demonizing doctors, doctors are human too, patient satisfaction, primary care

There’s a shortage of primary care doctors. Who is responsible for solving this problem?

According to Medical Economics, in their article “How can physicians combat industry shortages and meet patient demands,” the existing primary care workforce bears sole responsibility for this.

The article doesn’t start off too badly.  It says that by 2025, there will be a shortage of 46,000 to 90,000 primary care docs. It then states that one of the reasons for the shortage is the relatively low pay that primary care docs get. This is true. Most primary care practices are consistently in the red due to low insurance payments, which is why there are very few independent practices anymore. Most are owned by hospital systems, who can absorb the loss.

That’s about where the sanity of this piece ends.  According to it, the second reason for the shortage is that we have not “embraced technological advancements.”  The article tells us that we need to deliver services via telemedicine and apps.

No matter that technology for this is still substandard.

No matter that there are serious concerns about cybersecurity and the safety of patient info.

No matter that using these technologies requires a substantial financial investments, of which no primary care doctor can afford.

No matter that there is absolutely no guarantee that insurers will actually pay for these services.
The article then goes on to give this sage advice:

Expand Office Locations: Research market trends and population changes across surrounding areas. Opening office locations in underserved areas experiencing population growth asserts your presence before other practices follow suit.”

And who the heck is going to staff these other locations? I thought they just said we’ve got a shortage of doctors! Maybe the staff of Medical Economics has discovered the secrets of cloning and can be in two places at once, but I haven’t figured it out yet.

It goes on to say:

Reevaluate office hours. Take a look at appointment patterns. Do most of your patients prefer appointments later in the day or earlier in the morning? Should you offer weekend hours? What about extending services later in the evening, when people are out of work? Instead of becoming complacent with standard office hours, test new hours and see how patients respond. Tailoring hours by office location will better serve patients while maximizing your staff’s time and resources.

See, here’s the thing.  My schedule is full during standard office hours. Do I have patients that would love evening or weekend hours? Sure. But am I supposed to work 24 hours a day, 7 days a week? It’s not like I sit around twiddling my thumbs from the hours of 9-5. I’m seeing patients for just about every minute of that time, and doing paperwork during any time I’m not seeing patients (and after hours and on weekends, too).  You can’t claim that there’s a shortage of doctors and too many patients to go around in one breath, and then claim that the doctors are the ones that need to be more accommodating in the next.  Supply and demand, people.


Here’s the thing, Medical Economics. The reasons for the primary care shortage are many. Low pay. Low prestige. Too much paperwork. Every-increasing government and insurance regulations and requirements. And, most important of all, not enough residency spots for training doctors.  There are only a certain amount of residency spots a year to train graduating MDs. If a doctor graduates from medical school but does not complete a residency, they can’t practice. They can’t get a license.  Their education is, in essence, wasted.  These are not bad students. There are just not enough spots.  Every year, almost 10,000 doctors do not match! Most of these doctors have gone to international schools.  All of them would do just about anything for the chance to practice medicine here.

It takes a 3 year residency to train a primary care doctor.  If those 10,000 doctors a year were able to do an internal medicine, pediatrics, or family medicine residency, our shortage would be non-existent in less than a decade.

Medicare needs to fund more residency spots.  Period. The way to solve a physician shortage is to make more physicians. It’s that simple, really.

The way to solve a physician shortage is not to place the responsiblity for it on the backs of those already bearing its brunt.


insurance, insurance insanity, Medicaid, primary care

Well, no chance of confusion here.

You know how insurance companies drive me crazy with their drug approval forms?  Well combine an insurance company with the government, and you get Medicaid. And when you get Medicaid, you get gems like this:

Approved?  Unable to approve?  Which is it???

