Not Dead Yet

It is not necessary to change. Survival is not mandatory.
--W. Edwards Deming

“The superior doctor prevents sickness; The mediocre doctor attends to impending sickness; The inferior doctor treats actual sickness.” --Ancient Chinese quotation

I haven't been posting regularly for a while because, well, it takes a lot of work to keep up a blog. I mean, I do have a day job. And that day job has changed a little.

I started this blog on September 25, 2003 in order to "chronicle my attempt to replicate what family practitioner Dr. Gordon Moore has pioneered in his "solo-solo practice" (Going Solo: Making the Leap) in the hopes of regaining some control and sanity in my professional (and personal) life" and to "help anyone else who might be attempting the same foolhardy stupid insane brave endeavor".

I am as surprised as anyone that this blog has survived. For those of you who are considering, or have started your own medical blogs, know that, like everything else in life, medical blogging is not without risks.

For those who are interested in starting your own solo micropractice, there are risks, too, but I still think it is possible under the right conditions and with a lot of help.

I am still a solo family doctor. I started off as a solo-solo operation (aka the Gordon Moore model) about 5 1/2 years ago, in February 2004, and have been trying to figure out how to make this thing work for me and my patients ever since. I signed up with a bunch of PPO insurance plans and Medicare, but chose to avoid Medicaid and HMO because of the low reimbursement/high hassle factor.

What have I learned?
1. Submitting claims to insurance companies is easy, but collecting payment from them is sometimes very, very difficult, and in some cases, impossible.

2. The more time you spend with a patient, the more there is to document in the progress note.

3. Perfect progress notes are the enemy of timely progress notes.

4. EMRs don't save time in charting, but they do when retrieving notes.

5. There is no perfect EMR so get the cheapest one that does what you need it to do.

6. The ideal personality to run a solo-solo office is someone who is either in a permanent manic phase or who has the energy of a hyperactive kid on Pixy Stix and caffeine.

7. I live in a "dead zone", an area with conditions (in my case, high cost of living and low insurance reimbursement) that makes it very difficult, if not impossible, for an Ideal Medical Practice to survive.

8. The fixed low reimbursement of primary health care coupled with relatively high expenses means that the current American Healthcare System forces primary care doctors to continue following the business plan of the Underpants Gnomes:

Phase 1: Provide primary care (or collect underpants, your choice)
Phase 2: ???
Phase 3: $Profit$!

It's that Phase 2 part that's killing off primary care.

Changes I have made in my practice since 2004:
1. I got a part-time biller. My first biller was a lifesaver for me in that she is able to follow up on denied and "forgotten" claims that I didn't have the time or energy for. I call her my "pitbull" because once she gets hold of a claim, she doesn't let go until they pay up or all options have been exhausted. She has since moved on due to other obligations, and I have a new biller who is still learning the ropes. Still, it is better than when I was submitting (or not submitting) claims on my own.

2. Changed my practice name from a "Family Practice" to "Family Medicine". I should have done this at the very beginning, but that was right around the time that AAFP was changing our specialty name and I guess I didn't have the foresight to see what a hassle it would be later to change business cards, stationary, phone book listings, insurance contracts, etc. People still aren't really sure what Family Medicine is, but it's better than being confused for a daycare center.

3. I opted out of Medicare. I had been thinking about opting out of Medicare for a long time, basically ever since I opened my solo practice. Medicare's reimbursement level was low but usually no lower than the PPO payers and sometimes even higher than them, which is pretty depressing. They usually paid quickly and it wasn't that difficult to talk to a live person when we had a problem. But after my first 3 years in practice, only 4% of my patients had Medicare.

My main concern with Medicare has always been about accidentally running afoul of Medicare regulations and being tossed in jail or fined. When you first enroll with Medicare, they send you a CD with their rules and regulations. I have never opened that CD. In book form, it is over 500 pages long.

Medical coding is probably 2nd only to income tax calculations in complexity. In a study with 300 coding experts given 6 hypothetical cases to code, there was only 57% agreement on the correct E/M code. And this was with coding experts. It's got to be even worse when physicians do it but as physicians, we are ultimately responsible for any errors.

Medicare can fine you if you waive a patient's copay. They even sell Medicare supplemental fraud insurance in case you get hauled in. Under the False Claims Act, you can be fined up to $11,000 per claim and liable for 3 times the actual damages. Kind of like having a rich, beautiful and famous girlfriend who will cut your arm off because you didn't compliment her new shoes.

And while I realize that the few horror stories are rare and unlikely to ever affect me, they were enough to make me question, as for this physician, whether I should continue taking Medicare. Since dropping Medicare wouldn't affect my income significantly, I decided it wasn't worth it for me so I opted out.

4. I started charging an extra fee to help me survive the dead zone. More on this next time.

So anyways, both my practice and this blog are not dead yet.

