DPC, PHR, EMR, SoME and a couple other abbreviations

Watching the beginning of a training video for hospital administrators a couple of days ago made my head swim (and I can't find the link on-line). It began with a gentleman walking his dog. Both he and his pet sustain minor injuries. They are sitting in the living room and his wife counsels her husband to see his doctor for an evaluation while she takes the dog to the vet. She calls the veterinarian office and is greeted with a real person who tells her to bring the dog right in. As she leaves her husband calls his doctors office and I'm already cringing at what I know will follow. Three minutes into the film (where it stops unless you want to buy), the gentleman is still on hold and has repeated his story to two different people. Meanwhile, the dog has already been seen by the veterinarian. This is getting better but it has been my personal experience and I hear frequent complaints from my patients. Fortunately they are less about my office than they used to be, so I think we are making progress. Rare the doctor's office that has a real person answer the phone. It is discouraging to think that our pets get quicker, more empathetic care than we do.

Most of my Saturday was spent in the VA ER with a friend. It's always interesting to be on the other side of the examining table. What I observed was the usual mix of caring and apparent disinterested staff. The individual I was with was in such pain he could not sit down. So for thirty minutes he stood, in obvious sight-line of three staff members. There was only one other patient in the waiting room at the time but it still took thirty minutes to get him processed and into the back. Once in the back, same scenario. No physician walked into the room for thirty minutes, it took another thirty to get him any relief. As I sat there being witness to this care, he said to me "Is this what a US single payer system would look like?" My thought was, "Gee, other countries do single payers well but can the US?" My French friends rave about their healthcare. My patients from Canada talk about how easy it is to get in to see their family doctor.

Lately I'm leaning more to changing how we reimburse primary care, rather than a radical change to a government-run payer system. The DPC system that David Chase discusses in Forbes makes sense to me.  As mentioned in previous posts, this is concierge medicine without the concierge price. For me it would be a win-win. I could see my patients for a reasonable monthly fee (which could be paid for by employers or patients) and in return they get more time with me and better preventive care. Add PHR (Personal Health Records), EMR (Electronic Medical Records) and social media to the equation and you have an opportunity for patients to become true partners in their care ( see the link to 6 things patients want from social media here).

Now if I can just convince my employer! 

KY Pill Bill

Today the doctors in the office had our yearly meeting with the regional medical director of my group. He explained what he understood about the newly passed KY law for prescribing controlled substances. Here are some details on the law:

Every patient prescribed controlled substances such as hydrocodone (a common synthetic codeine that is given for moderate pain and an ingredient in many cough medications) must have something called a KASPER query done on them. This involves obtaining information on the patient regarding prescribing of narcotics by other physicians from a website. This typically takes ten to fifteen minutes to do. We must discuss the risks and benefits of using a controlled substance including tolerance and drug dependence and get written consent for giving the patient that drug. 

I can only imagine what that written consent is going to look like. Some estimates suggest that it will be a seven page document. The timeline for implementation of these new rules is July 12. This may not sound like that big a deal, so let me give a couple of circumstances that are not uncommon to me. A patient presents to my office with a persistent moderate viral respiratory infection who I have known for fifteen years. She doesn't like to take any type of narcotic or other addictive substance but hasn't slept for three nights due to the coughing. It's late afternoon and she is my last patient of the day, I'm already behind and need to be at a meeting on the other side of town in fifteen minutes. She's allergic to codeine. Guess who's probably not going to get her cough medication? Or my neighbor who is also my patient, sprains her ankle on the weekend. She doesn't need to be seen immediately but she would like some pain medication in order to sleep tonight and I'll see her in the morning. With this bill in place, I cannot relieve her pain. I've been in practice for more than 25 years. It is my job to know my patients. I know who has a tendency to overuse their pain meds. I wasn't born yesterday and can spot a drug-seeker at ten feet. However, because Kentucky allowed "Pill Mills" to run rampant in our fair state, my patients and thousands of other Kentucky citizens will be held hostage to this new state law HB1. Here's a link to one legal firm's interpretation of the bill. I suppose the good news is that I can always prescribe oxycodone, since it is hydrocodone that is targeted in the bill. (What?!?!!?)