On a side note…the best thing someone can do for their health is quit smoking.  Forget about losing weight, exercising, getting a Pap smear.  If you want to get the best bang for your buck, quit smoking.  With this in mind, why is it that Medicaid will cover Buproprion and nicotine replacement like the patch or gum, but won’t cover Chantix?  After all, the results for Chantix are superior to those for nicotine replacement.  In the long term, it’s even cheaper than trying and failing other therapies.  So, what gives, Medicaid?  I don’t like requirements that my patients “try and fail” medications.  I aim for success the first time out.

naturopaths, naturopathy, primary care, woo

Naturopathic Doctors vs. MDs

When I moved to New Hampshire 11 years ago, I was in for a bit of a medical culture shock. One of the biggest surprises was my first realization that there are “Doctors of Naturopathy,” or “NDs” in New Hampshire who are licensed to practice medicine.  In New York, I had had no experience with this.  This is not to say that people there didn’t see people who practiced “alternative medicine.”  What I’m talking about are practitioners who had attended a school of naturopathy and held themselves out to be primary care physicians with equivalent education and training to mine.

My first encounter with this was a patient who came to me because she had been diagnosed by her ND with “heavy metal poisoning.”  She actually was my partner’s patient, but had been squeezed onto my schedule as an emergency appointment because she wanted to be admitted to the hospital immediately to begin treatment.  My curiosity was piqued when I saw the chief complaint on my schedule.  How does an adult in Portsmouth, NH end up with heavy metal poisoning?  Had she had some kind of toxic exposure at work?  What kind of neurological problems was she manifesting?  Imagine my surprise when I walked into the room and saw a well-dressed, healthy looking woman in her late 40s.  She told me that she had seen a local ND for fatigue and difficulty losing weight (her weight was perfectly normal, by the way).  The ND had tested her for heavy metal poisoning.  She told me she was given some sort of pill, and then had her urine tested for heavy metals.  She handed me a lab report that looked something like this:

I’d never seen anything like this.  I asked her about her history and possible exposures…there was nothing significant.  I asked her very specific questions about neurological symptoms- there were none.  I performed a neurological exam, and it was normal.  I did a quick test of cognitive status, and it was normal.  I then excused myself from the room and went to my office to make a quick call to a doctor I knew who specialized in occupational medicine and toxic exposures.  He gave a sigh after I outlined the case, saying “I’m seeing more and more of this crap.  The test is worthless.  The pill was a chelating agent (a medication that binds to metals in the body).  This makes them pee out metals, but the reference ranges for the results are based on what you should pee out when not given a chelator.  It’s a way to make patients think there’s a problem and then they can be convinced to do all sorts of useless, expensive therapies to cure their ‘toxicity.'”  I thanked him and hung up.  I went back to the patient and explained, trying to be diplomatic, what I had found out.  She didn’t exactly believe me.  I offered to repeat the testing, by checking both her blood and urine for any heavy metal issues.  She accepted.  The tests were normal.  I called her and gave her the results.

I never heard from her again.  She transferred out of the practice.

That was my first experience.  I’ve had many others through the years…and most of them have been similar. In my experience, most patients that see NDs around here end up being diagnosed with one of several diagnoses- heavy metal toxicity, chronic Lyme disease, adrenal fatigue, or systemic candidiasis.  I’m not going to go into each of these issues, save to say that all of those diagnoses are controversial, so say the least.  Perhaps in another post.

I was also quite surprised that in addition to NDs being licensed to practice medicine in the state of New Hampshire, they are able to prescribe pretty much anything I can.  Here’s a link to their formulary.  Then, I found out that licensed naturopaths are considered primary care doctors here.  Just like me.  So, silly me, I figured that their education and licensing process must be just like mine, right?  Well, here’s a link to the requirements to get a naturopathic license in NH.  Here’s a link to what’s required to get a license to practice medicine in NH.  Keep in mind, in order to get a medical license in NH, you also have to submit an application to the Federal Credentialing Verification Service (FCVS).  Here’s a link to the FCVS requirements.

Equivalent?  You be the judge.

Clearly the licensing requirements for MDs are much more stringent than for NDs.  But what about the education?  NDs claim that their education is actually more complete than traditional medical school, with more classroom hours.  Since I’ve only gone to medical school and not naturopathic school, I’ve had to take their word for it.