In fact, I'm a lot happier and more satisfied as a physician, with the freedom to practice medicine the way I was trained to. I have the flexibility to pick up my kids from school every day and drive them to get braces, or wait for the plumber, or run errands. I don't make as much as I used to at Kaiser, but my income has been growing every year and I anticipate it will keep growing.

One of the reasons I went into medicine was because I knew I didn't want to go into business. But when I got into medicine, I discovered that it had turned into big business. So I started my own business to rediscover the art of medicine. Funny how that worked out, huh?

Steward's Foresight

Even as physicians, patients, insurers, business leaders and politicians converge on Washington, DC to focus on healthcare reform, Ideal Medical Practices are making the news, this time in Anchorage, Alaska:

During a typical visit to the doctor, most people spend more time in the waiting room than in the examination room.

On average, a physician spends about 10 minutes with a patient, according to one doctor in Anchorage who's working to change that.

At Steward Family Medicine, Dr. Daniel Steward makes time for every patient -- the shortest appointment lasts 30 minutes.

"You have so much time to talk with him and can cover any issue that you could possibly have because he doesn't rush you out of the office," patient Tahneta Stroh said. "He's a fantastic doctor."

Steward has jumped on board a grassroots movement sweeping across the nation known as an "ideal medical practice."

Unlike the glacier-like progress of healthcare reform taking place in Washington, DC, Ideal Medical Practices are bringing a better and more satisfying experience to patients NOW and will continue to do so regardless of what changes eventually take place.

To see where other Ideal Medical Practices are in the lower 48, go to the IMP Map.

An Open Letter to President Obama

Dr. John Brady runs a successful micropractice in Newport News, VA, and was Virginia's 2008 Family Physician of the Year. He has written a letter to his state legislators and President Obama regarding the healthcare crisis that is so well written that I am reposting it here, with Dr. Brady's kind permission:

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Dear President Obama,

I feel obligated to express my opinions on health care reform. I am a solo family physician working in Newport News, Virginia and am part of a nationwide collaborative of physicians dedicated to providing great care to their patients (www.impcenter.com).

I am experienced working on the front lines of health care for the past 15 years, and I have dedicated my last six years to trying to understand how to provide superior care to my patients. I am independent, I have no axes to grind, and I represent no interests except those of my patients.

There is no question we need reform. The health care system is disintegrating daily and taking a lot of wonderful patients and doctors with it. Patients are literally dying from both not having access to good primary care and from the poor quality care they receive once they get through the door. Doctors are imprisoned by mounds of administrative minutia which strip away their freedom to practice medicine individualized to the patient’s wants and needs (patient-centered collaborative care) and serve as a wedge between them and their patient.

Study after study has shown that the stronger the relationship between a doctor and his patient, the greater the quality and the lower the costs, but our system is set up not to enhance but to destroy this cornerstone of medicine. Unless the reform ideas being proposed address this fundamental flaw in our system, they are doomed to increase healthcare costs while remaining unable to enhance quality. Indeed, it is the failure of the doctor-patient relationship over the past twenty years which has been the true reason behind the cost escalation and the quality chasm.

Doctors are paid for quantity. The faster we push our patients through, the more money we make. The problem is that the faster we push our patients through, the less we know each one and the less we know each one, the more we rely on testing and specialty referrals to augment our clinical judgment.

Over the past 20 years, reimbursement has not kept up with overhead costs and so doctors have had to see more and more patients a day. The number of tests being done has exploded with the resultant explosion of costs. Insurance companies, seeing this trend, have tried to put roadblocks up to halt testing and referrals, but all this does is increase the administrative costs of the office forcing the doctors to see even more patients per day.

Harried doctors become burned out and begin to lack empathy leading to worsening quality and increased liability. Medical students see the trend of increasing workload, flat salary, and miserable physicians and have begun to avoid choosing primary care as a life choice. All this is occurring at the exact time the population is aging, which puts the country on the precipice of a complete meltdown of the medical system.

Clearly, the toxic reimbursement system needs to be fundamentally changed such that policies are adopted which enhance the relationship between doctors and patients. A simple solution would be to offer doctors the ability to opt out of the current nightmare payment scheme into a new system where the physician gets a dollar a day for every patient who chooses him/her as their primary care doctor. That reimbursement is then adjusted up or down quarterly based on the patient’s experience of care. Questions surrounding access, efficiency (waiting time), continuity, information exchange, and coordination can all be easily attained through a simple survey like How’s Your Health (www.howsyourhealth.com).

By doing this, doctors will be encouraged to provide the best service to their patient, and the resulting happier, healthier patients will be much less likely to go to the ER or have to get admitted to the hospital. Doctors, vying for high satisfaction grades, will quickly adopt quality initiatives like secure e-mail, online appointments, etc. Primary Care salaries will become much closer to that of the specialists, but more importantly as the relationship with their patients strengthen, overall medical costs will decrease, physicians will have higher job satisfaction, and medical students will flock to primary care. Truly this becomes a win-win situation for everyone.