So now in addition to the insurance company, the lawyer, the employer, and the federal government in my examining room, please welcome the state of KY. It's getting mighty crowded in there, so much so that many days it's really hard to hear the patient. And that's unfortunate since that's the only way I can treat her.

Reducing Fragmentation and Patient Care NOW not Next Year

I do not recommend doing this, but today I attempted to listen to two Webinars at the same time. One was also tweeting the discussion and the other had very detailed slides which made it easier to follow but as studies show, we are not really capable of that kind of multi-tasking. The topic of the first suggested it would discuss Primary Care and its future. However, what the expert proposed was a "How to" plan for bringing more customers into a healthcare system. This was boiled down to a recommendation that these system open small clinics, run by NPs, in competition with drug store and grocery store clinics of similar ilk in order to funnel patients into the listeners' systems. The other Webinar was a discussion by three mobile health leaders (mHealth) on the future use of their products in the global mobile health arena (wow, that rhymed).

It's is a good idea to know what is going on in the minds of healthcare system development teams and as I listened to the expert's remarks I could not help but ponder on what, in my humble opinion, would build the kind of "team loyalty" that hospitals and other healthcare systems are dreaming of. What is it that patients want? I agree that they need healthcare access in their busy lives at more convenient times of the day than traditional physician offices offer. What my patients tell me (and what people tell me at cocktail parties) is that they would prefer access to their very own providers, those individuals who know them best. No insult intended to NPs because they are essential to the healthcare team, but they are physician extenders, not physician substitutes. What about developing systems that give patients greater access to their own providers? This would really engender loyalty to a healthcare system, especially one in which physicians are employees, more and more the norm these days. I believe mHealth can do that. What if you could access your physician after hours via Skype? Or text your doctor just for a quick conversation about whether you should seek immediate care or be seen the next day? Gee, what if the physician had access to their schedule and could book them on the spot?!? What I'm advocating here is a "concierge" type practice without the concierge price. Of course there would have to be some sort of reimbursement procedure to give already overworked primary care doctors the incentive to take care of patients in this way but wouldn't that be a cheaper investment than opening the equivalent of "Little Clinics" everywhere?

Along with the cost, the second complaint I routinely hear from patients about their medical care is its fragmentation. From a patient and a primary care perspective, no one on the health care team is talking to each other. In fact, frequently the word "team" is a misnomer. Using tools like Doximity physicians can employ a HIPPA compliant platform to discuss cases and improve care. Of course the phone always works, but with the ability to ask questions and respond in a timely but convenient fashion, doctors and other providers like NPs, PTs, etc. can reduce the fragmentation patients feel from their healthcare team.

Of course I realize that ACOs (Accountable Care Organizations) are supposed to be developing this kind of care. But does the bureaucracy that surrounds these systems bother anyone else but me? Do we really have to wait for the lumbering movement of government sponsored programs in order to improve communication, fragmentation and access to care when the technology is already here today? 

Menofuzzies in Perimenopause

Occasionally, the attempt to empathize with someone during a visit falls flat. She knows it, I know it, and the therapeutic encounter is anything but. Since I am around the same age as many of my female patients, when a woman comes in with perimenopausal symptoms I am quick to understand. It's common for women to complain of sleep disorder, mood swings, weight gain, fatigue, irritability, muscle aches and memory issues on top of the daytime hot flashes and night sweats. A couple of years ago, at my husband's 35th high school reunion, one of his former classmates was almost frantic because she thought she had early onset Alzheimer's disease. As she spoke of her word-finding difficulty, walking into rooms and forgetting what she went there for and awakening every 45 minutes, all the women surrounding her were sagely nodding their heads. Nope, we told her, you aren't crazy or paranoid, you are experiencing the "Menofuzzies".

In order of magnitude what women most hate is:

1. Weight gain.
2. Mood swings.
3. Weight gain.
4. Insomnia
5. Weight gain.
6. Memory issues.
7. Yep--Weight gain. It's a big issue.
8. Hot flashes and night sweats.