Until now.

There’s a new blogger in town, and her name is Britt Hermes.  She attended Bastyr University, which is really the premier naturopathic school in the US.  She then practiced as a naturopath, and gradually became disillusioned with naturopathy and the practice thereof.  She’s blogging about her experiences  and her move away from naturopathy, and in doing so has truly exposed the deficiencies in the education given at Bastyr.

Head on over to ScienceBasedMedicine for the full post.  It’s long, but definitely worth your time to read.  Some highlights:

I recently scrutinized my transcript, course syllabi, and student clinician handbook. (Here is a table detailing my coursework into more readable categories based on my transcript; credits were translated to hours based on all of my courses syllabi.) I graduated with 1,224.5 hours of clinical training, of which 1,100 hours were in what Bastyr considers “direct patient contact.”…..

More on what Bastyr considers “direct patient contact”…

On a clinic shift, one faculty member (a licensed naturopath) supervised several naturopathic students. …Each clinic shift had a specific structure that included three elements: shift preview, patient appointments, and shift review.
Shift preview and review took place in the first 30 minutes and final 30 minutes of shift. During these periods, primary students roundtabled their patients. The patient’s medical history, previous visits to the clinic, and previous naturopathic assessments were discussed. Patient cases were presented in a standardized S.O.A.P. (subjective, objective, assessment, and plan) format. The supervisor usually asked students about differential diagnoses and treatment protocols. Medical standards of care were almost never discussed on my clinic shifts, with notable exceptions for one or two of my supervisors who insisted on it, to the dismay of many students. I often heard statements such as, “the patient has a strong vital force and it is expected that the patient will heal in 3 to 4 weeks’ time with proper self-care and home hydrotherapy treatments.” Sometimes, the preview and review was attended by first-year students completing their Clinic Entry 1 requirements. These students generally did not contribute to the discussions but their time was considered “direct patient contact.”
Actual patient care accounted for three hours of a clinic shift.
Patient care visits were typically attended by two students, a secondary and a primary. Appointments lasted anywhere from one to two hours. During an appointment, the primary student charted the patient’s current medical complaint and relevant history. This charting included a typical medical intake, such as the seven attributes of the medical complaint, a review of systems, past medical history, medications and supplements taken, family history, social history, dietary patterns, and so on. Vital signs, like blood pressure and temperature, were usually taken by a student. The patient intake also included information thought relevant to naturopathic diagnoses, like toxin and heavy metal exposure, use of plasticware in cooking and eating, birth history, pesticide exposure through eating non-organic foods, food intolerances, religious affiliations, and a host of subjective assessments relevant for energy therapies (homeopathy, flower essences, UNDA numbers, etc.).

Let me tell you about direct patient care in medical school.  Let’s take my internal medicine third-year clerkship.  It was 12 weeks long.  The first 6 weeks were all on the inpatient side.  We were part of a medical team on the wards, consisting of an attending physician, a resident, an intern (first-year resident) and the medical student.  We would typically arrive around 5 AM to start pre-rounds on our patients, and there were usually between 15 and 20 patients to a team.  Pre-rounding is where you check up on how your patient did overnight, examine them, check labs, etc.  After pre-rounding is morning report, which would be a didactic presentation of an interesting case.  Then comes formal ward rounds.  This is where the team rounds with the attending.  Presentations of the patient are made at the bedside.  A care plan is made for the day.  Interesting physical exam findings are shared among the team.  This usually takes at least 2 or 3 hours.  Then it’s time for “lunch.”  Lunch is always eaten in the lecture hall, because there’s a didactic lecture during lunch.  After lunch, it’s time to start doing any new admissions that have come in during the day so far. If you’re the lucky team on call, this will last until 11 PM.  If it’s just a normal day, it’ll last until about 6PM.  At 6 PM, you do a final quick round on your patients, make sure they’re figuratively tucked in for the evening, and then sign out their care to the night float team who will cover them until you come in at 5AM the next morning.

