Sunday, March 25, 2012

Accountability Care Organizations (ACOs)

Tonight’s episode is the case of the Curiously Capitated Conundrum.  The problem: rising health care costs. The proposed solution; globalized payments.  Thankfully you have me to serve as your gumshoe, scrubs wearing detective on this journey.

Let’s start by rounding up our suspects. The list includes hospitals, doctors, insurance companies, drug companies, the government and even patients.  While it would be nice if everyone would just work together the reality is that each have a unique agenda and therefore different motives. The unfortunate patient is being knocked back and forth like a ping-pong ball between rising deductibles, rising premiums and less coverage.

As you can see, it all boils down to the almighty dollar and the constant struggle to get it, to not spend it or to at least spend less of it.  That said, let us now examine the motives of our suspects:

Insurance providers want to cover the most people for the least amount of money. This means they’re likely to conjure up ways to cut the cash flow.  In fact this is exactly what they’ve done by enacting generic mandates, pre-authorizations (for both technology and medications) and high deductibles.  They argue that they have to raise costs because people are living longer, technology is increasingly expensive as are medications.  They further bemoan the recent changes to the health care law that eliminate pre-existing conditions and expand coverage. Their critics assert that if they were just willing to pair down their massive profits and paychecks a bit; there would be plenty to go around.  The government payors simply wants more of everything. More control, more cost restrictions, more tax revenue. 

Doctors want to be paid for what they do without questions or hassles.  In recent years they’ve had pay cut after pay cut as reimbursement shrinks or fails to keep pace with inflation all the while their costs and demands are increasing. E-scribing, EMR’s, increased paper work all come at an expense.  Meanwhile critics portray them as greedy whiners that order unnecessary tests and office visits to pad the bottom line.  If we can eliminate the fee for service, a reward for work done system, docs will buck up and offer better care more affordably.  The same argument is pretty much true for hospitals. 

And the patient? They want the most care they can get for the least amount of money.  Some go so far as to be deluded into thinking the government can provide it for free.  I’m not sure where they think the money ultimately comes from but alas I’ll save that discussion for a different day.  Patients argue that they should be cared for. They shouldn’t be turned away for pre-existing conditions or go into bankruptcy over an unexpected illness.  They should get what they need when the need it.  Critics argue that what is needed and what is wanted is not always clear. They accuse patients of running up the health care tab by clogging emergency rooms unnecessarily and demanding unwarranted tests.  Doctors fear the public, with the aid of their friendly neighborhood lawyer, is sue happy which in turn drives wasted money on defensive medicine. 

So what further can we do to slow costs? Will it work?  Most importantly, what does that mean for you, the patient?
The most popular solution is that of global payments, in one way or another, in place of the traditional fee for service. Under a global payment system, theory goes, paying one set fee to render care hospitals and health care providers will no longer have an impetus to over treat and thereby save money. For example, whether a patient is seen every month, every three months or twice a year the fees remain constant. Other proposals take this a step further making one global payment to a regional health care hub that then is responsible for all testing, doctors, hospital care etc. 

Now global payment systems are not new.  If you’ve been around the game a while you may have heard the term capitation.  It was in play as recently as the 1990s with dubious outcomes.  So much so, the current pundits carefully avoid the term and I included it in my opening paragraph with much trepidation.  In its most modern iteration it is referred to as an A.C.O or accountable care organization. Another variant is termed the medical home. 

Insurance providers (including Medicaid and Medicare) like it for several reasons.  For one, they no longer have to deal with variability.  Bean counters hate variability.  They want to deal with fixed costs. With fee for service they can project their costs for a particular population but can never be sure.  Patients may end up getting more or less care than they projected.  With a global payment it’s a fixed number per patient.  The trick, though, is in determining this capitated amount. I have little doubt it will be a low-balled figure and result in further savings for the insurance underwriter. Other reasons include affording insurance providers added control as well as the ability to shift risk.

But what are the ramifications for you, the patient? So far it sounds good, right?  Well not entirely. Before we accept its success as a forgone conclusion, let us dig a bit deeper. Let us roll around the floor and look at the situation from different angles and analyze the motives of our suspects a bit further. All the while we must not forget that in the end it is about you, the patient. So how will this work for you? 