Even though I struggle with the fifteen pounds I have gained over the last 17 years, I am 5'10' so the weight distributes well and I don't look like I'm at the top of the acceptable BMI (Body Mass Index). Having never had any issues at all losing weight until I hit 40, I understand how frustrating it is to walk over fifteen miles a week (often more than that), eat far less than at any other period of my life and still have difficulty with the zipper. The mood swings I can deal with, the insomnia gets better with the exercise, the memory issues fluctuate but my older colleagues and friends (female) tell me that it will improve and the light at the end of the tunnel no longer appears to be a train. Except for the weight. Some of my patients have gained 20 to 50 pounds or more during this time of life and they are frustrated and angry. And they do not need me to empathize with them. Or tell them that other women are having the same problem. What they care about is THEIR weight gain and how to deal with it.

Unfortunately there are no easy answers to mid-life weight gain. It's still a calories in/calories used kind of equation. I recommend Weight Watchers and these already time-stressed patients are frequently not interested in finding yet another meeting to attend. I suggest using the on-line and app versions of Weight Watchers and they promise to look into it. I encourage exercise and talk about the fact that it is the closest thing yet to a Magic Pill but they are already exhausted and look at me in disbelief when I tell them that one has to invest energy to make energy. I recommend apps like LoseIt to use self monitoring as a technique for weight loss. I advise them that there are no good pharmacologic solutions and rarely recommend lap-band surgeries or other similar procedures except in extreme cases.

I try to steer them away from hormones except when their insomnia from night sweats and persistent awakenings is intolerable. Generally patients don't find much relief with over-the-counter preparations (OTC) but they seem generally safe to try. Many patients come in requesting anti-depressants but these often worsen their weight issues. Again, that Magic Pill of exercise can make a difference if an individual will stick with it. There's no down side to exercise (unless you run in front of a truck) and a safe thing to try for many of the issues arriving in peri-menopause and beyond.

The bottom line is, like many health issues, there are no easy answers and certainly no ONE pill is going to make this transition and its difficult aspects all go away. Staying physically fit, maintaining or developing good dietary habits, having a fulfilling home life and a satisfying life outside of one's home seems to be the best medicine for navigating this time of life. But not everyone has the supports in place to make the kind of lifestyle changes necessary to achieve these goals--their jobs exhaust them, their kids are in trouble, their husbands are unsupportive or absent, there is no flexibility in their schedules, their is no flexibility in their thinking and any number of other difficult circumstances. And when they are frustrated with little or no time to develop these kinds of lifestyle changes, they may find my advice lacking.

The Lurking Physician

In addition to reading a number of medical bloggers, I "lurk" on twitter chats and try to watch twitter updates from the 88 people I am currently following. The majority of the people I follow are doctors who are interested in how social media can help patients, plus a few "learning" entities like Brainscape just to improve my language studying skills (which I highly recommend). I am just a neophyte to Social Media but am excited by its potential for my patients.

Brainscape

Suddenly the ability to followup with patients directly without a medical assistant playing messenger in between seems more attainable. Communications would be cleaner and both physicians and patients would be better served. Right now I do this on a small scale by using email but this is fraught with difficulty. Patients send me their information and sometimes they cannot open my email response because it is encrypted (per HIPPA requirements). Other times their emails are caught by my spam filter and I never see them! As I've written about in previous posts, there are recommendations by august bodies like the AMA on how to use email professionally but frankly, they are both out-of-date and a little out-of-touch with their recommendations. However, having said that, HIPPA fines are substantive so no one wants to be caught in the wrong while communicating with patients.

In the meantime, patients are becoming more web and social media savvy. It is exciting to have a patient come in who has been on the Mayo clinic website and is asking about what preventive steps they should be taking instead of me initiating the discussion. It makes me feel like a partner in their care instead of a mother giving advice. I am a mother and I enjoy that role. Nurturing is part of healthcare but when I feel more like the disciplinarian then an advisor, neither I nor the patient are likely to benefit.

The "early adopter" physicians and e-patients on Twitter, Facebook, Google+ and LinkedIn, among others, are working hard to improve the lines of communication so that patient care is better. It's an exciting time to be involved and I am looking forward to learning more and sharing a lot.

What's my Worry Today in Primary Care?