And you do this six days a week.  One day off for good behavior.

The next six weeks are luxurious in comparison, because they’re outpatient.  You work alongside a primary care physician in his or her office.  So, it’s much better hours.  We’d start around 7AM with hospital rounds on their patients, then see patients in the office until 5 PM, and then go back to the hospital to check on any inpatients or do any admissions.  But we got both Saturday and Sunday off!

By the way…the internal medicine rotation is considered to be one of the “easy” rotations, schedule-wise.  During my surgery and OB/GYN rotations, for example, there were days where I didn’t even bother going home for 2 or 3 days at a time, because it just wasn’t worth it.

And check this out:

Our student clinician handbook contained a list of broad medical categories such as cardiovascular disease, hepatobiliary disease, and female gynecological disorders, for which students were required to demonstrate medical competency. Medical competency in these areas was based on the number of appointments a student clinician had with a patient with that category of disease. The number of appointments varied. For example, competency for cardiovascular disease required treating two patients with any type of heart/circulatory disease. Competency for hepatobiliary disease required treating just one patient with any liver or gallbladder disease. Any patient needed to be seen twice to achieve competency.
While students were required to see a variety of primary care conditions in order to graduate, the majority of students never had the opportunity to see an actual patient suffering from such conditions.
Some diseases were very common in the teaching clinic. To the best of my memory, these included irritable bowel syndrome, anxiety, food allergies, fibromyalgiachronic fatigue, adrenal fatigue, chronic Lyme disease, chronic mononucleosis, chronic back pain, and esophageal reflux.
Less common diseases included hypertension, asthma, hypercholesterolemia, anovulation and menstrual problems, and acute illnesses such as the flu, pneumonia, bronchitis, gastroenteritis, and conjunctivitis. Students used to fight over seeing acutely ill patients as these patients were so rare!
Patients suffering from serious diseases, such as diabetes, cancer, and HIV/AIDS, could only be seen on specific clinic rotations. If students were unable to have direct contact with a mandatory health condition required for competency (due to a lack of patients and a lack of variety of disease in the clinic overall), students could present to fellow students on their clinic shift on the disease/condition to earn competency. A presentation usually lasted about 10 minutes and would cover the basic etiology, differential diagnosis, and naturopathic and/or medical treatments of a condition.

They were considered to be competent in treating all cardiovascular diseases by seeing two patients with any type of cardiovascular disease?  This is incredible.  Also, please take note of what Britt says about the dearth of patients with serious disease.  This is incredibly important to note.  You can’t be a good primary care doctor unless you’ve seen a lot of serious disease.  Here’s the thing.  Any idiot can diagnose and treat 90% of what we see on a daily basis in a primary care office.  The problem is with the other 10%.  Those are the patients with strange presentations of either common or rare illnesses.  You need to have seen a ton of stuff to be able to accurately diagnose a patient who is presenting in this way.

Now, I posted above about patient contact during my third year medicine rotation.  In the fourth year, I did a medicine sub-internship.  This is basically where as a fourth-year student, you pretty much function as an intern.  So it was more of the crazy rounding schedule above, plus some.

Once I graduated, the training wasn’t finished.  Internal medicine is a 3 year residency.  You’re not supposed to work more than 80 hours a week (what a luxury!) but in truth, we often did.  By my calculations, going off of 80 hour weeks, I had more than 11,000 hours of patient care in my 3 years of residency.

Naturopaths don’t do a residency.

Tell me again how they’re qualified to call themselves primary care physicians?

Do you want to see the doctor who is considered competent to treat all cardiovascular disease after seeing two patients with hypertension?  Or do you want the doctor who has completed over 12,000 hours of training in internal medicine alone, not to mention several thousand hours of surgery, OB/GYN, psychiatry, pediatrics, family medicine, and neurology?

Your choice.  Your decision.  After all, it’s your life.  Literally.

assistant physicians, Missouri, primary care

Never a shortage of bad ideas….

