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Archive for July, 2009

Short term measures to increase Primary Care Medicine and lower medical costs

Primary Care Physician

The health care debate has demonstrated several cogent facts principal among them is that there is a shortage of primary care physicians. Some estimates put this as high as 40,000 fewer primary care physicians than are needed.  The experience in Massachusetts has shown that as more people are covered more primary care physicians are needed. As uninsured in Massachusetss fell from 13 to 7% wait times for primary care visits have jumped from a few days to weeks if not months according to a recent New York Times article.

In my opinion politics will prevent any major health care reform that will significantly impact this problem over the next 18-24 months, if ever. There simply are too many special interests and other orgnizations that benefit too much from the current model of care.

So what short term measures can be taken that don’t require special legislation but could improve the availability of Primary Care services in this country?

Primary Care and all phyhsicians be salaried

Most physicians are current compensated based on some form of volume sensitive measures.  These include fee-for-services rendered in which case physicians will increase their reimbursements by doing more for a patient whether or not it is medically warrented. Even in large groups the physician’s reimbursement is based on productivity that is measured by either Work Relative Value Units (WRVUs) which are directly tied to the volume of services they order whether or not their annual day-to-day pay is directly affected by the patient loads and services rendered.  
Keeping track and monitoring these services involves particularly elaborate relationships between what a physician documents, codes for Evaluation and Management (E&M) services, orders tests and services, documents CPT (Current Procedural Terminology) codes or other sources of volume-based measurements.  This leads to large overhead costs for physicians and 3rd Party Payers that doesn’t contribute at all to patient care.  An average Primary Care Physician must bill out over $400,000 a year in order to break even in most organizations.
Eliminating or reducing this practice has the potential to free up countless minutes, if not hours a day that could be devoted to seeing new patients.  Organizations like Cleveland Clinic and Mayo Clinic have experimented with salarying physicians and have documented reduced the total cost of medicine significantly compared to other institutions that continue the current paradigm.

PCP physicians need to give up inpatient services

Primary Care Physicians need to give up their hospital priviledges. All too often clinic care is delayed because the physician is caught up rounding in the hospital and encounters delays.  Every minute they spend in the hospital is a minute they cannot provide Primary Care services in their clinics.  Hospital care is not primary care by definition and current pressures on hospitals to process patients and discharge them as rapidly as possible require hourly interventions which a physician in the clinic cannot provide without detracting from their clinic services.  Simply eliminating their hospital care would add perhaps as much as a day a week for new or other types of clinic visits per primary care physician and cut into the shortage of clinic spots available.

PCP physicians should treat their entire practice instead of individual patients

Focusing their attention on their entire pool of patients to increase the percentage that are immunized, adhering to medications, and assuring all are getting preventive care has the potential to reduce the number of unnecessary clinic visits and may even improve the health of the community whereas continuing to serve only those that come to the clinic for acute care needs has little or no impact on the health of the community.

Routine follow-up and low level care should b provided by physician extenders

Once a patient is seen by a primary care physician and a plan of care is created, routine follow up care should be provided by physician extenders. Yes, the physician should touch the patient on these visits and assure that they are adhering to the plan but not be dragged into extended documentation or billing procedures for that visit. They should concentrate their attention on complicated patients, new patients and those requiring special services.

Too often we see physicians in large groups that are reimbursed by WRVU criterial "packing" their schedules with easy-to-see follow up patients for 1, 2 and 3 month follow ups in which no major medical decisions are made. Yet, these patients can be billed out as mid to complicated care for reimbursement reasons and could be seen by lower level providers.

Doint so would open up significant blocks of time for the Primary Care physicians to see new and complicated patients thereby reducing some of the shortage of primary care physician visit times.

Not doing so will continue to allow retail clinics who are staffed by nurse practitioners to provide this care which is not integrated into the primary care physician’s patient pool.

Immediately forgive medical school debt for those entering and practicing primary care

While this option may not be availabel for many solo or small group practitioners, larger entities ought to immediately pay off the medical school debt of those who have chosen primary care.  Servicing the large (average $140,000) school debt is given as one of the primary reasons medical students and residents avoid primary care.  Eliminating this would immediately benefit those that are currently in the field as well as dramatically increase the number of students choosing primary care in the next 18-24 months.  There are many mechanisms for doing this and it is true that many rural areas are already providing this as an enticement for primary care physicians to choose to locate in rural areas.  However, this should be a standard national policy.