Worrying about patients is part of my job. In these last couple of weeks it's been a long-time patient with a life-threatening illness, a pregnant woman who didn't want to be pregnant, and a young person who thinks that a pill will fix her out-of-control life. (I get a lot of older folks who are looking for that magic pill as well but they don't worry me as much). Mostly I leave those thoughts at the office but sometimes they come  home with me. Lately what's followed me home are patients who are avoiding treatment or visits because they have a high deductible or no insurance at all. Last week was a middle-aged woman who just got insurance after being without for several years. She had several concerning issues but the most worrisome to me was the thickened area in her breast. She didn't tell me about it but on physical exam there it was--it felt wrong. It didn't belong there. It was a little hard, a little irregular. Classic sensation for a cancer.. She hadn't had a mammogram or a physical in years because of the cost. Would it have made a difference if she'd had one last year? I don't know. Maybe. And maybe this "area" will prove to be nothing, though I doubt it. 

The number of uninsured Americans has gone up a few percentage points in the last ten years. What I am seeing more of are underinsured individuals--people with high deductibles and high premiums. These are the people who skip needed care because they can't afford it OR they have the perception that they cannot afford it. They are "non-adherent" with medications because they fear the cost of followup lab tests even when their medicines are on the $4 Kroger list. They don't come see me because they don't know we offer a 35% price cut for cash paying patients. They equate health care with health insurance. They are aware of the skyrocketing costs of hospitals, medicines and doctors and fear that if anything is found on exam that they'll never get insurance (a reasonable fear to have these days since many people are outright rejected and others are quoted outrageous premiums based on what are often minor problems). Or the patient may obtain insurance without coverage for a pre-existing condition.

I await the mammogram report with trepidation and hope she doesn't skip it. She was concerned about missing a couple of hours at her new job. God forbid she lose the job that is supplying her with health insurance. I am sure she can't afford COBRA. And if the worst occurs will she lose her job anyway because she can no longer work while going through surgery, chemotherapy and radiation? And then what?

Medical Testing in the Era of Insurance Certification

This morning I started out writing an entirely different blog post but decided to go another route after a painful episode with an insurance company, namely United Healthcare. Why yes, if you read my blogs, this is the same insurance company that denied my patient an antidepressant medication that is the only one in its class. This is the company I tried without success to discuss their rationale with a medical director. However, today was a radiologic procedure I wanted on a patient and was subsequently "invited" to talk to one of their physicians to get approval for it. Does this strike anyone else as odd that I can be essentially "ordered" to talk to one of their doctors but none of them will return the courtesy of my phone calls?

In the last six months medical insurance companies have become increasingly resistant to allowing physicians to order certain studies without certification by them. If you insist that the patient needs the test, then you must have a "peer-to-peer" review in which justification of your need for the test must be made to one of the company's physicians.

As documented in many studies, there are a lot of unnecessary tests that we physicians order for a variety of reasons. Those include liability concerns, patient requests, and concern that you might be missing a rare disease process. Recently the Foundation of the American Board of Internal Medicine developed recommendations from several medical specialty groups regarding tests or treatments which doctors should question the necessity of before ordering, in a document called Choosing Wisely.

I absolutely agree that we, as a healthcare system, are ordering too many tests. The insurance companies way of dealing with the problem is to have a majority of tests, particularly expensive ones, "certified" before they will agree to pay for them. Today I had two of them that apparently did not fit someone's algorithm and needed a "peer-to-peer" discussion. Sighing, I called the number listed on the fax paper request from United Healthcare. Dutifully I hit #4 as instructed. This didn't work immediately because a 30 second introduction had to be finished before option "4" could be chosen. Finally I got through and was instructed to key in the case number. Twelve numbers later, it repeated the number back to me and told me to press "1" if that was correct. Then I got a real person. Up to this point I was OK with how much time I had wasted but the real person on the line was not a doctor. It was someone who wanted to know if I was a doctor and if the patient's name was so-in-so and if the procedure ordered was a such-in-such. Affirming that was the case I was put on hold. About five minutes later I began to seethe.

