Sunday, July 2, 2017

Primary care has lost its quarterback position in patient care



There is a crisis in primary care and that crisis is now flowing over into the hospital when a primary care physician’s (PCP) patient is admitted. No longer cared for by the PCP, the role has largely fallen to the hospitalist. There has been a loss of the long time primary care physician- patient relationship, the trust that comes with time. There has been a frequent loss of satisfactory communication when the patient is admitted and again when discharged.  At a time when the patient most wants and needs the comfort of a long time trusted professional friend, the patient instead is confronted with a stranger at the helm. What has happened to this create state of affairs?

PCPs have seen their overhead costs rise dramatically along with insurer mandated paperwork and government mandated electronic medical record (EMR) time requirements. This means the PCP must see more and more patients for shorter and shorter periods to cover overheads and reserve time for the nonclinical requirements. The average visit time is now 15 minutes with only 8 to 10 minutes of "face time". It also means that most – but definitely not all – PCPs no longer attend their patients in the hospital, leaving that function to the hospitalist

Hospitalists are trained in caring for patients in the hospital. Since that is all that they do, they become very experienced in dealing with the types of medical issues that require hospitalization. Working full-time in the hospital means that they know how to get things done in that setting and do so fairly efficiently. The growth of the hospitalist movement over the past twenty years has been truly phenomenal – at 50,000 physicians it is the largest medical sub specialty (cardiology is next at 22,000), surpassed as a specialty only by general internal medicine at 109,000 and family medicine at 107,000.

Early studies suggested that quality was improved and costs reduced with the advent of hospitalist care. This was especially true for complicated patients who required multiple physician visits and interactions each day, something difficult for the community based physician to achieve. And with the need to see multiple patients each day in the office to cover overheads, many PCPs willingly ceded hospital care to the hospitalist. 

In our experience hospitalists are a heterogeneous group, many are just out of an internal medicine residency; some are working part-time because of childcare obligations. Many are contemplating a fellowship but want to catch up on loan obligations. Some hospitalists anticipate at a future point to become PCP’s. Still others intend to make a career as a fulltime hospitalist.

Frequently employed by the hospital, they still must meet productivity standards in order to earn their salary.  Often this means caring for a large number of patients, most of them quite ill. Although they are expert in what they do, they do not have the years of interaction with the patient that the PCP has. And so they did not know the patient before the hospital event and are not likely to know him or her after.  Each patient is an individual with his or her unique family, social, economic and of course medical background. The patient today may well have multiple chronic illnesses such as diabetes, congestive heart failure or chronic lung disease and now enters the hospital with a new problem or an exacerbation of an old one. The hospitalist can deal well with the reason for admission. Nevertheless they will not be cognizant of the fine balance of personality and medication that has otherwise maintained the patient as independently living in the community.  It also unlikely that they know what studies have been done prior to the admission. 

In recent back to back articles in the New England Journal of Medicine, Wachter and Goldman along with Gunderman present rather different perspectives on the rise of the hospitalist subspecialty yet the decline of comprehensive care. 
 
Our observations of routine hospitalist care is that a given patient may have multiple hospitalists over the course of the admission rather than one doctor who knows the patients well. In a four-day stay a patient may easily be cared for by three different hospitalists. Test redundancy and unneeded consultations are all too common.

There is also a tendency to ask for consultations from subspecialists when more time with the patients might have been sufficient to establish the issue at hand. Fever-infectious disease, pneumonia-pulmonologist, chest pain – cardiologist.  Relatively easy procedures are also handed off to a specialist, e.g., joint effusion - call the orthopedist to do the arthrocentesis.  Mildly demented patients all too often get a repeat head scan because of an inadequate handoff that the patient has already had a more than adequate evaluation for reversible causes of dementia. Typically a hospitalist service is made up of many physicians that have a minimum of three years of internal medicine training. We are not sure if the statistic exists but in many community hospitals the average number of years of experience after residency is likely less than five years.  So if an unusual problem arises, call for a consult. There typically are multidisciplinary rounds but the admitting hospitalist may not be the rounding physician. 

More discouraging is the finding that hospitalists tend to place the primary care doctor’s patients often on the wrong medication, very often there is inadequate communication between the hospitalist and the primary care physician to review details at the time of admission. This of course can lead to a more extensive hospital stay. To compound the problem, the handoff back to the PCP at discharge is often problematic with inadequate communication between them. The PCP may not even know that the patient was admitted or discharged until the patient calls for a new appointment. Meanwhile, the fine balance of those chronic illnesses may be out of kilter so that, not surprisingly, about 20% of older individuals end up back in the hospital with an unplanned admission within the following month.