Like any good caper it comes down to motive.  What are the motive forces at work here?  As mentioned above, the rules are clear; one payment no matter the expenses incurred all in the name of lower costs and improved quality. However, under this global system is not now the incentive to provide the least amount of care possible to the patient?  Has not the motive to flatten costs flipped the system on its head?

Let me illustrate this point a bit further. Consider, for example, a hypothetical patient, Mr. Jones enrolled in his local A.C.O. Let’s say $800 is paid out on his behalf (for the year) to his local medical hub we’ll call Local Care.  Those involved in Local Care know that no matter how much they spend to care for Mr. Jones they’re only getting 800 buckes, no ups, no downs, no extras.  Now let’s say Mr. Jones presents with a cough.  Will they be more or less motivated to authorize chest x-rays, blood testing etc.?  Will they employ more or less doctors?  Will this model positively or negatively impact a doctor’s autonomy?  Critics of fee for service accused the system of testing unnecessarily, will not this system promote under testing? Do you really want your doctor or hospital deciding your fate knowing that the more they do the more they will be penalized?  Do you want your doctors and health care rationed? Does this model not promote rationing?  We all know that life is a delicate and precarious existence wrought with much uncertainty.  Does this system not shift that uncertainty to the shoulders of your health care providers? Should doctors or hospitals be faced with this added burden as they make difficult decisions on your behalf? 

And what of the quality?  Another hopelessly ambiguous idiom being hurled onto the public scene.  What exactly passes for quality care?  For inspiration, let’s look at some of the current practices as they are all too likely to continue no matter what direction we take.  At present, insurance providers rate doctors as rendering high quality if they do it inexpensively and if they achieve certain percentages of health maintenance targets such as colonoscopies.  It’s commonplace for them to track a doctor’s use of generic drugs for example. Do such parameters really measure the quality of the rendered care?  And what do we do with the endless dichotomies they set up?  For example, lets take a hypothetical doctor caring for a diabetic patient.  Said doctor is rated on his or her ability to get the patient’s blood sugars, blood pressure and cholesterol levels down.  This frequently requires multiple medications.  There are generics available, yes, but what of the instances when a branded product is needed? If said doctor uses too many branded products he or she is penalized.  If they choose to forgo branded products or limit the number of medications in exchange for tolerating higher blood pressures or cholesterol levels they’re dinged again for missing their targets. It’s the proverbial damned if you do and damned if you don’t scenario. Then there’s the problem of determining what levels are the norm for a particular provider. Is it fair to compare them to their peers who may have very different patient populations? Is it fair for the provider to take responsibility for a patient’s poor compliance or genetic predisposition?  Again, is this really a measure of the quality of care being provided? Does this not again shift more risk onto the shoulders of the health care provider?  Furtherstill, won’t this promote “cherry picking” amongst providers. After all if I’m going to be judged on how well my patients do isn’t in my best interest to choose more favorable patients?  If said health care provider is now responsible for all of the risk are insurance companies under this system going to give up on their systems that limit access to CT scans or other testing such as burdensome pre-authorizations? 

So what can we conclude?  A.C.O’s and the like are apt to go to far.  There’s a strong probability they will posit a situation in which care is rationed, reduced and restricted under the belief it will slow costs.  Health care providers will be put in the precarious position of trying to do the best for the their patients all the while knowing that if they order tests or medicines they will ultimately be penalized.  Health care providers will wrongly be shifted into the position of bearing the inherent risks of health care in effect acting as if they were an insurance provider themselves. Doctors are likely to see their already vanishing autonomy take another devastating blow.  Faced now with the realization that in addition to being told how to practice medicine they may be told where they can practice as well. Health care in the United States will cease to attract the best and the brightest.  The new climate will stifle new discoveries and technologies and foster a slower, less advanced health care delivery model. Access to care will decline as many health care providers bail out whereas the other salaried drones slow their pace. Surely, insurance providers (both public and private) will like the fixed lower costs and risk shifting but are unlikely to moderate their restrictive practices. And in the end costs may or may not go down but care will likely suffer. The patient will have less options; not more. The true quality of health care as we know it will ultimately go down.   

Case closed boys. 

