices to add staff.  Most practices have a 'referral' clerk whose job it is to contact insurance companies to ask permission for patients to see other doctors and/or have tests performed.  Practices all have billing staff or billing services who wrestle payment from insurance companies for services rendered.  Practices have front office staff who query patients on insurance information and transpose that information into billing systems.  The practice then hires a practice manager to manage the staff.

Proposed solution:  Adopt health information technology.

HIT can streamline work flow but leaves the fundamental drivers untouched.  Stop the crazy billing wars and I can give up the very costly armies that make up the bulk of the overhead!  Insurance companies live on this craziness - it is the very essence of their 'value add' and to give it up puts their very existence into question. This is why the 'Patient-Centered Medical Home' pilots fail to address fundamental drives of high cost and low quality - to do so is too threatening to the business model of health insurers (and hospitals, but let's leave that for another post).

The Ideal Medical Practices project worked with more than 100 PCP volunteers from across the U.S.  Many of these volunteers used a low overhead approach, using much more technology to reduce staffing costs (71% of overhead in a typical practice is salary and benefits of staff according to a study by Ken Smithson MD of VHA Inc.)  We published results demonstrating very low overhead compared to national stats.  The sad news is that low overhead and health information technology alone cannot solve the problem.  

In some regions of the country the combination of high cost of living (NJ, Southern California, for instance) combined with very low insurance payments (NJ, Southern California, for instance) makes it impossible for primary care to survive without some kind of subsidy.  PCPs across the nation are finding it increasingly difficult to keep up with the rising tide of unfunded administrative trivia mandated by insurers.  We are spending the bulk of our time responding to demands from insurers rather than addressing the needs of our patients.  It is no surprise that these 'Dead Zones' turn out to be fertile environments for Hello Health.  Any help in creating a truly supportive environment is attractive in these dire times.

Failure to address these root causes is driving PCPs into the ranks of early retirement.  Those who still love the profession are desperate for a truly supportive environment.  An increasing number find it by going AWOL from the insane billing wars and figuring out how to work directly with their patients and local employers.  I would love it if the insurance industry would simultaneously fund the full scope of effective primary care while eliminating the bulk of the value-detracting administrative trivia game, but the middleman is killing primary care.  If they won't address root cause, they're not part of the solution.
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Aug 10 / 10:06am

Extra fees or other subsidy is the only way for primary care to survive this toxic environment

by L Gordon Moore
Primary care is embattled by a set of policies that simultaneously crush the offices with unfunded mandates (the 'billing wars') while paying for only a fraction of the work.  Because we in health care are used to the idea of cost-shifting (those who pay are charged more to cover those who can't pay), we use the technique to cover the losses of primary care.

Here is how subsidies support primary care in our current system:

Hospital owned primary care
The hospital accepts losses in primary care to ensure the pipeline of people who end up paying 8:1 on the losses by ending up in the emergency department or in a hospital bed.  If the hospital can manage the practices with little loss, so much the better.  The typical management approach is to crank up the hamster wheel so that each primary care physician has a very large panel of patients, sees as many patients as can be (in)humanly packed into waiting rooms and kept waiting in the sensory deprivation experiments we call exam rooms.

Community & Rural Health Centers
States and the Federal Government provide cost-based reimbursement as part of the social safety net.  While a private practice in NYC might receive $23 for an hour long workup of a complicated Medicaid patient, a community health center would receive $160 for the same work.  These centers would not survive without the huge subsidy.  The federal agency that oversees the program drives the docs onto the hamster wheel by defining work as "office visits" and setting the bar at a level that makes it difficult to address the full health care needs of these medically complex and fragile patients.

Independent/private practice
Any economist or small business owner can tell you what happens when a person is faced with fixed-fee price control and rising costs:  crank up the hamster wheel. When we reach the limits of endurance on that front we start looking for other lines of revenue to keep the business afloat.

New lines of revenue 
More and more primary care practices are testing new fees so that they can remain in business.  Some have purchased lasers and other devices to address the raging epidemic of body hair or unsightly spots.  Others are learning how to sell hormones and snake oil to baby boomers desperate to be forever young and buff.