The PCP was always the backbone of American medicine. He or she not only cared for patients in the office but also collaborated with the emergency room physician and attended to hospitalized patients, seeking specialist consultation as needed. Today, only a few PCPs even visit their hospitalized patients, relying entirely on the hospitalist and the emergency medicine physician.

Hospitals are scary places. You never really want to be admitted but sometimes it is necessary and indeed even lifesaving. This is the time when you most want a knowledgeable professional friend of long standing, one you with whom you have deep seated trust.

Although most PCPs do not visit their patients in the hospital today, some do and they are committed to give the patient the expert care that the patient requires. But for these physicians some community hospitals for various reasons have determined that only the hospitalist may have privileges to care for the patient. That’s right; hospital managements are discouraging primary care doctors from coming to the hospital and in many cases have prohibited them from having active admitting privileges.  Somehow, they discount the possibility that the primary care doctor knows the patient best and can work effectively and collaboratively with the hospitalist for the patient’s benefit. Erroneously, hospitals in many cases believe that primary care doctors diminish quality and increase the length of stay. We have discussed this very issue with a retired board member from a large Maryland insurer and confirmed that a huge  uncontrollable expense to the hospital bill is over consulting with specialists and redundancy of procedures and testing ordered by hospitalists.

The PCP is being marginalized. This is distinctly to the patient’s disadvantage.

Interestingly insurers are having an impact on control of costs but not in the hospital. Primary care physicians are now rewarded for guiding patients to the less costly specialist and using visiting nurses to manage co-morbidities that have saved hundreds of millions of dollars. We believe now the insurers need to understand the value of comprehensive primary care that extends into the hospital; this would translate into even more savings. PCPs need to earn enough with a smaller panel of patients that they can afford to care for fewer patients but with greater time spent with each as appropriate including visiting their hospitalized patients, working collaboratively with the hospitalist and interacting with the emergency medicine physician. Insurers (including Medicare) need to dramatically reduce the unnecessary paperwork and requirements so that the PCP can actually spend time with the patient.

We are not intending to disparage hospitalists. They are well trained, committed and productive and overall have added quality to the hospital environment. We are advocating however for a collaborative process of hospitalist and PCP working together. Returning the PCP to his or her positon as the quarterback of patient care is good medicine; it means greater quality, a more satisfied patient, less frustrated physicians yet much lower total costs of care. A win-win-win.

Harry A Oken MD, who coauthored this post with Dr Schimpff, is a primary care physician in private practice who still cares for his patients when hospitalized and is a clinical professor of medicine at the University of Maryland School of Medicine.



Thursday, June 29, 2017

United Airlines Fiasco Should Be a Healthcare Wakeup Call




The forcible removal of a passenger from the United Airlines flight has reminded flyers of their general dissatisfaction with the airline industry. Perhaps surprisingly, it should also be a stern warning to physicians. The brunt of dissatisfaction in healthcare delivery will fall on the providers although the real culprits are the insurers; they too should take notice.

The airlines do not appreciate the real basis for the outburst by the traveling public. The forcible eviction, despicable as it was, was really just the “straw that broke the camel’s back.” Airline travel was once a special, adventurous part of the journey. Today it is an undesirable but necessary means to an end. Why? Because the airlines treat their customers with disrespect at every part of the process. It is not just United; it is all of the airlines. The uproar is not about the rules, “the contract of carriage,” but about the manner in which airlines think about their passengers – definitely not customers who deserve respect. Respect and dignity are the key words.

The public’s general consensus – it's not fun anymore; there has been complete loss of autonomy and dignity; flyers often feel they are herded like cattle with total loss of all control and definitely not treated as valued customers. The sense is that the corporate view is "stockholder value "as the priority, not customer satisfaction, preference and loyalty as a means to generate that value.  "The friendly skies" are no longer, if they ever were. There is no sense that the airline executives who set the employee standards and culture remember that a customer pays the employees’ salaries, their bonuses and ultimately the stockholders’ dividends. In this environment, the employee from captain to gate agent to luggage handler is captive. They may – and I suspect to a large degree do – want to treat their passengers as real people, real customers deserving of real respect but it is clearly not the corporate ethos.