Saturday, October 9, 2010

Make Today, Today

Have you ever thought about today?  Now you might think I’m crazy and say to yourself, “Of course I think about today.”  I think about everyday.

But that’s not what I mean.   What I’m getting at is whether or you not you’ve ever limited yourself to just thinking about today. Whether you’ve ever truly lived in the moment; experienced the tremendous power this mindset affords.  Try it. Just one day of Today can be quite liberating. 

See, the problem is that most of go through life with too much baggage. We’re like the guy trying to get on a airplane with a bag over each shoulder; pulling another suitcase and clutching his laptop with his free hand.  Wouldn’t it be nice to stride effortlessly through the airport with just a small bag, get on the plain easily, sit back and relax?  You can.  By not bringing yesterday’s baggage into today. 

Now what do I mean by that?  Take a typical day.  It’s filled with endless possibilities but most of us wake up stressing.  Perhaps we’re thinking about all of the injustices perpetrated on us in the past by our co-workers, like the job promotion we should have had. Maybe you had to get a new job or got laid off and you’re sitting around thinking of what used to be or thinking about how thin you used to be. How young you used to be. How simple life was before you got married, bought a house and had kids.  Don’t get me wrong, I’m not trying to trivialize all of this or to say that you can’t learn from the past.  Instead, what I’m saying is that this is in the past so for once let’s try and leave it there.  If you pull it into the present it can often ruin today.  The reality is it’s over. You can’t change it or go back. Why waist your energy on it?  Ask anyone who’s gone to AA, there motto is take it one day at a time.

All you have is now, today.  Sounds simple doesn’t it?  Pause for a second and really think about that.  Do you have yesterday? Sure you have memories, pictures, videos blah blah blah but do you really have yesterday. NOPE! It’s gone people.  Aside from the IRS not too many people care about what you did or didn’t do in the past.

And the same is for the future.  Do you have it either?  Think about that.  You can look forward to the future, you can plan for the future or even sit around waiting for it.  No matter, do you have it.  NOPE again.  No one can say what their future holds or how long it will last.  So why burn up today stressing about it?  It may not even play out like you thought it would.  Today is what you have.  If you live fully today you’ll feel immensely satisfied. You can do great things and be better ready for whatever future you experience. 

Now I want to take a brief diversion here and discuss a few traps. When I talk about this with people they often misunderstand this concept. 

First is the trap of misunderstanding what living for today means.  I’m not advocating that you have no plan for the future, that you blow all of you’re money, drink, smoke and throw caution to the wind.  That’s not at all what I’m getting at.  Living each moment fully is about being free, fulfilled and the best we can be.  Think about it, even if you did go out today and spend all of your money, drink all you want, eat until you drop. Will you feel fulfilled?  Will you be at peace. No, that’s a trap.  Instead of experiencing life to the fullest you’re trying to make yourself happy by overloading your senses, won’t work.  Ever sit down with a carton of ice cream or a bag of chips.  At first it tastes wonderful, so you keep going.  Do the chips taste better as you go? No.  But you keep eating, keep trying.  Soon you’ve eaten way to many and now you feel bloated and have an upset stomach.  Sensory overload is not the answer here.  It’s the freedom of living moment to moment. Knowing that that is all that you have, that’s all you really have to deal with.  Dance and laugh now knowing the opportunity will eventually pass. 

Another common trap is WHY?  You can beat yourself to a pulp with this one.  Why did xyz happen to me? Why didn’t xyz happen to so and so? What did I do to deserve this?  I’m a good person why do bad things happen to me?  A good example to illustrate this is cancer.  I repeatedly see this happen with cancer patients or their families. Cancer is devastating and no on is trying to belittle that fact.  It is what it is.  It’s an attack on your mortality, a most unfortunate card from the deck of fate.  But what good will come of adding to it the condrum of taking a ride on the WHY Merry-go Round? Stand up and fight, yes.  Don’t waist you’re energy asking why unless it can lead to a treatment or cure. 

