An Update on healthcare reform.

Cash medical practice or, in the phrase favored by leftists critics, “Concierge Medicine,” seems to be growing.

Becker is shifting to a new style of practice, sometimes called concierge or retainer medicine. With the help of a company that has been helping physicians make such shifts for over 13 years, he will cease caring for a total of 2,500 patients and instead cut back to about 600. These patients will pay an annual fee of $1,650. In exchange, they will receive a two-hour annual visit with a complete physical exam, same-day appointments, 24-hour physician phone access, and personalized, web-based resources to promote wellness.

The article suggest that all these doctors choosing to drop insurance and Medicare are primary care. Many are but I know orthopedists and even general surgeons who are dropping all insurance.

The concierge model of practice is growing, and it is estimated that more than 4,000 U.S. physicians have adopted some variation of it. Most are general internists, with family practitioners second. It is attractive to physicians because they are relieved of much of the pressure to move patients through quickly, and they can devote more time to prevention and wellness.

Several years ago, I attended the annual meeting of the Geriatric Medicine Society. There I met a young women who was the only fellowship trained Geriatrician in central Iowa. Geriatric medicine is all Medicare by definition and the physicians do not make much money. In fact, the practice of geriatrics cannot survive without subsidies, usually from academic centers.

She had been an independent practitioner and found she was being harassed by Medicare for seeing her homebound elderly patients too frequently. She was not even allowed to see them on additional visits for cash. Medicare does not allow physicians to provide additional services that are beyond what is “allowed.”

She had finally dropped all Medicare and had an all cash practice, including Visa and Mastercard. She was making a living and was left alone by Medicare.

By adopting a concierge model of practice, Becker is trying to expel an expanding cast of characters who have interposed themselves between patients and physicians: people with forms to be filled out, stopwatches to be obeyed, and cash registers to be fed. He hopes to build a future in which only one person will be in the room with every patient—the physician—and every physician will be free to practice with the level of patience and dedication they believe good medicine requires.

The electronic medical record is a significant contributing factor to the distress of physicians in practice. For years I was a member of the American Society for Medical Informatics, and was enthusiastic about it. That has changed. The implementation has been awful. It is as if the DMV was designing your TV programming.

As an InformationWeek staffer recently assigned to this beat after only occasionally covering health IT in the past, I was surprised how unanimously and passionately dissatisfied most doctors are with the usability of this software, which they see as draining rather than enhancing their productivity. I’m sure there are exceptions where doctors are more enthusiastic about technology, the software they are using is higher quality, or a little of both. But if you open the door to a conversation about how horrible medical records software is, you’ll get an earful.

Why is this the case ?

“I use several EHRs in my clinic and hospital,” wrote Denton, who practices in Portneuf, Idaho. “None of them allow transmission of data between systems. They all are encumbered by poor graphic user interfaces that make it hard to see patient data in a way that makes sense and helps patient care. It is actually much harder to take care of sick patients in the ICU with our new hospital system. They also tend to hide the pertinent by scattering it through the program and displaying all types of ancillary data, time stamps, and formatted notes that are inserted to ensure appropriate coding, but get in the way of seeing what is important. I have made several errors by failing to find the correct information in the chart because it was buried in the note. Finding what is important has become a treasure hunt.”

I have been trying to teach medical students to use these system and have found several problems. One-many of the interfaces are clumsy and counter-intuitive. One requires a diagnosis be entered before any other information. If you don’t know the diagnosis yet, you have to make one up. Later, when you have figured out the diagnosis, the fake one cannot be deleted.

The bottom-line answer from most (but not all) of the doctors and healthcare workers chiming in on that discussion was, essentially, no, not going to happen as long as there is such a mismatch between how the software in healthcare works and how the people in healthcare work. Clearly, the government agencies promoting the technology are in thrall to the software vendors, or why would they be pushing this so hard?

Gee, who would think that crony capitalism has invaded medicine ? Anybody active in healthcare, that’s who.