In any business, for profit or not for profit, it is true that "no money, no mission" but money has become the mission.

Such is the case with much of healthcare. Patients are frustrated feeling that they are not respected, not afforded autonomy or control and not valued. As a retired physician and academic hospital CEO I have witnessed and felt the transformation within medicine over the past 50 years. As with the airlines, most physicians, nurses, pharmacists and other staff are all well-meaning and caring. But patients are at the breaking point. In short, the patient is not treated like a valued customer but more like a commodity.

 It takes about three weeks to gain an appointment, there are long waits in the “waiting room” and then just a few minutes with the doctor.  You may personally like your physician but you are not pleased with the situation and feel helpless to rectify it because you are not the customer, the doctor’s customer is the insurer.  The insurer will determine if and how much the doctor is paid; the patient is a bystander to the transaction yet saddled with copays and deductibles. The patient cannot even request more time for more pay – the insurer prevents direct payments to the doctor. 

From the doctor’s perspective, he or she is undervalued by the insurer who acts capriciously, produces extensive rules, regulations and requirements that do not add to patient care but require extra work – time not spent with the patient. And since insurance payments for primary care especially are notoriously low yet with ever rising overheads, the physician is obliged to shorten visits often to about 8-12 minutes of actual face time.

It is a situation right for an outburst – from both patient and doctor although for different reasons. An event – not malpractice but just something totally unacceptable like being dragged off the plane – could dramatically upset the status quo. Patients will cry out that they “will not take it anymore.” They will demand accommodation for privacy, courtesy, autonomy and especially respect and dignity. They will expect to be treated as valued customers. 

Physicians are in a bind as well. If the time per patient is short and the PCP only deals with “simple” problems, referring all of the rest to specialists, then the patient comes to feel that the PCP (e.g., internist, family medicine doctor or pediatrician) is irrelevant, often unavailable and yet expensive. The patient is increasingly likely to go to CVS, Walmart or Walgreens and get seen promptly for minimal cost. Here is an example from a friend: “For Boy Scout camp it is necessary to have a health form filled out by the pediatrician. In our son’s case, our insurance covers one physical a year, and we usually go around his birthday in June. But the form is due April 17th so I found myself in a Catch 22 situation. The insurance company won't pay for a physical until June, the pediatrician won't fill out the form without doing a physical. So I ended up taking him to CVS WellCare and paid them $69 to fill out the form, much less than what the pediatrician would have billed.”

There is a clear difference between the airline industry and the healthcare industry, even above and beyond the obvious that one is an option much of the time and the other is frequently not an option. The issue with the airlines is not price which is generally reasonable; it is the lack of being treated as a customer. In healthcare, the prime issue is also about not being treated as a valued customer – with respect and dignity. But now, where price never mattered in the past, it has become very important. Previously, I have suggested some “fixes.”

Healthcare needs to open its eyes and realize that its bread-and-butter is highly vulnerable. Yes, the insurers make life difficult if not near impossible. But the object of healthcare delivery is, or at least should be, for the patient. The hospital and the physician may be vulnerable to the whims of government and insurers but – more importantly yet unrecognized– may be exceedingly vulnerable to the very patients who have entrusted their care to them. Let this be a wakeup call and let it begin a careful look in the mirror rather than looking for external demons. When the uprising occurs, the blame will be heaped on the providers – hospitals and physicians alike. If it is a hospital issue, the doctor can’t escape – the patient looks to the doctor as the face of the hospital.
Insurers should take a close look as well. In their effort to reduce costs, they – beginning with Medicare - have systematically held primary care reimbursements low yet added excessive nonclinical work requirements. The result is the morass of today with frustrated, burned out physicians, angry patients and increased costs.

The initial response of United Airlines completely missed the depth of societal outrage and later did not appreciate how deeply the traveling public feels devalued. More recently, the board chair stated that this was a “defining moment in the history of United Airlines pivoting to customer service and customer delivery.” If he means it, it will mean a momentous change in corporate ethos and business practice. Let’s hope.

Perhaps healthcare – including Medicare and commercial insurers – will come to recognize that it too must change or ultimately feel the wrath of dissatisfied patients – their customers. Meanwhile physicians need to take the offensive to direct change. Unified they can force the changes needed for the benefit of their patients, themselves and the total costs of care.
The forcible removal of a passenger from the United Airlines flight has reminded flyers of their general dissatisfaction with the airline industry. Perhaps surprisingly, it should also be a stern warning to physicians. The brunt of dissatisfaction in healthcare delivery will fall on the providers although the real culprits are the insurers; they too should take notice.