 I want you to live like Lass.  Lass is my black lab.  She gets up in the morning and eats.  It’s time to eat, so she eats.  She doesn’t run around, eating and multitasking, worrying she’s late.  She may have been kicked in the face by the dog next door yesterday, do you think she cares?  Does she even think about it?  So today maybe she won’t go next door.  Do you think she’s worried about whether or not she’s going to get a better bowl for her food tomorrow, or a bigger dog bed to sleep on? Nope?  The one she has works just fine. Smells like mine, has my hair all over it and has a nice soft spot right there in the middle.  If we go out for a walk she runs around sniffing the ground as if she’s never smelled it before.  There might be something new to discover, right?  If it starts raining she doesn’t get all upset and complain. So, it’s raining?  She doesn’t care what time it is or whether or not it’s the weekend. She’s ready to go at a moment’s notice.  She enjoys riding in my rusty old plow truck more than in my good car.  Why?  It has a big fat vinyl seat and she can plop down right beside me. 

I wonder sometimes what she’s thinking, as she glances up at me as I fly out the door to go to work.  "Yep, there he goes again.  I hope he makes some more money so I can enjoy keep hanging out right here in this nice basement."

Now I ask you?  Who’s the smart one?

Live today, today.  Experience the tremendous freedom it affords.

Sunday, September 19, 2010

Why Me? Conundrum

I hope this never happens, but in some form or another it probably will at least once in your lifetime. What I’m speaking about is the chances that you or a close loved one is on the receiving end of bad medical news. For instance, a cancer diagnosis.

I wanted to talk today about this because I see so many of my patients and their families struggle through these difficult times, often making it worse; adding insult to injury.

Often I see patients and/or their family fall into what I like to call the “Why Me” trap. It goes something like this:

Consider for example, a 45 year old mother of 3 being diagnosed with breast cancer. After the initial shock wears off and some of the preliminary testing is done it’s not unusual for patients to dwell on the situation. And often times, obsess. They begin, in earnest, asking Why Me? I lived a good clean life why did I get cancer? What about so and so that drinks, smokes or is a mean person? I have kids that depend on me, why me? I go to church regularly, why me? No one in my family got cancer, why me?

Families do the same thing. How can my son/daughter have cancer? It’s not fair? I wish I could trade places with him/her. How could my sister or brother have cancer? How could my mom/dad have cancer? Why? They’re good people. They didn’t do anything wrong. And on and on.

Some go so far as to curse religion and God. I had a patient that swore off church 25 years prior after his daughter was born mentally challenged. He wallowed in Why Me land. He liked to joke that the only church he would attend from now on was St. Mattress with Sr. Sheet and Fr. Pillow.

It is frustrating as a doctor to watch the patients and their families literally torture themselves. I know it’s perfectly natural to ask these questions but it needs to be controlled. Go ahead, ask these questions, get it out of your system but only for a short while then move on.

The bottom line is that the endless conundrum of Why Me serves no useful purpose. Literally, no good will come of it unless there’s closure. If you ask it for a short while and conclude correctly, there really is no answer then it was cathartic, good. But, if like so many, you continue to beat yourself up over it all you really do is end up ruining what precious time you have.

Think about that. You or your loved one has just been faced with major mortality issues; they’re staring at the real possibility of a life that may be much shorter/differerent than they had planned. And what do they do? They waist time worrying about why it happened. Asking questions that can’t be answered. I’m not saying you shouldn’t pursue therapy; or ask if there are ways to improve things, prevent things in the future. I’m talking about the endless barrage of unanswerable questions I outlined earlier.

Acceptance, that’s what is needed. The truth is that cancer and disease don’t discriminate. They’re the result of a complex interplay of genetics and environment. The sooner you accept that fact, the sooner you can move on.

Therefore, in conclusion, my advice is to punch up the famous country music song, “Live Like You Were Dying” on your ipod and blow out the speakers.

Do like he says: live each and every minute to the fullest; give thanks for every beautiful day.

Saturday, July 10, 2010

The P.A. "Praying for Authorization"


It strikes fear in the hearts of doctors across the country; it is not the deadly Ebola virus or a new strain of cancer, but its malignancy is equally apparent.  It is the dreaded “PA”, which is insurance-speak for “prior authorization” and it seems that no matter which way we turn it appears, standing between our patients and the care they need.

