Archive for the ‘AAFP’ Category
Posted on October 19, 2009 04:00:00 PM
I have a lot of friends in Boston this week who are attending the annual meeting for the American Academy of Family Physicians (ie - Congress of Delegates or AAFP CoD). And, they may not be too happy with what they read in this post, but here goes.
As some of you know, I’m scheduled to present at BlogWorld Expo (BWE) later this week in Las Vegas. I’m going to be moderating a panel about how patient privacy and the HIPPA law can impact blogging, podcasting, and interacting with social networking.
When I was offered the moderating spot, I did think to myself, “You know, this is the same week that the AAFP national meeting will be taking place in Boston.” I haven’t seen many of my AAFP friends and colleagues for a while now. Through the summer, I’ve gotten a lot of messages through Facebook asking whether I was going to attend the Boston meeting this year.
After thinking about it for a while, I decided that I would rather go to BlogWorld Expo than AAFP. There are a couple of reasons for this. First, I believe that this is an important point for social networking (like twitter, facebook, etc) and medicine. This year will be the first year that there will be a “Medblogger Track” of programming at the BlogWorld conference. It was nice to be asked to be a part of the first type of gathering like this at a primarily tech-centered meeting.
Secondly, I’m probably not the first to say that I’m feeling a little frustrated with organized medicine right now – whether it be AAFP, or AMA, or AHA, or other national medical organizations. I’m a guy in small town NE Ohio who’s trying to make the best of it in these economic times and “sociomedicolegal” environment. My patients, my community, and my colleagues are just frustrated. And, all I’m seeing organized medicine do is just play the same “inside the Washington beltway politics” that I’ve seen for years when I attended the AAFP annual meetings.
So, to all my friends in Boston, I hope you have a good time this week and I hope AAFP reveals some plans on how to advocate better for the fundamentals and ideals of Family Medicine. I hope to return to the AAFP annual meeting soon in the future, when I feel my voice can again make a difference for organized medicine. But for now, I’m just not feeling it is…
*This blog post was originally published at Doctor Anonymous*
Posted on October 12, 2009 05:00:00 AM
I’ve been following the career trajectory of Dr. Gordon Moore since I first became aware of his low-overhead, high-tech model of medical practice. He’s come a long way since the AAFP first interviewed him in 2002. I had the chance to catch up with him at the recent Health 2.0 conference in San Francisco, and we discussed the future of primary care and a practice model that I believe in (I just joined DocTalker Family Medicine myself!) Here’s our peek into our healthcare crystal ball…
Dr. Val: Tell me about what got you interested in creating a new practice model for primary care?
Moore: I came into healthcare with a somewhat Pollyannaish vision of reducing suffering and improving health. Without any docs in my family, I had no understanding of what it meant to actually practice. About 5 years after residency, I realized that there was an increasing disparity between my vision of practicing medicine and its reality. At that time I joined a quality improvement initiative at the University of Rochester, and we looked at increasing efficiency in primary care, including creating the idealized design of clinical office practices.
These designs keyed off on the concepts of open access, health IT and the use of technology as a means to track chronic disease. I built on these ideals and created a no-staff, high technology-enabled practice that reduced the pace of care and its overhead.
Dr. Val: What was your practice like for patients?
Moore: I worked all alone and had one room that I rented from an ophthalmology practice. The first day I had 6 patients and the phone rang in the middle of my doing a physical exam. I suddenly realized that I had one line and no answering machine, so I had to run out to Radio Shack in between patients to get one. I had all sorts of issues like that one in the first year – trying to figure out the details of my work flow. I had to give out my home and cell phone numbers to all my patients because I had no one else to answer phones.
I had no business model associated with the extra work I did on the phones – it came out of the lower overhead associated with being my own administrator. It was strange working alone at first – I had to wear all the hats, take out the trash, and do my own billing. There was a real documentation learning curve.
I realized that the machinations of office practice seem daunting because they’re obscure, but when we unmask them, it’s not that hard. We’ve learned how the endocrine system works, we can learn how to do billing. It’s a pain, I don’t like to do it, but it can be done… though the paperwork burden seems to be getting worse and worse.