The airlines do not appreciate the real basis for the outburst by the traveling public. The forcible eviction, despicable as it was, was really just the “straw that broke the camel’s back.” Airline travel was once a special, adventurous part of the journey. Today it is an undesirable but necessary means to an end. Why? Because the airlines treat their customers with disrespect at every part of the process. It is not just United; it is all of the airlines. The uproar is not about the rules, “the contract of carriage,” but about the manner in which airlines think about their passengers – definitely not customers who deserve respect. Respect and dignity are the key words.


The public’s general consensus – it's not fun anymore; there has been complete loss of autonomy and dignity; flyers often feel they are herded like cattle with total loss of all control and definitely not treated as valued customers. The sense is that the corporate view is "stockholder value "as the priority, not customer satisfaction, preference and loyalty as a means to generate that value.  "The friendly skies" are no longer, if they ever were. There is no sense that the airline executives who set the employee standards and culture remember that a customer pays the employees’ salaries, their bonuses and ultimately the stockholders’ dividends. In this environment, the employee from captain to gate agent to luggage handler is captive. They may – and I suspect to a large degree do – want to treat their passengers as real people, real customers deserving of real respect but it is clearly not the corporate ethos.

In any business, for profit or not for profit, it is true that "no money, no mission" but money has become the mission.

Such is the case with much of healthcare. Patients are frustrated feeling that they are not respected, not afforded autonomy or control and not valued. As a retired physician and academic hospital CEO I have witnessed and felt the transformation within medicine over the past 50 years. As with the airlines, most physicians, nurses, pharmacists and other staff are all well-meaning and caring. But patients are at the breaking point. In short, the patient is not treated like a valued customer but more like a commodity.

 It takes about three weeks to gain an appointment, there are long waits in the “waiting room” and then just a few minutes with the doctor.  You may personally like your physician but you are not pleased with the situation and feel helpless to rectify it because you are not the customer, the doctor’s customer is the insurer.  The insurer will determine if and how much the doctor is paid; the patient is a bystander to the transaction yet saddled with copays and deductibles. The patient cannot even request more time for more pay – the insurer prevents direct payments to the doctor. 

From the doctor’s perspective, he or she is undervalued by the insurer who acts capriciously, produces extensive rules, regulations and requirements that do not add to patient care but require extra work – time not spent with the patient. And since insurance payments for primary care especially are notoriously low yet with ever rising overheads, the physician is obliged to shorten visits often to about 8-12 minutes of actual face time.

It is a situation right for an outburst – from both patient and doctor although for different reasons. An event – not malpractice but just something totally unacceptable like being dragged off the plane – could dramatically upset the status quo. Patients will cry out that they “will not take it anymore.” They will demand accommodation for privacy, courtesy, autonomy and especially respect and dignity. They will expect to be treated as valued customers. 



There is a clear difference between the airline industry and the healthcare industry, even above and beyond the obvious that one is an option much of the time and the other is frequently not an option. The issue with the airlines is not price which is generally reasonable; it is the lack of being treated as a customer. In healthcare, the prime issue is also about not being treated as a valued customer – with respect and dignity. But now, where price never mattered in the past, it has become very important. Previously, I have suggested some “fixes.”

Healthcare needs to open its eyes and realize that its bread-and-butter is highly vulnerable. Yes, the insurers make life difficult if not near impossible. But the object of healthcare delivery is, or at least should be, for the patient. The hospital and the physician may be vulnerable to the whims of government and insurers but – more importantly yet unrecognized– may be exceedingly vulnerable to the very patients who have entrusted their care to them. Let this be a wakeup call and let it begin a careful look in the mirror rather than looking for external demons. When the uprising occurs, the blame will be heaped on the providers – hospitals and physicians alike. If it is a hospital issue, the doctor can’t escape – the patient looks to the doctor as the face of the hospital.
Insurers should take a close look as well. In their effort to reduce costs, they – beginning with Medicare - have systematically held primary care reimbursements low yet added excessive nonclinical work requirements. The result is the morass of today with frustrated, burned out physicians, angry patients and increased costs.