To their credit, PAs are truly equally opportunity barriers to care.  Odds are that you will be required to get one regardless of whether you are young or old, male or female, or if you have the sniffles or a stromal tumor.  And like magic, somehow they are filled out, submitted, denied, resubmitted, denied, telephoned about, put on hold for, resubmitted, and finally approved without you (the patient) ever lifting a finger.  Yes, the PA “dance” is too complicated for patients to learn; thus, we the physicians of overly-educated lore, and our countless staff members, are required to learn an array of delicate maneuvers determined by, and different for, each insurance partner we choose to dance with.  And to make it a little more complicated, every so often they change the rules of the dance and usually forget to tell us or ask that we intuit the steps. As you might imagine, this causes a lot of toe stepping and even a fall now and again.

The most recent dance began three months ago.  During a routine office visit, a patient shared with me that she was having difficulty with pain caused by her fibromyalgia and her symptoms were becoming increasingly severe and bringing her down. She had already tried a host of medications including SSRI’s, so we discussed trying a different medicine.  I selected an agent (FDA approved for fibroymalgia), e-scribed it to the pharmacy, and then the dance began. 
As they say, no good deed should go unpunished.  It didn’t take long for the fax machine – recently renamed the denial machine – to start spitting papers into the office with the usual title: REQUEST DENIED.  And so it began … we began filling out the requisite PA form which asked the usual questions: What was tried in the past? Why was the medicine needed?  How did previous agents fail?  How long would it be needed?   That PA was promptly returned for insufficient data.  No further explanation.

I called.  “Sir, please enter the dates of prior trials with the recommended agents and return the form” intoned my dance partner.  I followed her lead as closely as possible, despite the vanishingly low likelihood that she had anything that remotely resembled medical training.  Nonetheless, the forms were re-completed and re-submitted, this time mentioning all other agents tried and approximate dates of the trials.  We presumed success, due to a lack of response from the insurer (No news is good news or so they say) and we moved on to dance for the rest of our patients.

However, after some time had elapsed we learned that it was denied, again for insufficient data.  Feeling perturbed, we banged out a personal letter pleading with them to authorize the prescription. No such luck.  You see, when this insurer, which will remain nameless (Hint: It covers patients that probably cannot afford other insurance) asks for details, they want all the gory details. They want to know exact start and stop dates plus precise details on what side effects and (lack of) response the patient experienced. 

We complied.  My assistant did an exhaustive chart biopsy and filled out yet another PA form. DENIED AGAIN!   That evening I got the attached voicemail from a representative from the insurer (listen for yourself).  The next morning we called again and they claimed that the exhaustive analysis we submitted was never received.  Nonetheless, they finally zapped over an approval to the denial machine the next day.

As I drove home that evening, I began to reflect on the whole dance-debacle.  There seemed to be only a few conclusions that could be drawn from the experience: Either insurance companies don’t trust physicians to be honest with their requests or they have devised the most vile and devious of means to put up every roadblock in their power to save money. Either way it is a sad state of affairs. Obviously, we cannot put this kind of effort into every prescription, test, or procedure that I believe my patients need, and they know that. Translation:  money saved. 

Sadly, this scenario plays out every day of the week, every week of the year, in every physician’s office across the country.  And although the dance wears us down and imparts unnecessary costs on our office in the form of both time and money, ultimately it’s the patients that suffer.  Delays and denials have human consequences that insurers seem to fail to recognize.

A bright point on the horizon is an effort by the American Medical Association (AMA) to promote insurer practices that prevent the egregious ballroom antics described here, and similar practices that hurt patients and inhibit effective care.  Last month, the AMA released its Insurer Code of Conduct which calls for insurers to adopt consistent practices (everyone is dancing the same dance), that will bring transparency and accountability to insurer practices.

Particularly germane to this example, are sections of the Code that state “no care may be denied on the grounds it is not “medically necessary” except by a physician qualified by education, training and expertise to evaluate the specific clinical issues”, “insurers must eliminate complexity and confusion from their processes and communications”, and “requirements … to obtain approvals and respond to information requests must be minimized and streamlined.”

The Code seems to have gained considerable support from medical societies (my own, Massachusetts Medical Society, signed on), but the real question is what will it take for patients to catch on that these reforms are needed and encourage insurers to adopt the Code? 