Everyone seems to know that there is a shortage of primary care physicians.  In the next 6 years, there is a predicted shortage of over 20,000 primary care docs.  There are lots of reasons for this- primary care doctors make less money, have more paperwork, have to see more patients…I could go on and on.  Of course, in the United States the prestige of a job is directly proportional to the paycheck received, so…you do the math.  The fact remains that only about 30% of medical school graduates go on to a primary care residency, and even fewer than that actually end up doing primary care, as many people who do an internal medicine residency eventually specialize.

Now, I obviously love doing primary care. I love seeing patients for years and having an ongoing relationship.  But I will admit that I seem to be part of a dying breed, and I would love to see that change.  However, true change will take a whole lot of adjustment in the US medical system.  Since that’s hard to do, Missouri has decided to take another tack.

Missouri has passed a law that creates a new entity- an “assistant physician.”  No, not a “physician assistant”- PA’s have been around for decades.  A PA is a health care provider who has completed a masters degree and is certified by the Board of Medicine.  They work under the direct supervision of a physician.  An “assistant physician” is something else entirely.

First, a quick review of the US medical education system:
1. high school
2. 4 years of college
3. 4 years of medical school
4.  1 year of internship
5. 2-4 years of residency
6. 1-? years of fellowship

Primary care doctors stop after step 5.  For example, after high school I did 4 years of college at the University of Rochester, 4 years of med school at the University of Rochester,  1 year of internship at St. Vincent’s, 2 years of residency at St. Vincent’s, and then I stayed on for an extra year as the Chief Resident.  Specialists go on to step 6.  A cardiologist has a 3 year fellowship.  An endocrinologist has a 2 year fellowship.

Medical students apply to residency during their fourth year of med school.  It’s a very competitive process, because there are only about 29,000 first-year residency spots available for about 40,000 applicants. Now, there are only about 16,000 graduates from US med schools a year, but there are also graduates of international medical school competing for spots, along with those who did not match in a previous year and are trying again.  In 2014, internal medicine filled 99.1% of its spots through the match, and family medicine filled 95%.  The most competitive spots, in specialties like orthopedics, radiation oncology, plastic surgery, etc pretty much fill completely.  The remaining spots go quickly in a process called SOAP.  1,075 positions were filled during SOAP, which leaves about 10,000 medical school graduates without a residency spot.  The vast majority of these are graduates of international schools, but about 500 US students were left without a residency.

Missouri has decided that these unmatched medical school graduates are perfect to fill the primary care void in rural areas.  They’ve decided that if a graduate passes Step 1 and Step 2 of the USMLE, they can work with an established doctor for 30 days and then basically go out on their own.  Forget about the fact that they don’t have to pass Step 3 of the USMLE and obtain an actual license.  They have to be within 50 miles of a designated preceptor and have 10% of their charts reviewed by said preceptor.

This idea is so bad that it really, really blows my mind.  First off, these new graduates are one of two groups: either they are a bottom-of-the-barrel student who truly could not get into any program or they really wanted a competitive specialty and couldn’t get it.  Both are poor candidates for primary care.  One group probably can’t hack the difficulty of it, and the other has no interest in primary care at all.  Add to this the fact that US medical schools are not set up to graduate doctors who are ready for practice. That’s what residency is for.  Med school teaches you the science and the basics.  The true training comes from residency.

Primary care is difficult.  I’m biased, of course, but I think it is one of the hardest specialties.  For many sub-specialists and surgical specialties, the diagnosis is already made by the time the patient reaches the door.  Look at the most competitive specialties that I listed above.  Not as much in the way of cognitive work in those specialties.  Of course, they have amazing other skills, but historically, cognitive work in medicine is incredibly undervalued.  After all, how do you put a price tag on a physician’s thought process and diagnostic acumen?  It’s difficult.  Anyway, what I’m saying is that in primary care a patient doesn’t walk up to you and announce, “Hey, I’m experiencing an occipital lobe infarct!”  They come in and say, “I’m kind of dizzy and not myself.”  And you are left to figure it out.