“How did IT get more powerful than the people who actually care for patients? The answer is that IT charges by the hour, while Docs can be made to do more work for less money, that is, add 2 hours work to every day without additional compensation. If we asked IT to do the hard work, we’d have to pay them.” I don’t want to quote by name without permission, but another commenter identified as a medical director for a healthcare group pointed out that any drug or medical device would have to be proven in FDA testing before being adopted into a hospital, while EHR software “impacts quality of care, and expecting to improve it ‘on the job’ causes delays in care, complications and death. Piece of advice, if anyone of you or your family has to go to a hospital make sure someone stays with the patient because the nurses will be on the computer.”

A common complaint is that physicians do not make eye contact with patients any more. I’ve seen that in my own encounters with primary care docs. They are typing and looking at the screen. A friend of mine, a few years younger than I am, recently retired a month after he told me that he spent three hours every day after office hours, entering data into his EMR.

The systems at LA County Hospital and USC University Hospital are different. The EMR systems at UCLA and Cedars-Sinai, even though they share most attending staff, are not compatible and do not share information. From the comments to that article,

HealthCare IT serves two masters with widely differing agendas – administrators and caregivers. The administrative burden is to provide summary reports and billing coding for insurance and mandated government reporting. Caregivers need easy data input and timely and relevant synopsis and correlation of critical information based on inputs from various sources – for example, conflicting prescriptions from specialists treating the same patient but who are not familiar with what other regimens the patient may be under from other Doctors and caregivers. The point of the EHR was to have a single source of truth provide a global view of what is happening to a patient. Instead we have multiple systems that cannot communicate with one another – creating silos of information. This is what I am hoping the Affordable Health Care act addresses – but it will take time. WIth the Political element trying to destroy better healthcare for Americans it will take even more time. Currently we have “Health Care Systems” built from older IT building blocks and re-purposed for health. They then had to expand to include the regulatory environment, billing environment and somehow lost the plan to build an “ideal” practice UI for doctors and nurses.

Some of the comments appear to be from Obamacare enthusiasts who are probably from big medical centers. Those medical centers have been buying up physician practices and anticipating big returns from their vertically integrated systems that they hope will function like Kaiser-Permanente. The EMR seems to be part of the revenue system and not much concerned with patient care.

I think they are finding that Obamacare is not the bonanza they expected and that fixed overhead can be painful when costs exceed revenues. Young doctors with student loans are indentured servants in this system but older doctors are bailing out in significant numbers.

23 thoughts on “An Update on healthcare reform.”

  1. Piece of advice, if anyone of you or your family has to go to a hospital make sure someone stays with the patient because the nurses will be on the computer.

    In my recent experience the above statement is accurate re the nurses, and good advice.

  2. Yep … reminds me of the last time I had to stay in hospital – and it was a good hospital, too; one of the central showpieces of military medicine, but I was sharing a room with a retired military nurse with a catastrophically broken hip – and I had one hand bandaged up and suspended. The one person who really helped me do things … like cut up food so that I could eat it with one hand was the retired nurses’ equally retired nurse housemate, who came in every day to see to her friends’ daily care, bring in fresh PJs, and a newspaper. God bless, they were both nurses of the old school.

  3. I have a prediction. The Obama administration will wage a stealth war, via regulation, against those doctors bailing out of government provided healthcare. The FDA will begin issuing rules and regulations by the bushel. There will severe penalties attached for violations. There’s more than one way to skin a cat, and the Left is dug in deeply in the civil service. The GOP could win both houses and White House, and the Left would, for all intents and purposes, still run the country. Expect a media assault as well.

    I also have an observation. One of my daughters recently had a baby. I was visiting her in the hospital when a nurse popped in with a few meds for her. I asked the nurse if she gets a little pop-up when a patient is due for their meds. Patient name, room, medication, dosage, all that. No, she said, We have to keep track. Wow. I was stunned.

  4. I gather that the evidence suggests that annual check-ups are worthless – to the patients, at least.

  5. I disagree about the annual checkups with a caveat. I have paid extra to have a lab run every year for the last 15 years and have also had a physical every year since I can remember. I have not had anything serious come up, but when I get older and things start breaking down, it will be good to have my baseline of bloodwork numbers to refer to in the future.