Until then, we’ll keep shining up our old dance shoes for another tortured saunter through the grand ballroom of futile paperwork.

Tuesday, May 18, 2010

Goint Out of Business

Mark Trenton sat at his desk as the sun was setting on the horizon. Another busy day was ending in its usual manner as he sat trudging through paperwork. Soon things would be different, he thought, as he leaned back in his chair to look over another of the forms he snatched from his inbox. His chair jerked forward with the knock on the back door.

He turned down the radio and called out loudly, “Who is it?”

“Kenny. Kenny Sparks.”

“Be right there.”

Mark tossed the form aside with a feeling of relief. Not relief that his work was done but the relief of knowing that the evening’s monotony would be interrupted. He undid the lock and opened to door to find a young Kenny Spears grinning back at him.

“Well look at you. You’re the spitting image of your old man, you know that?”

“Everyone says that.”

“The last time I saw you, you were yeah high.” Mark held his hand about 3 feet off the ground. “Well come on in.” He paused a moment then commented, “The bounty you seek my good boy is over here.” He pointed to a late model refrigerator in the corner then walked over to it.

“Never had any trouble with it. It’s only about 5 years old. Your dad says you need it for the frat house?

“Sure do. We can always use an extra refrigerator if you know what I mean.”

“Do I ever. Live it up son. One day you’re going to wake up with a houseful of kids and a full time job.

“That’s what everyone keeps telling me.”

“Well it’s true.” Mark went around to the side table and motioned for Kenny to grab the other end. “Here help me move this so we can get at the fridge.”

They moved the table up and over into the hall, then loaded the fridge onto a dolly. They then wheeled it outside and hoisted it into the back of the truck Kenny came over in.

Slamming the tailgate Mark said, “Well that ought to do it. Want some water or something?”


They went inside and moved the table back. Mark poured out two glasses of water and sat down across from Kenny.

“Can I interest you in anything else around this place? A table, some chairs? How about a gently used microwave?”

“Really? You’re just gonna just give it all away?”

“Yep. Like I told your dad. I’m closing the whole place down. Don’t want any of it. Take what you want, seriously.”

“Well since you’re asking I’m sure the guys could find a use for this stuff. So why are you closing down? I never heard anyone in your line of work going out of business.”

“A lot of people say that. Truth is I never thought it could happen myself. When I went into this business it was different. There was respect, prestige and a code of honor. You paid your dues and had a job for life, to save lives. Sure it was always a demanding job but at the end of the day you went home gratified you helped people and put in an honest day’s work. And it used to be a good living.”

“And that’s not true anymore?”

“Nope. The bureaucrats have taken over. All they care about is whether or not you file the proper forms. Then they cut the pay down so much I can barely cover my expenses. By 6 in the evening I’ve barely covered my overhead and still have two hours worth of paperwork to justify my keep. “

“So what are you gonna do?”

“Don’t know. Thankfully my kids are done with college. I always thought I’d grow old here helping people out and seeing them through their ups and downs. But like I said no one cares about that anymore. “

“It’s still hard for me to believe. When I was a little kid I thought Doctors had it all.”

“So did I my friend. So did I.”

Mark took one long last swig of his water then stood up. “Well young man, let’s load up the rest of this stuff. Whatever you don’t use feel free pawn on EBAY for some beer money. I’ve got to get back to my paperwork so I can hopefully see my wife before she falls asleep.

“Thanks, I appreciate it.”

“No problem. I don’t envy you young guys. I don’t know what to make of the future for you. It’s a different world...”

Wednesday, April 7, 2010

Patients Or Paper?

We’ve all seen the headlines – “Primary Care Physicians Becoming a Scarce Breed”, “Wait Times for Appointments Increasing”, “Primary Care in Crisis” – and have heard the pundits pontificating on the deteriorating state of primary care, but rarely do we hear what’s happening from physicians on the front lines, those actually seeing patients. Consequently, with direct access to the primary care trenches, replete with an overworked physician and staff members, I decided to investigate the life of a primary care physician a little further.

Although my research involves an unenviable sample size of one physician (me), I think it sheds light on some of the critical issues facing the majority of PCP’s. The simple question I set out to explore was: Do I spend more of my time working with paper than with patients?