Still others are offering extraordinary access through the use of new technology like the Hello Health platform. 

It would be wonderful if our nation provided these services as a natural extension of citizenship, but given the climate in Washington I don't expect it any time soon.  Many policy makers are betting on 'medical home' projects while ignoring or missing the obvious flaws: big increase in unfunded work, big expense in electronic systems that are designed as weapons for the billing wars, measurement that addresses tangential issues while missing the essence of the solutions.

I wish there were a better way.  I don't relish the idea of asking people to pay more, but I'm not in control of the policies that drive up insurance rates every year while strangling the system with a Byzantine set of rules and regulations.

If you're a struggling primary care physician you have a choice: jump onto an employer's hamster wheel, build your own hamster wheel, or use another subsidy to free yourself from the insane strictures of our broken system.
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Aug 9 / 9:05am

We're supposed to buy health plans like this? Small business is getting creamed by insurance costs.

by L Gordon Moore
I received a quote on health insurance for our medical practices in NYC.  We want to do the right thing by our employees and we'd like to cover the cost of their health insurance.  We know full well the benefits that come from good access to care - if you have good access you are more likely to be up to date on your preventive services, to care for your conditions well, and to be on top of new symptoms before they get out of hand. 

Giving ourselves and our employees access to good care like this is not just a nice thing that gets better results for our employees - it reduces the risk that our people end up in the emergency room or hospital, makes it less likely that people miss days from work or work at less than full capacity due to illness.  Call it enlightened self-interest.

The problem is the cost of the premiums.
Family plan with no deductible and typical ($30-50) co-payment costs more than $19,500 annually.
Family plan with $2000 individual/$4000 family annual deductible & typical co-pay ($10-50) is a mere $15,800 annually.

I have to say that I'm attracted to the high deductible health plan (HDHP).
Family plan with annual deductible of $5800 per individual/$11,600 per family is a lot more attractive at $8,400 annually, or the Family Plan $10,000 individual/$20,000 family annual deductible with annual premium of $5,856.

We could take the tens of thousands of dollars in annual savings and fund a good portion of the deductible through a health savings account (HSA).  The HSA money is a benefit to the employee since they can roll it over to the next year.  

We need cheaper plans like these HDHPs with linked HSA so that we can break away from the unbelievably high premiums of typical insurance, especially as the high premium insurance doesn't seem to cover that much any more and comes with a boatload of hassle and denials.

The other thing I like about the HDHPs and linked HSA is that we or the employee can guarantee access to high performing primary care by purchasing membership in a Hello Health practice.  People who get care in practices like this are more likely to achieve good health outcomes, be up to date on prevention, take care of wellness, and therefore are less likely to ever approach their deductible limits - a good thing all around.
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Aug 5 / 8:22am

2009: jump in uninsured and 47% of individually insured people average $2500 annual deductible

by L Gordon Moore
We live in interesting times.  There's so much promise in the air around health reform and everyone having health insurance by 2014.  Some of that promise is tarnished by the reality faced by many Americans in the here-and-now.  

  • USA Today reports that 3 million more Americans joined the ranks of the uninsured in 2009.
  • In Kaiser Family Foundation survey they found that individuals purchasing health insurance (part of the mandate that is coming in 2014) faced the steepest increase in health premiums in 2009 (20%) and had an average deductible of $2,500.

These two groups have something in common: they have to navigate the obscure and hidden fees of health care and hope that a visit to a doctor's office doesn't blow their budget.

"..healthcare is like fine dining...if you have the money, you get it, and if you don't, you won't."  Professor Uwe Reinhardt on Oprah 

Too many people will probably let symptoms go up until they get serious enough to force them in for care.  This results in hugely expensive care and misses the opportunity for early intervention.  If a person had good access to primary care they could get on top of things before they got out of hand and became difficult to treat.  If they had good access to primary care they could keep their conditions under control and prevention up to date so they'd be healthier in the long run. 