The initial response of United Airlines completely missed the depth of societal outrage and later did not appreciate how deeply the traveling public feels devalued. More recently, the board chair stated that this was a “defining moment in the history of United Airlines pivoting to customer service and customer delivery.” If he means it, it will mean a momentous change in corporate ethos and business practice. Let’s hope.

Perhaps healthcare – including Medicare and commercial insurers – will come to recognize that it too must change or ultimately feel the wrath of dissatisfied patients – their customers. Meanwhile physicians need to take the offensive to direct change. Unified they can force the changes needed for the benefit of their patients, themselves and the total costs of care.
20,2017

Originally appeared in Medical Economics, May 

Tuesday, January 3, 2017

Home Hospitalization – An Innovative and Transformational Approach Whose Time Has Come



American healthcare delivery is seriously dysfunctional. It takes you about three weeks to get a doctor’s appointment, you sit in the waiting room for a long time, you get 10 to 12 minutes with the doctor and then you have a hefty deductible and/or copay despite paying handsomely for insurance. American medicine costs about three times per capita more than most other developed countries yet outcomes are no better, patient satisfaction is low and burn out among physicians is high.

As to hospitalization, it is very expensive, the risk of a medical error is real, hospital acquired infections are all too common and the patient frequently leaves feeling unsatisfied.

But do all those individuals admitted necessarily need hospitalization? Today the answer is generally yes. But tomorrow that could and probably could change, for the better. What if many of the attributes of the hospital could be brought to the home? Attributes like nursing care, electronic monitoring of vital signs and intravenous therapy, to name just a few. There is really no reason why the home cannot serve this purpose for some selected patients today. When it does, the patient remains in familiar, comforting surrounding; the chance for errors and infections can go down and the costs of care can decline substantially. The critical question, of course, is whether the clinical outcomes are just as good, or possibly even better.

Enter an innovative and exceptionally transformational approach. Think of it perhaps as a virtual hospital that maximizes the capacity to use today's digital technology.

Embryonic at best in the United States, there are multiple examples worldwide as recently reviewed in the New England Journal of Medicine. The basic idea is to follow emergency room evaluation (or even doctor’s office evaluation) with the decision to admit to the hospital or to use hospital at home care. Not all patient conditions are appropriate for home care of course but among those that are often appropriate: exacerbation of heart failure and chronic obstructive pulmonary disease, community acquired pneumonia, asthmatic attacks, deep vein thrombosis and possibly pulmonary embolus and deep-seated skin or soft tissue infections.

One recent study compared 50 patients treated at home for a 34 day period to a similar group treated in the hospital after initial evaluation in the emergency room or observation unit. At the conclusion of the study period, the hospital at home patients had greater satisfaction with multiple query categories and met standard quality measures for their specific diagnoses.   Those patients were less likely to need readmission over the ensuing ninety days.

Some keys to success include effective two-way digital communication systems that allow for virtual physician and nurse visits in an HIPAA secure setting along with remote virtual biometric monitoring. Proper patient selection is important as those who might need more intensive diagnostics (e.g., MRI) or therapeutics (e.g., surgery) are inappropriate candidates. It is also important that the work traditionally done by hospital personnel not be offloaded to the family members; this will defeat the purpose and lead to ill-will. Maintaining contact virtually and with home visits for a prolonged period after the immediate acute episode will likely improve the care transition and lead to fewer readmissions.

With positive results nationally and internationally, why hasn't the hospital at home model become commonplace? I suspect it has multiple causes not least of which is physician concern. Medical professionals are loath to make dramatic changes when the current system works, or at least works reasonably well for most episodes. Add in, of course, that the fee-for-service reimbursement model for physicians and hospitals discourages interest. Only when the physician can be paid for virtual/digital care approaches and the hospital benefits financially from fewer admissions will real interest develop.

Innovative? Certainly. Transformative? Definitely. Makes sense from a quality of care perspective? Yes. Leads to greater patient satisfaction? Yes. Means fewer safety lapses and care associated infections? Perhaps. Reduces unplanned remission rates? Probably. Costs less? Yes.

In sum, the time is right for implementation in those settings where payment models do not discriminate against in-home care models. Logical places to start would be Medicare Advantage plans, military or veterans plans and other entities that hold total fiscal and care risk.


Home hospitalization could be one step in improving the American dysfunctional healthcare delivery system with improved care, greater satisfaction and reduced costs – the Triple Aim

This was first published at Medical Economics December 19, 2016 


Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).