The methodology was also straight forward – I documented my daily tasks during an average day in the office, including time spent caring for patients and administrative work.

Data collection kicked off at 10:00 am when I arrived at my office after early morning rounds with my patients in the hospital. (Interestingly, I am one of only four physicians in our community, population ~45,000, that still chooses to admit and care for my own patients rather than transfer their care to a hospitalist; a topic for another day.) Data collection ended at 6:00 pm when the final paper of the day was pushed.

The raw data are somewhat interesting but tell a typical tale … patients outnumber hours in the office by roughly 4 to 1; if signatures equated to money I would be rich; and sometimes doctors fill out forms and call people on their own! Here are the numbers for your consideration:

Total hrs in office (10-6):                                                8
Total patients seen:                                                         18
Number of times I signed my name:                                77
Number of prescriptions (new and refills):                       36
Forms completed:                                                          7
Required telephone calls:                                                3
Minutes doing paper work during patient hours:              75
Minutes doing paper work during non-patient hours:      170
Total minutes seeing patients during patient hrs:               225

Although interesting in their untransformed state, when you begin parsing the numbers, they begin to tell a much more interesting story. Using advanced statistical techniques that I learned in 4th grade – addition, subtraction, and division – it appears that I spent more time with my pen and computer then with patients.

I spent eight hours at the office, which I can confirm is typical, and 47%of that time was devoted to patient care (225 min/480 min). Averaged across the 18 patients, that works out to ~12.5 minutes with each patient (range 7 to 45 min). This is right in line with the national estimates that range from 10 to 18 minutes for patient visits and 55% of total office time devoted to patient care.1-2 Yeah, I’m average! … or as scholarly-types like to say, I am consistent with my peer group.

Despite uniformity with my cohort in these categories, I wonder whether I’m on the right track if I am devoting only half of my time to patient care? In other words, if 100% efficiency is spending every minute with patients, is 50% efficiency good enough? Although it seems unreasonable to expect 100% efficiency since few systems, biological or mechanical, come close to 100% efficiency. For example, the diesel engine, which is famous for its efficiency, only approaches 50%1, so should we expect healthcare to do any better? Am I better than a diesel?

Intuitively we all know reaching 100% efficiency is beyond utopian and probably defies some law of thermodynamics. However, important questions remain: Where does rest of the time go? How productive is that time spent? How does it impact patients?

In my little study the answer to the first question is fairly simple: 35% of my time was spent doing paperwork during non-patient hours (4-6 PM), and another 15% was devoted to paperwork during patient hours. So 50% of my day – actually 51% when decimals are accounted for – went to filling out paperwork and administrative tasks, which answers the primary study question: Indeed, I spend more time pushing papers than seeing patients.

Obviously, if none of these administrative tasks were completed, I could not bring in the revenue required to pay myself, the staff, malpractice insurance or the overhead, so some of this effort is necessary. But it seems counter-intuitive that after jamming so much potentially useful information into my brain for so many years that half of my working hours should be used signing my name and ordering batteries for a scooter!

This split – 50% patients: 50% paperwork – is what frustrates so many of us. Like my colleagues, I became a doctor to care for patients and understand that documentation and paperwork are necessary but wonder if a more productive split such as 80:20 in favor of patient care (of course) couldn’t be achieved?

I hope you can understand the frustrations PCP’s are feeling now. We’re not a group prone to complaining; we are trained to endure and we do it gladly for patients, but for the sake of paper and the insurers lurking behind them, never. I have not even begun to enumerate the endless piles of paper my two staff members must read, label, fax, shred, trash, shovel, and curse on a daily basis – a moment of silence for all the trees that have sacrificed for this country, oh, I mean insurer paperwork!

The conclusions of my study are quite clear and simple, time allocation in primary care is loathsome, and those that suffer the most from the system are patients. Every 12 minutes spent with paperwork is another patient not seen or an important health question not answered.