  6. I had a comment vanish. I tried to repost and got the duplicate message.

    Annual checkups are useful in a few instances. One is blood count and the other is stool occult blood tests. Blood sugars are another.

  7. Annual checkup is worthless until it uncovers a potentially serious problem that’s easily cured if caught early. IOW you are buying insurance by getting checked. As with all insurance the main question is whether you are paying too much relative to the expected value of the payout. In the case of annual checks the answer is probably no for most people above a certain age.

  8. To reframe that: Worthless is in the eye of the payer. Most discussions of medical cost tradeoffs are done (sometimes naively, sometimes with intent to deceive by socialized-medicine proponents) from a public-health perspective that considers only population average costs from the POV of third-party payers and ignores the perspective of individuals and the value of individual choice. The average benefit per patient of annual checkups may not exceed the cost to a third-party payer, thus we read statements like, “annual checkups are not worth it”. However, from the POV of an individual an annual checkup that can detect an early-stage cancer or other serious condition in time to get effective treatment may be well worth the few hundred bucks a year that it costs. It’s effectively an insurance premium, and as with any other product there are different consumer preferences for insurance coverage.

    A doctor I knew said, in response to the 1994 Clinton health scheme, “People should have choice. America is about choice.” I think that puts it well.

  9. Most annual physicals should not require a doctor to do them. They involve blood tests, maybe a mammogram, stool OB and blood pressure. After 50, an EKG but that doesn’t need to be annual unless there are pulse changes or symptoms.

    The future of medicine is going to be more and more nurse practitioners and PAs. I have told my students who are interested in primary care to get an MBA. USC now has an MD-MBA program that takes five years.

  10. >>The future of medicine is going to be more and more nurse practitioners and PAs

    MikeK, I’m going to offer an opinion on something I know almost nothing about, medical practice. It seems to me an effective way to drive down medical costs and increase access would be to bring medical care to the retail level. Allow nurses and PA’s to open facilities that offer basic services, including inoculations, blood tests, writing prescriptions for common ailments, etc. I shouldn’t need to see a PhD in medicine to get shots for my child. In fact, when I was child, inoculations for measles were gotten at school. We are offered flu shots every year here at work at no cost administered by PAs. I think a PhD’s time is more effectively used for more complex problems and treatments. Your thoughts on that?

  11. I’m sure there is much work that doctors have typically done that could be done at lower cost by nurses and PAs with no loss of quality. The problem with schemes such as Obamacare is that their main goal is cost reduction, and they attempt to achieve it by imposing arbitrary price reductions on every product and service in the system. That kills incentives for doctors and other high-end service providers and for drug and device makers. But, of course, something has to give in the name of cost reduction and political control.

    Edited to add: Agree with Mike H.

  12. Cheer up, a bit of good news for those thoroughly depressed by this story. The control freak OCD king of the computer user experience world just entered the healthcare information field. Apple just a few weeks ago announced healthkit, an API.

    The important piece is about the partners

    I would expect Epic integration meaningfully rolled out in 2015 and via their Mayo partnership (which uses Cerner) Cerner to not be very far behind. These are very big names in the EHR world and will likely make Apple an influential player going forward in this field. I don’t see Apple as being institutionally capable of leaving that UI mess to fester all over their corporate brand.

  13. “I think a PhD’s time is more effectively used for more complex problems and treatments. Your thoughts on that?”

    I agree but the problem is supervision and ready access to help with complex problems. My ex-wife (We are back together now after 25 years) is a nurse practitioner with three degrees who worked for a GP I knew. She was very busy and well liked by her patients. Interestingly, she was the family “doctor” for the family of my son’s wife and her parents for years. They loved her. If she found something she was concerned about, the GP she worked for was too busy to help her and she would call me. Here is where the potential problem is.

    I spent years doing telephone review of workers compensation cases. Almost without exception, the people I talked to were PAs who worked for an orthopedist who had three or four offices. The doctor was interested in surgery and, if the subject was surgery, that’s who I talked to. If the subject was non-surgical, it was the PA and many were happy to discuss cases and get advice about what to do. They had little contact with their employer and ran the office as best they could. Most were quite competent.