Good primary care sharply lowers the chances of ending up in emergency or a hospital bed.  Employers and individuals who want to live long and be healthy invest in good primary care because that investment pays off in both the short and long term.

There is a growing cadre of clinicians doing what they can to help.  Hello Health practices reduce their own overhead so that they can make care more affordable and accessible to their patients and publish their fees openly so people know what to expect.  Like many of the other Hello Health practices, Agile Health Partners in NYC offers a membership plan that can help keep people healthy and provides access to treatment before a person has to run through their entire deductible.  
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Aug 4 / 3:53pm

Can you hear me now? Hello? Why are quality results falling on deaf ears?

by L Gordon Moore
A colleague of mine told me the other day that she hasn't taken home a paycheck in about four months. Since she's a primary care physician I guess I shouldn't be all that surprised. Current policies aimed at managing health care costs fall disproportionately on primary care practices with a toxic mix of unfunded reporting and administrative mandates coupled with fixed fee-for-service payments that cover only a fraction of the work of primary care.

What's really pathetic about this particular case is that this particular doc is phenomenally good. Her practice is an exemplar of primary care. She provides really good access, she takes time to build good relationships, she and her practice group have invested heavily in information technology so that they can better manage the oceans of data in which she swims every day. This doc has brought in external professionals to help turn her office staff into a true high performing multi-disciplinary team. Her results are terrific. People who really know quality point to her and say "There is a doc who really does it right."

So what's wrong with this picture? The entities that pay for health care in her region appear to be deaf to quality. Without referring to her specifically, some say "well, if this doc is already doing so well we don't need to put any more money into the system to support her, she should just keep doing what she's doing." A sound argument if we didn't know that the supply of primary care docs is drying up as medical students choose other more lucrative specialties. It might be a sound argument if we didn't know that an increasing tide of primary care docs are dropping out of the system by going part time (just so they can have a life beyond work). It might be a sound argument if we didn't find a growing corps of physicians waking up to the reality that the measurement and payment paradigm is broken beyond fixing.

It's time to move on. If the insurers and other monied stakeholders in the status quo are deaf to quality it is time to exit this dysfunctional relationship and figure out better ways to re-engage with our patients. If insurers stonewall quality and patient care it is time to move beyond their toxic reach and find other ways of financing health care - financing paradigms that align the interest of patients with the ethics of our profession.

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Jul 27 / 11:02am

ER wait times rise, putting people at risk. Primary care access is key to solution

by L Gordon Moore

In a report just released documents increased waiting times in emergency rooms across the US.  This does not bode well for the average person, for employers or even for health care premiums.   ER visits are an incredibly expensive way to deliver care.  A young woman told us that a sore throat visit to a NYC ER cost her $2000.  (see a 30 second YouTube interview)

Policymakers and the public should also have no illusions that the recently passed health care legislation is going to decrease ER use.  Massachusetts, which enacted health care reform in 2006, has seen an increase in emergency department visits, with no decrease in patient acuity.  It proves that health care coverage is no guarantee of health care access. American College of Emergency Physicians press release

When people have very good access to primary care they end up needing the emergency room much less.  The woman with the sore throat wishes she'd known of our office (AgileHealthPartners) at the time as she would never have ended up in the ER, and Jaclyn would have saved $1840.

Why is primary care access a problem?  In large part due to the payment policies of health plans.  Independent primary care practices are crushed by the administrative burden of fighting the billing wars with health plans.  Many are selling themselves to hospital systems that are financially better off with the $2000 ER visit than the  $160 office visit - why should the hospital system slaughter the cash cow?