The question is what is the solution? One place we-the-PCP’s of the country would start is lowering the administrative hurdles and barriers to getting the care our patients need. Never again should there be days that include spending 30 minutes on hold to simply speak to a human regarding a prior authorization for one patient. Never again should the fax machine that fields requests to change patients’ medicines require more reams of paper than the copy machine used for patient charts. Never again shall someone without a medical degree put up their proverbial hand through the phone or on paper and deny a patient the care they need because their manual told them so. And for the record I do not believe a single payer system or capitation would change the 50:50 split one iota. In fact, the forms Medicare requires are some of the most cumbersome.

Building checks on the paperwork required by insurers would dramatically improve the efficiency of my care and, most likely, primary care physicians across the country (since I’m such a good representation of my cohort). It’s time to re-focus our attention on taking the ‘honorary’ medical degree off insurance company walls.

Sunday, March 21, 2010

Will PCP's Quit?

A survey going around this week projected that if President Obama’s Health Care Reform passed 46% of primary care physicians would quit. Several sites stated that the survey was reprinted in the New England Journal of Medicine though when I searched their site I’m unable to find it. I did find a survery that quotes a figure closer to 33%.

Regardless of the exact number I personally believe a large block of PCPs really would quit.

No, it’s not likely going to happen in the short run. Obviously a lot of hard work and training goes into becoming a doctor and finding a career with similar income levels is going to take some doing. So, again, in the short run most won’t quit. But what about 2, 3 or even 5 years out? Then I would say yes.

First off you have those that could retire. The 50-55+ group. Many of them could simply retire or branch off into another field. Many physicians in this group have older children that are done with college and have left home. Many have made wise investments. Therefore, I’d venture to guess many of them might simply decide it’s not worth it to practice anymore and up and quit.

Secondly, many will probably quickly look for a change such as an administrative position, an academic position or becoming a hospitalist. I’ve personally witnessed this already. There were four of us that were friends in medical school that went into primary care. Of those four I’m the only one left; albeit hanging by a thread. One went into ER and the other two are hospitalists.

Finally, many can and will find new career paths. I’ll never forget the first talent show I went to at my medical school in Cincinnati Ohio. Anyway, every year we had a talent show put on by the students. I staggered out of the auditorium. The amount of talent many of my classmates exhibited just blew me away. I remember thinking had they not wanted to be doctors they surely would have been successful in other areas. Just to name a few, there was the award winning violinist that graduated from West Point, an opera singer and a professional illusionist. This last guy had paid his way by working gigs now and then. Outside of this we had a guy in our class that quit pro-football, a pharmacist and another classmate that was a model. We had numerous engineers. These are intelligent, motivated people with means. If the rules change to the point it no longer makes sense to practice medicine, they can and will change.

This is not new or unique to primary care. I remember commenting to my wife about this very topic, way back 11 years ago in my first year of practice. I had been sitting in the doctor’s lounge at the hospital doing paperwork and was just sort of randomly listening to conversations. I remember going home and telling her that I’d never seen a profession that took so long to achieve your position yet so many were trying to get out.

Don't think it’s just about money. Quality of life has tanked also. Doctors have seen their autonomy and prestige systematically stripped away. Endless forms now need to be filled out for everything from a prior authorization for a medicine to a new set of batteries for a scooter. Rules regarding documentation keep getting ratcheted up and enforced. Medicare uses ex-IRS auditors to look over physician charts. Some insurance companies, under the rouge of increasing quality, rank physicians using dubious means. Most physicians will tell you they are spending more and more time doing paperwork and less seeing patients. EMR’s and e-prescribing are great for tracking diseases and reducing errors but they are expensive and time consuming.

And what about the money? Incomes keep going down. Medicare again has frozen reimbursement, which is in all actuality a pay cut when you factor in inflation and the rising costs to do business. And don’t forget the staggering debt loads. I’ve seen statistics that greater than ten percent of the medical students graduating from a state school today are over two hundred thousand dollars in debt. If this is paid back over 10-15 years it will typically balloon to 1.5 times the principal or three hundred thousand dollars. Do the math, that’s $1667 a month for fifteen years or $2500 a month for ten. This doesn’t include private schools or undergraduate debt.

The final straw will be on the supply side. The percentage of medical students going into primary care has already plummeted. This will only get worse and I suspect will spill over into the specialties.

Medicine will cease to attract the best and brightest students. You figure out the rest