The last place in the world that a new grad with no residency training should be is in a rural area taking care of patients who have not had adequate primary care in ages.  Those patients are likely to be sick, sick, sick.  They need and deserve real health care, not some new grad who has no training and doesn’t really want to be there in the first place.  Missouri seems to be operating under the delusion that some care is better than no care at all.  They forget that poor care can do actual harm to a patient, and someone who doesn’t know what he’s doing can be a true danger to others with a prescription pad in his hand.

I also want to know what sucker physicians are going to agree to be preceptors for these assistant physicians.  The liability implications of this make my head spin.  No way would I agree to be responsible for the actions of some wet-behind-the-ears new grad who is 50 miles away from me.  No way.

Look, there are always going to be difficulties in getting physicians to practice in rural, remote areas.  That’s why the areas are rural and remote.  No one else wants to live there, either.  But this is the wrong way to go about solving this problem.

AAFP, ACP, JAMA, Patient Centered Medical Home, PCMH, primary care

The "Patient Centered Medical Home": A Pig in a Poke

Some of my readers might find this post a bit dull, but as a primary care doctor I find this information fascinating.  It also took me an hour and a half to write it, so please, read on…

Some of you might be familiar with the concept of a “Patient Centered Medical Home,” or PCMH.  This is something that was trotted out around 2006, and I’m both embarrassed and angered to admit that it was my own specialty organization, the American College of Physicians, that instigated it.  Now, in all fairness to the ACP, I think their intentions were good.  They saw that the cost of care in this country was rising in an unsustainable manner.  They saw that fewer and fewer doctors were entering primary care, frustrated with the low reimbursement and high paperwork demands.  They wanted a way to improve the primary care system.  But, you know what they say about good intentions. They pave the road to hell.

The American Association of Family Physicians jumped on the bandwagon the next year…and then in 2008 the bureaucrats joined the party.  A veritable alphabet soup of acronyms (The NCQA, JCHAO, AAAHC) began creating guidelines, accreditations, and payment schemes.  The Affordable Care Act specifically included provisions for PCMHs.

So, what’s so great about a PCMH?  Here is the general idea, taken from the 2007 guidelines developed by the ACP and AAFP:

  • Personal physician: “each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.”
  • Physician directed medical practice: “the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.”
  • Whole person orientation: “the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals.”
  • Care is coordinated and/or integrated: Care is coordinated and/or integrated between complex health care systems, for example across specialists, hospitals, home health agencies, and nursing homes, and also includes the patient’s loved ones and community-based services. This goal can be attained though the utilization of registries, health information technology and exchanges, ensuring patients receive culturally and linguistically appropriate care.[9]
  • Quality and safety
    • Partnerships between the patient, physicians and their family are an integral part of the medical home. Practices are encouraged to advocate for their patients and provide compassionate quality, patient-centered care
    • Guide decision making based on evidence based medicine and with the use of decision-support tools
    • Physician’s voluntary engagement in performance measurements to continuously gauge quality improvement
    • Patients are involved in decision making and provide feedback to determine if their expectations are met
    • Utilization of informational technology to ensure optimum patient care, performance measurement, patient education, and enhanced communication
    • At the practice level, patients and their families participate in quality improvement activities.[9]
  • Enhanced access to care is available through open scheduling and extended hours and new options for.[9][24]
  • Payment must “appropriately recognize the added value provided to patients who have a patient-centered medical home.”
    • Payment should reflect the time physician and non-physician staff spend doing patient-centered care management work outside the face-to-face visit
    • Services involved with coordination of care should be paid for
    • It should support measurement of quality and efficiency with the use and adoption of health information technology.[25]
    • Enhanced communication should be supported
    • It should value the time physicians spend using technology for the monitoring of clinical data
    • Payments for care management services should not result in deduction in payments for face-to-face service
    • Payment “should recognize case mix differences in the patient population being treated within the practice”
    • It should allow physicians to share in the savings from reduced hospitalizations
    • It should allow for additional compensation for achieving measurable and continuous quality improvements