I know this solution does not involve covering the uninsured or forcing the implementation of new tools or cool (expensive) technology, but that is why it will work. Covering the masses is a laudable goal, but doing this prior to fixing primary care is the equivalent of giving everyone a car and not building any roads.

Turning to computers and electronic medical systems to try and make a medical office a “medical home” is similar to thinking that adding the internet or a flat screen TV to a house will make it a home. It is the relationships, not the furniture, which makes a house a home. Similarly, to encourage the development of medical homes, we have to start by encouraging the development of strong relationships and only then worry about where the furniture (computers, integrated systems, etc) should go.

I appreciate you taking the time to read this letter, and I hope it resonates with you. I fear the potential harm to my patients and my country if we decide to do what might be politically easy instead of what is right. I remain willing to discuss any part of this in more depth if you desire and I can forward many good studies supporting everything I have stated.

Providing high quality, cost effective care is possible in today’s environment—I do it every day. But, in order to encourage quality care to become mainstream, we have to change the way doctors are paid. If that cannot be accomplished, nothing else will matter.

Sincerely,

John E. Brady, MD, FAAFP
The Village Doctor
2008 VAFP Virginia Family Physician of the Year

Positive Deviants

Dr. Atul Gawande is a general and endocrine surgeon at the Brigham and Women's Hospital in Boston, MA, who also writes wonderful articles for New Yorker magazine. One of his recent articles, The Cost Conundrum, is a disturbing in-depth exploration into why health care costs in McAllen, TX, one of the highest in the US, are twice as high as those in El Paso, TX, despite its similar demographics.

His most recent article was his commencement address to the graduating 2009 class of the University of Chicago Pritzker School of Medicine.

In his address, he related the story of a friend who ran a program to reduce malnutrition in Vietnamese villages but, like many humanitarian enterprises these days, had little funding. So instead of the usual methods advocated by outside experts, they used a low-tech approach.

They went to villages in trouble and got the villagers to help them identify who among them had the best-nourished children—who among them had demonstrated what Jerry Sternin termed a “positive deviance” from the norm. The villagers then visited those mothers at home to see exactly what they were doing.

Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways—feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet potato greens to the children’s rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped 65 to 85 percent in every village the Sternins had been to. Their program proved in fact more effective than outside experts were.

Gawande then goes on to explain how the United States is now that village, with our crumbling economy, rising unemployment, and auto, financial and housing industries in serious trouble.

More than that, though, we in medicine have partly contributed to these troubles. Our country’s health care is by far the most expensive in the world. It now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government at every level—squeezing out investments in education, our infrastructure, energy development, our future.

As President Obama recently said, “The greatest threat to America's fiscal health is not Social Security, though that's a significant challenge. It's not the investments that we've made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation's balance sheet is the skyrocketing cost of health care. It's not even close.”

While a large part of those costs are administrative costs, the bulk of extra spending is due to extra tests, procedures, specialist visits and treatment—things that doctors control.

Yet studies find that in high-cost places—where doctors order more frequent tests and procedures, more specialist visits, more hospital admissions than the average—the patients do no better, whether measured in terms of survival, ability to function, or satisfaction with care. If anything, they seemed to do worse.

He points out that, like the researchers in Vietnam, we need to look for successful outliers if we are to solve our healthcare crisis. But while he zooms in to some degree of some unique models, he doesn't zoom in close enough. I think the "positive deviants" he and the rest of the country are looking for are IMPs—Ideal Medical Practices.

Small, low-overhead, cost-effective practices with unfettered access that have both highly satisfied patients and healthcare providers, with reproducible measures of success. Definitely outside the norm. I'm not talking about solo no-staff micropractices such as mine, although that could be part of the solution. I'm not talking about all primary care physicians becoming IMPs. As has been pointed out before, we don't have enough primary care doctors to take care of everybody if we adopted that model for the entire nation. It is the underlying principles behind the IMP model that need to be looked at more closely.

IMPs focus on that "secret ingredient" that has been disappearing from our current healthcare system for quite some time. Namely, the doctor-patient relationship. Study after study has shown that when patients have a relationship with their primary care doctor, quality rises and costs fall.

When I have the time to know my patients, their histories and symptoms, I can order appropriate, targeted tests rather than a scattershot battery of tests hoping to hit something. When patients have easy access to me, we can wait and see if symptoms get better rather than get that MRI or refer to a specialist on the 1st visit. When patients know and trust their doctor, they are more likely to get preventive screening tests and feel motivated to follow through with lifestyle changes. When patients know who is in charge of their healthcare, they are less likely to end up in the ER or hospital. Healthier patients mean less disease or at least better controlled disease, which results in lower healthcare costs.

