An Update on Medical 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 physician 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.

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