An increasing number of practices are choosing instead to call out the irreparably broken system by leaving it behind.  By charging directly for our services we are able to divest the huge expense of the billing wars.  This allows us to reduce our charges while improving our access.  Getting out of the insurance wars we are able to offer care 24/7 via phone, secure email & video, and spend more time with our patients.  The winners in this new paradigm are the patients, the people paying for health care, and the primary care workforce.  The losers are those who profit from the billing wars.
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Jul 26 / 8:58am

The keys to successful management of chronic conditions: you and the support you receive

by L Gordon Moore
There is a nice article in the NYT:  For Chronic Care, Try Turning to Your Employer

Dealing with a chronic condition involves climbing a steep learning curve and doing a lot of work.  Successful management of a chronic condition rests on doing that work reliably and well.  The mistake most health care people make is that they believe that - aside from the routine follow up visits - the bulk of the work ends with the eduction phase.  

"Hey, I told the patient what to do.  If they don't do it, they're non-compliant."

The problem stems from reductionist linear thinking:  Patient has condition X.  Treatment for X is Y. Just do it. With rare exception, people usually prefer to live long and be healthy.  The source of their difficulty is the complexity of life.  Condition X is only one of many many things happening in the person's life.  Sometimes X has to take a back seat to things like "I just lost my job" or "I think my daughter is doing drugs" or "I have a make-or-break project."

There are a wealth of published studies describing how best to support people in their management of their conditions.  Effective support of people in self-management is rooted in supporting people in their own context.  A diet recommendation ignoring ethnic or cultural food choices is mis-informed and unlikely to be followed.  Writing that person off as "non-compliant" adds insult to injury.

Disease management programs - from employers, health plans or doctor groups - often fail to ascend beyond linear thinking and thus fail to address the complexity of human existence.  Successful programs focus on the person and not just the disease.  Read the literature and you'll find a common thread in the successful programs:  an external agent (nurse, health coach, caregiver, etc) helps the individual learn to successfully navigate lifestyle change.  The intervention is usually no more complicated than helping the person understand the nature of their choices, helping them make small successful steps in a healthier direction, and following up.

This is the work of effective primary care.  
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Jul 25 / 8:51am

Physicians owned by hospitals: the good, the bad, the ugly

by L Gordon Moore

One summer a few years ago, an MBA student and I worked through a big block of (de-identified) claims data.  We found that for every dollar the insurer spent on primary care, they spent an additional $8 on 'ancillary services.' labs, xrays, hospital based procedures, hospital based specialist visits, hospital based 'facility fees.'

I found out that when a patient has a consultation with a hospital based physician, the insurer is billed not only by the physician, but an additional bill is generated by the hospital as a 'facility fee.'  If the patient sees a non hospital based physician, no such 'facility fee' is generated.

Hospitals don't love owning primary care physicians and their practices - they tend to lose money on them.  Even 11 years ago this was obvious.  So why do hospitals continue to buy up physician practices?  If you count the eight-to-one return on the ancillaries the hospital comes out way ahead.  Hospitals tend to own physicians so that they can dictate where those $8 are spent.

'Once, my administrator announced that I was in breach of contract if I ever referred a patient to a system outside mine. “But don’t worry, he said, I wouldn’t dream of suing you … Unless your ancillaries dropped below the mean.”' From blog KevinMD

Fighting in the claims war is exhausting and I don't for a second doubt the integrity of my debilitated colleagues who explore the seemingly secure grounds of hospital employment, but be sure to consider underlying motivations of your potential employer.

Getting a salary check with 401k contributions every two weeks is good.  This keeps some primary care physicians from leaving the workforce entirely and that is also good.  Selling yourself to a hospital system expecting you'll get off the hamster wheel is bad thinking.  Trading your freedom to focus on your patients for indenture to a system rewarding productivity over quality is ugly.

Hospitals are not the font of all evil. They didn't set up a revenue model that rewards them every time a person gets sick enough to fill a bed and provides bonus dollars every time the person has complications and needs the ICU.  There are some very good hospital systems that have learned to do well with primary care while managing their revenue model.

It is important that physicians assess the underlying motivations and understand the revenue model: the more we do in primary care to keep people healthy and out of the hospital, the more we harm the hospital revenue model.  

This is not a system designed for optional function and does not bode well for the relationship and it makes me wonder about the future of Accountable Care Organizations organized by hospital systems.
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