Whatever healthcare reform ultimately looks like, it has to include the doctor-patient relationship as a centerpiece in order for it to succeed.

Gawande ends his address to the future physicians with these thoughts:

No one talks to you about money in medical school, or how decisions are really made. That may be because we’ve not thought carefully about what we really believe about money and how decisions should be made. But as you look across the spectrum of health care in the United States—across the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. And as you become doctors today, I want you to know that you are our hope for how this battle will play out.

I graduated from medical school in 1987. One of the reasons that I went into medicine was because I didn't want to go into business. I never thought that medicine would turn out to be one of the biggest business battlegrounds ever. And yet, as in Tolkien's epic Lord of the Rings, the battle may ultimately be decided by someone small and seemingly insignificant.

You might even say, IMPish.

The Best Health Care System The World Has Ever Known

From the Washington Monthly, this article quotes Senator Richard Shelby's (R-Ala) June 7th comments about the current healthcare reform efforts:

One, we don't know how much [a reform package is] going to cost and who's going to pay for it," he said. "Secondly, it will be the first steps in destroying the best health care system the world has ever known."

The best health care system the world has ever known?

Do you suppose he is referring to:

• the one with 18 percent of the population under age 65 being uninsured?
• the one that spends more in healthcare than any other country in the world ($2.4 trillion in 2007)?
• the one that is only ranked 37th among industrialized nations by the World Health Organization for health care quality and performance?
• the one where 61% of bankruptcies are due to high medical bills?
• the one that wastes $31 billion a year just so doctors can get paid by insurance companies?
• the one that contributed to the collapse of the American auto industry ($1500 per car gap between GM vs Japanese vehicles)?

Oh, okay. I get it. Just like Gigli is the "best" movie the world has ever known. And like the 1972-73 Philadelphia 76ers were the "best" NBA team the world has ever known.

He's just kidding, right? Right?

Because if he's not, then Senator Shelby is the "best" Senator the world has ever known, where "best" actually means "worst". Just like our healthcare system.

If All Doctors Had More Time To Listen

From today's New York Times:

LILI SACKS, a primary care doctor in Seattle, says she began thinking differently about her work on the day she realized she was beginning each appointment with the words, “Sorry I’m late.”

Scheduled to see as many as 25 patients a day at a large clinic, she lacked the time for thorough examinations and discussions. Because of this, she said, primary care doctors are often forced to order tests and send patients to specialists.

“Could I have helped some people without specialists and tests? Absolutely,” said Dr. Sacks. “Would it have saved the patient and the insurance company both money? Absolutely. Is the system set up for the best care and cost efficiency? Absolutely not.”

Dr. Sacks said she worried that seeing so many patients would lead to errors. Last year, she moved to a clinic that focuses on longer patient appointments, 30 to 60 minutes. This translates to 10 to 12 patients a day. Patients also communicate directly with her by phone or e-mail.

I am reading a book right now called The Tipping Point by Malcolm Gladwell which talks about what factors are involved in causing trends to change, whether that trend is an epidemic, fashion, crime. In it he describes a study that is relevant to today's practice of medicine.

Two Princeton psychologists, John Darley and Daniel Batson, did a study where they asked theology students to prepare a talk on a Biblical theme and then walk to another building to give the talk. They were not told that along the way they would pass by a man slumped over in an alley with his eyes closed and groaning. They wanted to see what factors would increase the likelihood that the theology students would stop to help the man, and in effect emulate the parable of the"Good Samaritan".

What determined whether these otherwise caring and conscientious students would stop and help was not their desire to help others, how recently they were reminded of the Good Samaritan parable or even whether they were about to give a talk about the Good Samaritan. What made the difference was how much time they had. If they were told that they were running late, only 10 percent stopped to help. If they were told that they had a few minutes to spare, 63 percent of the students stopped to help.

From The Tipping Point:

What this study is suggesting, in other words, is that the convictions of your heart and the actual contents of your thoughts are less important, in the end, in guiding your actions than the immediate context of your behavior. The words, "Oh, you're late" had the effect of making someone who was ordinarily compassionate into someone who was indifferent to suffering -- of turning someone, in that particular moment, into a different person.

So I don't blame doctors who are harried and rushed to see 20+ patients a day if they are less thorough or even less caring. The current dysfunctional healthcare system will harden even the kindest hearts.

But more and more doctors are choosing a different path, the same one that I chose 5 years ago. One that allows for more time to listen, to think, and to do what we have been trained to do. For a directory of where to find like-minded doctors, go to the IMP Map.

If all doctors (or even just primary care doctors) had more time to listen, then we would have better healthcare. The question is, will the new healthcare reform that is shaping up in Washington give us that time?