Friday, March 15, 2013

Danny Sands states the problem

My friend and colleague Danny Sands (seen here with e-Patient Dave) posted this remark on Facebook:

The good news: I provided superb and compassionate care to the patients, many of whom were quite complex, who I saw today.

The bad news: I ran behind and one of my scheduled patients left without being seen. 

Primary care is tough. I can either do a great job or run on time, but can't do both. Maybe I could do it if I didn't take care of sick patients, but those are the patients who really need care.

Ok, so how to deal with this? One theory--the current one traveling around the country--is that hospitals and doctors should be paid by a capitated or global payment.  This theory is based on the idea that such a payment mechanism will result in better coordinated care, with the primary care doctor empowered to act as the patient's traffic cop vis-a-vis the interaction with other participants in the continuum of care.  If and when the accountable care organization beats the capitated budget, the surplus will be recycled back to the PCPs and others who made it possible.  But I have explained before why this incentive mechanism is not likely to work.  Certainly, it does not provide a precise enough signal to PCPs that it would cause them to add the kind of time Danny seeks to take care of patients.

There is a much simpler solution:  Pay the PCPs more.  Make it possible for them to have smaller panels of patients so they can spend the time they need to.  Recognize that the value of their cognitive skills is equivalent to, if not exceeding, the skills of proceduralists who now get paid so much more.  My theory--which has at least as much empirical support as the capitated ACO theory--is that society will save the extra dollars spent on PCPs in reduced hospitalizations and procedures.


Cynthia Barnard said...

Dear Dr. Levy,
I am curious if you have encountered this (see below) and what you think of it. I find it both horrifying and likely to be quite effective among some patient/consumer groups.

Cynthia Barnard

From: Matt Street
Date: Thu, Mar 7, 2013 at 3:40 PM
Subject: Exciting Telemedicine Opportunity in IL

I hope that you are doing well. I thought you might be interested in this exciting Telemedicine opportunity in IL. Below you will find a detailed description of this opportunity. If you are interested I would love the opportunity to set up a quick 15 minute call to discuss the additional details and answer any questions you may have. Have a wonderful day and I look forward to your response. If you provide a couple of days/times that are best to reach you and your phone number I will be more than happy to call.

1. You will be doing online (web based w/ webcam) patient encounter. These patients are enrolled in this system that is known as NowClinic.

2. We are building a network of physicians in all 50 states so you as the doctor will only be seeing patients in those states you are licensed in. No additional licenses will be required.

3. Each encounter will last a maximum of 10 minutes.

4. There is no special software or equipment needed. Just a computer with a web camera.

5. Here is how it works:
• The patient will log into the secure online system. Fill out a patient history form and select a chief complaint.
• Once they select you as the doctor they would like to see you will be notified via your contact preference (email, text, call, etc..) that they are in your virtual waiting room.
• You will have 15-30 minutes to log onto any computer, view history/chief complaint then take the encounter.
• You will then accept the encounter. You can also decline if you feel it is something that you will not be able to consult on.
• You will then do the 10 minute encounter with the patient. There is a chat log kept on an electronic medical record. There is no coding to do, just simply a record of the encounter.
• There is a clear defined list of diagnosis’s and prescriptions that you can choose from if you think any are needed. The patient will put all pharmacy information in the system for you. All you have to do is electronically send the prescription.

6. The encounter is over and you can resume doing what you were doing. Most doctors do this while practicing in their clinics
7. Like locums, your malpractice insurance is covered. The policy is like that of locums with 1mil/3mil w/ tail and is provided by AIG.

8. You are paid per encounter. No follow up, admin or overhead to worry about.

Have a wonderful day and I look forward to your response.


Matthew Street
Chief Operations Officer
MedTel Solutions, LLC.
P: 256.217.5878 x104

e-Patient Dave said...

Of course I love my primary, Dr. Sands, and his total concern for patients' well-being, and in recent years I've been schooled in the disgusting money-centric system that causes those problems.

Nonetheless, I continue to discuss with him that I still think there's no excuse for not explicitly making clear that appointments are likely to be very late. Years ago I learned to bring my computer to work in the lobby, but the reality is that this takes a much bigger chunk out of my day than when I visit someone who runs on time.

And half the time I find a very frustrated, angry fellow patient in the waiting room, who was not aware that this is normal in this business.

I believe that this failure to warn (effectively) boils down to lack of sufficient concern for the patient's time and frustration. As Danny said, new staff in this case wasn't aware of his patterns; heck, I've NEVER found anyone at the clinic's desk who would give me a straight answer when I directly asked.

Dr. Sands and/or whoever runs HCA need to get honest about this, IMO, and not be all "there's nothin' we can do." That's being disempowered. C'mon, respect others' time as you respect their health: fix this.

(As I say, this isn't gossip - he and I have discussed this repeatedly.)

BIDMC is too world-class in some ways, to have this bush-league "we can't help it" aspect of the patient experience.

Danny Sands said...

Cynthia, the offer you received is from a company that is arranging physician staffing for a United Healthcare benefit to some group through which they provide 24x7x365 access to physicians. This is done by recruiting physicians in each state in which they want to operate (for licensing reasons) and scheduling one or mor physician to be available online at all times. When a physician is available, they declare themselves to be available by logging on to the site. When a patient needs a consultation, they log onto the site and the physician is notified via email, text, or whatever and they need to respond within 15 minutes. They decide if they want to take the case, and if so the physician and patient connect using a combination of video and chat. The physician is paid 25 dollars for the 10 minute encounter. The system uses a technology developed by American Well and is quite good.

It certainly meets a need we have in healthcare, which is easy access to medical care whenever and wherever we need it. Downside is the lack of integration with the rest of the healthcare system. But, like retail clinics, this should push physicians into providing more consultation and treatment options to their patients.

It's worth physicians exploring if they want to generate a little extra income.

jonmcrawford said...

Dr. Sands, I'd be interested in your response to Dave's comment, because that was my first thought. "Did anyone tell this patient that the doc was running late?"

We all understand that quality care takes longer, and I think people will be happy to wait if they know that you will spend extra time with them too, but our time is just as important as yours (in our view at least) and we can't wait indefinitely, we also have other obligations.

Personally, I'd like to see some sort of dashboard online that you could check the day of, so that if the practice is running say an hour behind, you don't bother driving over and get some more work done/get some lunch before you show up. However, even a quick FYI when you sign in would be appreciated.

All that said, I also think Paul's suggestion is great, and PCPs should be appropriately compensated to coordinate care at a higher level.

Jim said...

Are there any data that support your idea that higher salaries for primary care doctor would cause them to see fewer patients?

I don't see proceduralists seeing fewer patients.

I suspect this will result in greater expenses with no change in the number of appointments per day.

We have a tremendous capacity for recalibrating income expectations.