Dr. Val: What do you think of practices who simply stop taking insurance so they can avoid all that paperwork?
Moore: It’s breathtaking. At first I was uncomfortable with the idea because I thought it would create a two-tiered healthcare system. However, when you think about it – we already have a two-tiered system now: those who can afford healthcare and those who can’t. Insurance-free practices cut out the “mother-may-I?” scenarios that keep doctors from doing what’s right for their patients.
In most places, insurance reimbursement is so low, and the administrative burden of accepting insurance is so high that it’s not feasible to practice medicine without some additional subsidy. And that subsidy comes in the form of a hospital center loss-leader for admissions, or a community health center supported by the federal government, or by charging patients cash for certain services or extra access.
Qliance and Hello Health (who are in the direct practice model) have achieved breathtaking simplicity. I love how they have been able to take their price point down to a place where average working folks can afford it. We need that level of simplicity in primary care in the US.
Dr. Val: What’s the major barrier to having more practices adopt this “breathtaking simplicity” model?
Moore: Fear of the unknown. A lot of docs I talk to yearn for simplicity but don’t have the confidence that they’ll be able to generate the patient volume to keep their practice afloat. They don’t know how to do it. I’ve joined Hello Health University to help physicians learn how to shed those burdensome legacy systems for their work flow.
The other barrier is that more employers need to recognize the incredible cost savings of buying a high deductible, direct primary care payment model, bundled in with a catastrophic plan. It’s cheaper, the care is phenomenal, and patients love it.
Dr. Val: What will the insurance companies do if high deductible plans and HSAs really start to take off?
Moore: The smart ones will get into the market early and vigorously and try to snap a bunch of it up. Others may try to dig their heels in and wait, but market forces will reward those who get in early. Insurance companies will have to figure out how to make do on what will be small margins on a contract basis, but will be a significant book of business if they get in early.
Dr. Val: Do you think healthcare reform will influence this potential new model of primary care in one way or the other?
Moore: I’m not sure how things will pan out. But we seem to be pushing towards the idea that “everyone needs a ticket to ride.” Of course, full service health insurance is too expensive for everyone to buy, so a good solution may be to make sure everyone has a high deductible/catastrophic coverage plan, and uses a direct care model for their primary care.
That would create broader access to healthcare, happier physicians, and decompress the system. When practices can have direct relationships with patients (and stay in frequent contact by phone, email, house call, or office visit), the outcomes are vastly superior. It gives physicians the time they need to look research options, engage in care coordination, and help people make those lifestyle changes that affect their chronic diseases.
It’s better care that costs less.
Posted on September 29, 2009 01:00:50 PM
Please allow me to coin a new term:
Medical Homelessness – Not having access to a consistent familiar medical setting. Not having a care location where one is known or where the medical information is accurate.
credit
I think medical homelessness is one of the main problems in our system.
Given the nature of care in the US, most patients are required to be their own homes. They serve as the conduit where medical information from one provider goes to another. They are the prime decision-makers in their care – often making these decisions without understanding or assistance from those who do understand. They are the only ones with the “big picture” of their health, yet they don’t really know enough to say if that picture is good or bad. They are helpless and vulnerable to sales pitches from drug companies, device manufacturers, insurance companies, and unfamiliar doctors.
I am not talking about every patient in our system, but I am talking about a large portion (perhaps the majority). Some may spin this as patient empowerment, but unfortunately much of it is a case of patient abandonment. People are left to fend for themselves in a confusing, complex, and hostile system, and unfortunately many of their lives depend on their ability to manage this.
Sadly, most Americans have come to accept what is as what is best. They don’t know what not being homeless would look like, so they don’t push to find a home.
Reasons for the Medically Homeless
There are a number of reasons that people have no medical home, with many places to lay the blame. The center of the storm, however, is the state of primary care.