Have you heard how primary care physicians are inundated with patients, how we don't have time see the patients that we have much less makes sure all our refills are done, referrals letters read, referral letters sent, prescription prior authorizations done, patient lab work reviewed as well as keep up with CME (continuing medical education--you want me up-to-date, right?), patient emails, and any other business of healthcare? Every afternoon there are a minimum of 75 charts to be gone through, lots more on Thursdays (because I take off on Wednesday) and Mondays look like a truck backed into my office and dumped the charts onto the desk, chairs and credenza. Don't even make me think about when I come back after vacation. Well, apparently United Healthcare thinks responsible patient care involves me sitting and waiting on a phone for one of the "peers" to pick it up and determine if my ordering is within their guidelines. This is not something I'm willing to do--so my question to my audience is--should I be willing to? Is this now another part of my job and is it a reasonable thing? Please input, I'd love to hear. 

Please remember that the opinions written in this blog are entirely my own.

Twitterchatting

Last night I participated in my second "Twitterchat". With my first one I was simply a "lurker", sitting in the background, watching the logistics and remarks. The topic of this one was mobile health, better know on-line as mHealth, and was sponsored by a group I follow on Twitter, iMedicalapps. This time I was an active participant as the group discussed several topics--how knowledgeable physicians are about mHealth, how it can help our patients and how to get more physicians to understand and use it.

While physicians have adopted personal use of Facebook and iPads in droves they are much more hesitant to use these tools on a professional basis for many reasons--time constraints, HIPAA concerns, no familiarity with the technology, etc. This Twitterchat's purpose was to address those issues and see if individuals had ideas on how to make changes in physician habits.

After the chat was finished my reflections went somewhere along the lines of "Well that didn't seem to be very helpful." And then it hit me, the actual chat may not have been all that substantive, especially when everyone is talking at once and it is impossible to read all of the comments as they go whizzing by on the Tweetchat screen. What was of significance was meeting these individuals, seeing how they are approaching similar issues to your own and making contacts that could grow into collaborative efforts in the future. To quote Homer Simpson "DOH!"

Somewhere "out there" on the net, I read that Twitter is most akin to a giant cocktail party. It's great metaphor but someday soon I hope to meet many of these fascinating people face-to-face. In the meantime I will lift a glass of wine as I tap my laptop keys and toast to this fascinating new technology.

A Payment Quandary for Medicine and Social Media

These days I spend a lot of time reading other doctors' and patients' blogs and Twitter posts. One recurring theme is the use of Social Media to improve wellness in our patients. This is a great idea and I'm excited to participate especially when the data shows that patients who are on social media are already getting heath advice: PricewaterhouseCooper:

Consumer Activity on Social Media Sites Dwarfs that of Healthcare Companies, Finds New PwC Study on Social Media in Healthcare

But who will pay for this? More specifically, who will pay ME for this? Much as I enjoy answering patient emails, would love to have a professional Facebook presence and am happy to Twitter; all these things take time. And time is not something any primary care doc has much of. Since I do enjoy a life outside of the office, including learning a new language, spending time with my family, trying to exercise a MINIMUM of five days of the week, plus bear primary responsibility for feeding my husband and daughter, and would dearly love to read a book on occasion; in the absence of an obvious ROI (return on investment) to present to the healthcare system that employs me, how do I find the time during working hours to do these things and not get paid? My contract specifically defines how much "face-to-face patient contact" I must have. As long as the present reimbursement system persists when I'm not in physical contact with a patient I am not generating income.

As with any service industry it is difficult for our "clients" (I HATE that word, I have patients not clients), to understand that my pay is directly affected by how many people I see every day, or more specifically, how many RVU's that I generate on a daily basis. This is directly tied to how "sick" a patient is. So the sicker the patient, the more I can charge. Wellness? With the exception of ONE "well" visit per year for the commercial insurance patient, I am not paid to promote wellness or good health at all. Of course I try to throw that in with every patient visit but until primary care undergoes the revolution that it needs and deserves, prevention is not something I can afford to spend a lot of time on with patients.

And that truly, to use the vernacular, sucks. There are doctors out there doing it "right", who have left the traditional practice model to become concierge doctors and by all reports these professionals are happier and more fulfilled in their jobs. My expectation is that this is the reimbursement model we will see in the future but in the meantime, how do I find the time to give patients what they want before they or the insurance companies and/or employers and/or government is willing to pay for that time?

modified 5-31-2012 (misspelled quandary--oops!)