When I first read about this, I kind of thought, “OK?  How is this different than what I do now?”  The answer was that it really wasn’t.  But if I wanted to be considered an Official PCMH, I would have to be accredited.  And in order to be accredited, I’d need to meet certain benchmarks, which basically are 10 standards that must be met:

ELEMENT 1A—Access and communication processes
The practice has written processes for scheduling appointments and communicating with patients.
ELEMENT 1B—Access and communication results
The practice has data showing that it meets the standards in element 1A for scheduling and communicating with patients.
ELEMENT 2D—Organizing clinical data
The practice uses electronic or paper-based charting tools to organize and document clinical information.
ELEMENT 2E—Identifying important conditions
The practice uses an electronic or paper-based system to identify the following in the practice’s patient population:

  • Most frequently seen diagnoses
  • Most important risk factors
  • Three clinically important conditions
ELEMENT 3A—Guidelines for important conditions
The practice must implement evidence-based guidelines for the three identified clinically important conditions.
ELEMENT 4B—Self management support
The practice works to facilitate self-management of care for patients with one of the three clinically important conditions.
ELEMENT 6A—Test tracking and follow-up
The practice works to improve effectiveness of care by managing the timely receipt of information on all tests and results.
ELEMENT 7A—Referral tracking
The practice seeks to improve effectiveness, timeliness and coordination of care by following through on critical consultations with other practitioners.
ELEMENT 8A—Measures of performance
The practice measures or receives performance data by physician or across the practice regarding:

  • Clinical process
  • Clinical outcomes
  • Service data
  • Patient safety
ELEMENT 8C—Reporting to physicians
The practice reports on its performance on the factors in Elements 8A.

Read these carefully, please, and tell me what you think might be wrong with these standards.  Well, aside from the bureaucratic gobbledygook, the vast majority of these standards only have to do with tracking data.  Elements 1B, 2D, 2E, 8A and 8C are about data tracking.  So 5 of the 10 “must have” standards for the Patient Centered Medical Home have nothing at all to do with patients.  They are just about data collection.

You can’t just say that you’re a patient centered medical home.  You have to apply to one of the 3 certifying agencies and do a ton of applications and undergo an on site audit, which can cost up to $8000.  You can’t just say that you track referrals and coordinate care with specialists.  You have to hire a nurse case manage to do this or designate a staff member.  You can’t just track data with a paper and pencil or Excel spreadsheet.  You have to purchase an EMR with special registry capabilities.

Therefore, the cost of becoming a PCMH is quite high.   Factoring in cost of the technology and electronic medical records along with the additional staff needed to be hired to perform “care coordination,”  it can be anywhere from $100,000 to $500,000 per physician.

Now, something that is so heavily promoted, so supported by every major medical organization, so expensive, must be good, right?  There must be a ton of data to support the effectiveness of the PCMH and its ability to improve health outcomes and reduce costs to the average American.  That would be the logical thought.  However, logic often plays no role in public policy.  In fact, there is very little evidence to support any of this.  A study released last year concluded that:

This evidence indicates some favorable effects on all three triple aim outcomes, a few unfavorable effects on costs, and mostly inconclusive results (because of insufficient sample sizes to detect effects that exist or uncertain statistical significance of results because analyses did not account for clustering of patients within practices).

This is in direct conflict to this report, which extols the virtues and success of the PCMH model.  Of course, that report is put out by the Patient Centered Primary Care Collaborative, which is an advocacy group whose stated agenda is to promote the PCMH model.  So, no conflict of interest there, right?  Plus, this report is based almost entirely on industry data from insurance companies, so again, pretty biased.

The fact is that there is a serious dearth of evidence to support the PCMH model.  Most of the “evidence” comes from extrapolating the better health outcomes from other countries that rely more on primary care rather that the fragmented specialist system we have here.  But that’s comparing apples and oranges.