    The doctors who employ nurse practitioners are usually busy and the same time constraints operate on the NPs and PAs. WalMart already has NPs working in some stores. I think this is fine but they need access to advice with minimal delay. Often a phone call is enough.

    Kaiser heavily uses NPs and my ex-wife was an “advice nurse” for Kaiser for a while. I have seen the problems that Kaiser gets into with its 100% unionized nursing staff. I used to review malpractice cases for plaintiff and defense for Kaiser as well as private lawyers. And for the state medical board which was the least effective. I have many stories, some of which are in my memoir book that I may publish as an ebook. One was a death during a 15 minute surgery for a pilonidal cyst (at the tailbone) in an obese man. The surgery is done under spinal and the patient is face down.

    The nurse anesthetist (Kaiser uses all nurse anesthesia) was changed twice during the short case, because of lunch rules, and they lost track of the level of anesthesia. They got a “high spinal” and the man died. This is an indefensible case. He was only about 45, as I recall.

    Primary care consists of hours of routine stuff with an occasional unusual or even rare problem. After my ex-wife retired, my son’s mother-in-law got mistreated by a jerk of an oncologist and I wound up supervising her treatment and sending her to people I know. Among other problems, he told her that she might have leukemia but, since it was Christmas time, he would not have time to do the tests until after New Years! I got her to a guy at UCLA who did the test (a bone marrow exam) and told her she didn’t have it.

    This sort of thing is a case where, when you hear hoofbeats, it really is a zebra.

  14. Off topic, but, MikeK, I was delighted to read about reunion with your wife. Glad you included that side note.

  15. MikeK,

    My brother-in-law the ER doc would agree with you about most primary care being routine, and then add: “But how do you know when you’re seeing one of the exceptions?”

  16. It’s pretty obvious that the EHR software was *not* written for doctors. It was written for insurance companies or whoever it is that is paying the bills.

    We had tons of crap like that back in the 1980’s when automation was first creeping into the military sphere. Whatever program you were running wasn’t to make *your* life easier or to help you get your job done. It existed to feed some staff dink 3 or 4 levels above you to enable him/her/it to generate a report.

    One of the systems that I wrote for 2nd Armored Division many moons ago was designed to feed *me* information but also generated reports that the people giving me input could (and did) use to fill out their Unit Status Report (USR) much easier than doing so by hand. Win-win.

  17. I agree that EMR is a total mess-

    But it has followed a consistent pattern: the majority of government IT projects fail, and for that matter most federal contracting seems to go terribly wrong somewhere.

    A common theme is that the companies that secure the work initially invest in lobbying, and then change the laws and regulations to lock-in their advantage and prevent better companies from coming along and actually competing. Federal hiring laws are an example of this. The rules are so arcane, with so many requirements for federal contractors to fulfill minority quotas and fill out all kinds of forms that no one can compete.

    Perhaps we need a ban on political lobbying of any kind by any for-profit company that contracts with the government; or whose products are mandated for use by federal law.

  18. ““But how do you know when you’re seeing one of the exceptions?”

    That is the chief problem and the reason why the primary care provider, MD or not, must have ready advice available.

    My daughter-in-law asked me about a child of a friend of hers a couple of weeks ago. The girl had what looked like osteomyelitis in one leg. In kids it’s usually blood borne and there are typical locations. This girl had some findings in the right spot but then she got better and this week developed the same thing in the other leg. It seems that the current diagnosis is CRMO which I had never heard of before. The same mother has another daughter with Xeroderma Pigmentosum a rare genetic defect. The other daughter’s problem way also be genetic or autoimmune. To have both diseases in two daughters is bizarre.

    I’m glad I wasn’t the primary care doc.

  19. The best and most intuitive EMR I’ve seen was a few years ago and was written by a surgeon for surgeon’s offices. He wrote it in Visual Basic with some Visual C++ applications. He was showing it at the American College of Surgeons meeting. All his own work.

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