These are just a few of the things that can be done relatively quickly that would increase the effective availability of primary care physician services in this country.  There are others but it all boils down to the money so the attention should be focused on reducing the negative impact to individuals who choose this if it is a national prioriy to increase the volume of primary care services in this country.


Of Linking and Sharing

Microsoft’s HealthVault has released their HealthVault Connection Center that begins to make Personal Health Records functional.  I’ve been experimenting with various Personal Health Records and have installed one, Healthe Connections (formerly IQHealth) as part of a patient portal.  One of the problems that we’ve uncovered is while these portals are great for looking at the Electronic Medical Record as a portal, they are really poor at enabling us to manage our own health information.
The primary difficulty with most PHRs is they are so labor intensive in that each of us as a patient must manually enter data into the record in order to maintain an accurate and up-to-date record.  Very few of us are willing to do so nor do we have the time and the expertise to do this.  Both Google Health and Microsoft’s HealthVault are working hard to make it easy for information to be automatically uploaded into the Personal Health Records and are creating database links to an ever increasing number of healthcare entities.  Microsoft has gone one step farther and also created a Windows Sidebar gadget that quickly enables a user to upload measurements into HealthVault effectively lowering the barrier to information maintenance.
The HealthVault connection center also contains an ever expanding set of links to electronic devices (glucometers, scales, blood pressure cuffs, etc.) that can be configured to upload their data directly into HealthVault via USB connections.  These are easily installed as using the Setup device.
Hopefully in the near future all EMRs will automatically be configured to link into one or all of these Personal Health Records which will eventually enable bidirectional data flow so that physicians using their own EMRs will automatically receive and update patient medical histories when patients register or schedule a visit.

A Social Media Model for Electronic Records

I’ve been thinking lately that the model towards where we’re heading is a combination of real-time social media linked to one or more EHRs and PHRs. For example, one of the problems we’re seeing in medicine is the cost (both in time and money) of real-time or near real-time contact with patients. Lack of this real-time contact usually means interventions occur too late, are too costly and sometimes ineffective. I’ve been really impressed with the ability of a group of people to address situations using a tool like Twitter with the primary access device being the smartphone (with 3.3 billion cell phones in the world and 90% of the world population living within reach of a cell phone signal, the smartphone is the natural platform for e-health services).

 In this model the physicians and their teams would follow patients in much the same way that we follow others using our Twitter accounts.  Patients, with access to their medical records would submit periodic short “tweets” with the tiny URLs pointing to specific parts of their charts. In this example a patient might walk into a drug store, take a blood pressure at one of those free electronic monitors and then tweet the results with a link to their vitals section in their charts. This tweet would be immediately seen by the provider team following this patient. If normal no intervention needed. On the other hand if the blood pressure was abnormal or trending one or more of the health team members would tweet the patient with instructions to increase or decrease their medications or take some intervention.  Takes very little time.

 So the two-way street would have a Twitter account  (as the Patient Centered Medical Home) with all of the patients who have identified that provider as their medical home following the health care team while the team follows all of the individual patients. This would allow a single team member to broadcast important information to all of their patients and patients to be assured they have instant access to all members of the team.  Both entities would share the access to the EMR, be able to contribute and link their conversations with the record.

 Of course we’d have to come up with technology so that all the followers don’t see all of the person-level tweets (but hey, that should be an easy technological problem to solve) and individual portions of the EMR should be able to be referenced in tweets (like tiny urls).  Again, that’s relatively easy solution. I would think we could do something where patients’ tweets would be treated like direct tweets but they could determine whether tweets in any directly are retweeted to the entire group of patients following their medical home or restricted.

We would want to make the record searchable by patients so they could link to other patients with similar problems and collectively manage their diseases in the way that www.dreveryone.com is trying to do.  This would allow providers and patients to gain from their collective wisdom.

I think we’re seeing the model for collaborative, cloud computing platforms being developed and will be able to use them daily with Office 10 later on this year. This application links a traditionally personal application to the web so that users can edit documents simultaneously, share portions via links.  In short, like Office 10, the EMR needs to move outside an individual physician’s office or hospital to the internet cloud, with each view or portion being directly linkable (with its own URL).  That would free up huge resources that are now spent on maintaining individual unique EMRs that only a few people can access.