Primary care physicians are the logical choice for the medical home. People know their PCP over many years, and the general nature of primary care physicians’ training allows them to oversee the overall care of the patient. Most PCP’s don’t rely on procedures to make their living, so the act of meeting with the patient, organizing their information, and discussing a plan is natural in the PCP’s exam room. But several things have made it difficult or even impossible for primary care physicians to provide an adequate medical home:
1. Being a medical home takes time
To gather and organize the patient information is sometimes very complex. Discussing the big picture and explaining why certain things need to be done takes a commitment from the PCP. The problem is, there are no billing codes to cover this procedure. There is no procedure of medical information oversight that is covered by most insurance plans. Yet doing so takes more time than it takes for an ENT to put tubes in a person’s ear (which takes about 5 minutes), and more thought than it takes to remove a wart from someone’s skin. These other procedures are paid for, but coordinating care is not.
Yes, there is the “preventive physical” that is paid for by many insurers, but there is nowhere in the required documentation for this regarding care oversight. Plus, a “physical” requires that the patient be present, but care coordination can be done in their absence. The money paid for a physical is for “doing something” (i.e. examining and ordering tests), not for organizing and planning.
Given that PCP’s are among the lowest paid physicians, for them to take the time to do a big job without pay is not only bad business, it is a surefire way to go out of business quickly.
2. Insurance companies pretend to be the medical home
Insurance companies have moved from the insurance business, and now are in the “care management” business as well. This is convenient, because the management of care involves deciding which tests are paid for and which are not. The problem is, like the PCP, the insurance company must often decide between what is best for the patient and what is best for business. Is it better for all of their patients to get colonoscopies, more frequent diabetes visits, and more aggressive cholesterol lowering? Perhaps these reap a benefit in the long-run, but they cost a lot of money up front. Shareholders tend not to think in the long-run.
This wrestling match between doctor, patient, and insurance company over control is a major part of what goes on in a medical office. The reason insurance companies have such bad reputations is that this conflict of interest between business and patient care makes their motives always suspect.
3. Good information is hard to come by
Not only is it time-consuming to gather comprehensive medical information on a patient, it is often impossible. Between HIPAA, which greatly increases the work it takes to get medical information, and the horrible informatics infrastructure we have, much of a patients’ record is often inaccessible. In 2009, I get far less communication from consultants and hospitals than I did in 1995. Why? There is no easy way to communicate, and there is no motivation to do so.
Specialists, hospitals, and labs used to rely on referrals from physicians – referrals that depended on the PCP’s opinion of the specialist. If one of these treated my patient badly or did not communicate with me, they’d lose all of my business. Now they are chosen by insurance companies, who make a deal to get the best price possible. There is hence far less reason for them to give me good service, with the end result: non-communication.
4. Primary care is increasingly scarce
Even if all of the other things were in place, the shortage of primary care physicians would still leave many people medically homeless. There are not enough PCP’s, and those who are still there are being deluged with patients. The more the system shifts to primary care, the larger this problem will become. If the system paid better for doctors to spend time organizing records, there would be fewer available appointments. This could be compensated for by using a “care team,” but that is yet one more added expense.
Plus, the addition of new payments for care oversight would undoubtedly come with many strings attached. Would they need to follow up on any lab that was ordered and had not come back? Would they be responsible for mammograms ordered by the GYN, or lipids ordered by the cardiologist? Very few offices are equipped to do this without a major time investment.
Fixing Medical Homelessness
There is no easy fix to this, but one of the first steps is for people to be aware there is a problem in the first place. People don’t demand high quality care because they don’t realize they are not getting it. And people don’t know they are getting it because they don’t know how good care could be. The first step would be to show it working well somewhere.
Obviously reform of the payment system as well as promotion of primary care is critical. I would say that if PCP’s got a substantial increase in reimbursement, there may be some 50-something doctors who retired from practice due to the current situation who may reconsider. There are actually a substantial number of PCP’s who have retired rather than deal with our system that is hostile to primary care.
Whatever the solution, having a medical home for everyone should be at the top of reform agenda. Disjointed care is expensive. Disorganization leads to mistakes. Dumping the responsibility on patients creates fear and powerlessness.
We need to find the road that brings us home.
*This blog post was originally published at Musings of a Distractible Mind*