A great study was published this week in JAMA called, “Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization and Cost of Care.”  The study evaluated 32 primary care practices in Pennsylvania who voluntarily became PCMHs.  The data analysis compared their costs and quality outcomes to 29 non-PCMH practices.  It also compared their performance from before they became PCMHs to after.  Three years of data were analyzed.  The results were pathetic, to say the least.  Out of 11 quality measures, only one showed improvement in the PCMH group.  One.  Hospitalizations did not decrease.  Emergency room visits increased.  Specialist visits increased.  Total cost of care increased.   I mean, these results are bad.  Really bad.  Couldn’t really be much worse.  In typical understated academic fashion, the study concludes, “These findings suggest that medical home interventions may need further refinement.”

You think?

I’m not particularly surprised by results, and most of my colleagues aren’t, either.  We haven’t been buying what the PCMH is selling.  When you start concentrating on data collection instead of patient care, it should not be a surprise that outcomes are worse.  When you hire additional people to “coordinate care” instead of letting the patient’s doctor do it, continuity suffers and care quality goes down.  When you are dazzled by e-technology and start letting electronic charts be the focus point of a visit instead of the patient in front of you, patient care suffers.

This is not rocket science, people.  Unfortunately, this is what happens when policy is put before practice.

doctors are human too, humor, primary care

I’m a real doctor, I don’t play one on TV

I was watching TV this past weekend when a commercial for another latest-and-greatest drug came on. Have you ever noticed that on TV a doctor’s office always looks something like this?

Neat and beautiful, with framed diplomas on the wall.  The TV doc is always in a crisp white coat, which matches his (and it usually is a man) distinguished white hair.  He peers out earnestly from behind his desk, comforting his nervous patient who sits before him (sometimes with adoring, anxious spouse).

But in real life…well, not so much.  Of course, no one is ever going to mistake me for a distinguished genteelly graying gentleman.  As a matter of fact, I once had a patient walk out of my office because I “look too young.”  Here’s my desk:

Shoved against a wall, no room for patients to sit in awe before me…I’m clearly doing something wrong.

No diplomas on my wall! Instead, we’re featuring portraits.

Looks just like me, right?

No sedate, distinguished globe and pen holder for me!  Instead we have this:

The true essentials- lots of lip balm, hand cream, dental floss, and silly putty.  I know what’s important to have at hand.

Wanna know where my diploma is?

It’s crammed into a corner in the home office, on the floor next to the dog crate.  That’s actually a step up for it- up until a few weeks ago it was in a closet in the basement.  Maybe one of these days I’ll actually get around to hanging it up.  
But maybe not.  I’m in no rush.  Because it’s not about appearances and outward trappings.  The fancy desk doesn’t mean a thing.  I have to earn the respect and trust of my patients, because they deserve nothing less.
insurance insanity, medications, PBMs, pharmacies, primary care

Even my paperwork has paperwork

Happy New Year!  For me, the new year brings a new onslaught of those lovely prior approval forms– that oh-so-crucial paperwork that insurance companies make me fill out to prove that the medication I prescribe is really, truly indicated (because I like to put people on prescription meds just for kicks, right?) and the absolutely, positively, cheapest thing around.  

For some reason, insurance companies seem to think that sometime between 11:59 PM on December 31 and 12:00 AM on January 1, everyone’s medical problems are instantaneously cured.  They must think that, right?  Otherwise, why else would everyone seem to need new prior approval forms on January 1?  And new referrals to other doctors?  It makes perfect sense.
Here is a new and annoying trend that I’m seeing.  Instead of just making the prior approval form available to me, Caremark now makes me fill out a form to get the correct form.  You read that right.  I now have to do paperwork so I can get more paperwork.
So, I have to fill out this form with all of the drug information and fax it to them so they can send me an even more specific form.  And while they’re playing these games, on the other end there is a real live human being waiting for their medication.
By the way, the drug that I’m ordering?  Costs $15.99 cash.  
And we wonder why the cost of American health care is so expensive.