There are some indications this is happening. Microsoft’s Healthvault and Google Health are finally making PHRs functional by focusing on the automated updates and linkages with providers’ EMRs, laboratories and 3rd party payers’ systems. Interestingly Google Health has been likened to Twitter while Microsoft’s Healthvault’s been likened to Facebook. I’ll be very interested in following www.dreveryone.com to see if researchers, clinicians and patients take the time to answer the surveys on each of their diseases and treatments.  Might radically change how we do outcomes studies and manage our patients based on global real-time survey responses.  Looks like I, and the patients, might be able to ask whether a specific medication really worked in the real world in real-time before prescribing it.

Hey, medicine is really getting exciting and the key is transparency and sharing of the medical record.  


The Power of Patients

This week a patient of mine came in armed with research she had done about a perplexing set of symptoms she’d been having.  We’d discussed this virtually and tried several approaches to no avail.  We pulled open the Mayo Clinic and NIH web pages that she’d discovered through a variety of search engines and come up with a syndrome (http://www.nidcr.nih.gov/OralHealth/Topics/Burning/BurningMouthSyndrome.htm) that I’d never been exposed to that fit almost all of her symptoms.
As we read through the syndrome and also the recommended workup to rule out the other treatable causes that might be producing her symptoms it dawned on me that medicine would be a lot easier if we physicians would encourage our patients to help us with their diagnoses.
A little over 70% of my patients have electronic access to significant portions of their records. This access has enabled others, like this patient, to take second and third looks at their labs, medications and pathology results. I’ve tried to encourage them to ask the question I didn’t ask during the visit. Some are doing this and are taking charge of their own health in ways they didn’t think possible.
Another of my patients was astonished at all of the medications she’d been prescribed over the years by many physicians including me. When doing the research she discovered that the majority of her symptoms were side effects of one or more of the medications. She asked for my help in weaning her from those medications (if possible).  Over the last two months we’ve been able to eliminate all but two medications and she’s feeling better than she has in years.  She herself said that she always felt disappointed if she didn’t come away from the doctor’s office without a new prescription but now has a totally different approach?  When asked why she thinks it’s because she has access to the same information that her physicians do and now is working with physicians who don’t disparage her from managing her health.
Am really looking forward to the day when the entire electronic medical record that I use is the same one the patient uses. Where the patient and I can work together to improve a person’s health rather than treat a symptom.

Should all medicines, including narcotics, be Over-The-Counter?

Follow me on this carefully and add your thoughts. Treat this as an out-of-the box thought game than something being advocated. 
What would medicine be like if all medications, including narcotics, be sold directly to consumers over-the-counter?
  • For one, we probably wouldn’t have drug lords and the need for a big chunk of the DEA.  I doubt drug dealers could survive against the pharmas.  Their product isn’t pure enough nor has the quality control consumers would be demanding. They probably couldn’t meet the price competitiveness of global pharmas. 
  • Tax revenues from OTC meds might go a long way towards underwriting the cost of health care.
  • Emergency rooms wouldn’t have to guess what the overdosed patients would be taking and treatment might be easier.
  • Drug abusers would be better able to manage their own addictions since they wouldn’t have to look over their shoulders for law enforcement nor contend with lying to get their medications from doctors, nor deal with product cut with who knows what.
  • Doctors offices would have many appointments freed up that are now clogged with patients who don’t need to go to them to get the prescriptions they want. They could go directly to pharmacies.  More time for more patients with acute illnesses. Total costs would drop.
  • Opium would become an honest crop with outlets that would bypass drug lords and organizations like the Taliban.  The troops could come home from Afghanistan.
  • Personal health records and other types of self-management services would explode since people wouldn’t have to go to the physicians to get their medications.
  • Greater emphasis would be placed on sharing pharmacy information so that patients and clinicians would know what they purchased, when and how they purchased medications.
  • There would be much less government or regulatory intervention required allowing more resources to be spent on intervention and services.

See what else you can add. Of course there are many cons but my guess is that when the list is completed the pros would significantly outweigh the cons.

The problem I see now is that there is a trend towards the other way (taking more medications off the counter).  That will only clog up an overwhelmed healthcare system even more.