During my travels, I’ve been catching up on my journals. Given my current clinical work, I read both primary care and emergency medicine journals, and then there are the informatics articles that appear across a number of specialties.
I was amused by an editorial about cystic fibrosis in the June 15 edition of American Family Physician. It states, “The continuity and closeness that a family physician has with these patients has the potential to be a stabilizing and encouraging force in assisting with compliance and disease prevention, enabling patients with CF to maximize their quality and quantity of life.”
One of the main complaints I hear from primary care physicians across the country is an increasing lack of continuity. Patients are forced to change insurance when their company decides to update plans, or their providers may be dropped from insurance panels due to cost or quality profiling. Generally speaking, most primary care physicians I know entered the field because they wanted to have longstanding relationships with patients and wanted to help those patients live longer, healthier lives. Considering the average physician compensation across specialties, they certainly didn’t get into it for the money.
Because of my IT work, I’ve spent the last several years practicing in non-continuity settings such as urgent care or the emergency department. Although I occasionally work as a locum tenens in primary care practices, in those situations I usually see acute visits or overflow patients that can’t be accommodated by the other physicians in the practice. Not every practice has the luxury of bring in a locum when a physician is on vacation or leave, however. Many of them end up referring patients to local urgent care centers or walk-in clinics in order to address their needs.
Capacity isn’t just a problem when providers are out. In many of the practices I encounter, the physicians are carrying patient panels that are much larger than they should be to deliver quality care. This results in patients being directed to urgent care centers more often than they should, as well as patients electively choosing the urgent care route due to access and convenience issues. This in turn can drive up the cost of care and lead to increasing fragmentation. Physicians are carrying larger panels not only due to decreases in the primary care workforce, but also in attempts to tweak their payer mix to ultimately bring in more revenue.
Although we can celebrate interoperability and the portability of our health information as a way to smooth this fragmented care, that’s only part of the answer. There is a certain element of quality provided by being able to see a physician who knows you well over time. Merely having more pieces of information doesn’t always give physicians the information they need to provide the best care for their patients.
As the population ages and the burden of chronic disease increases, patients become more complicated. With the technology boom, we’ve seen an increase in the options available to manage patients and this also drives up the complexity of care. Complicated patients with complicated problems require more time and thought to manage. I can’t imagine how personalized medicine is going to play into the mix. We can throw layers and layers of technology at the problem, but that approach seems to frequently create additional problems.
In some situations, new therapies lead to the need for increasingly personal conversations with patients about whether a treatment is right for them and what the various costs and benefits might be. Additionally, we don’t have long-term studies on some of these treatments, so we’re trying to predict risk with our patients without adequate data.
In one of my journals, there was a write-up about a new diabetes medication that has a unique mechanism of action. This may be perceived by many patients as new and improved, but there is no long-term data on the morbidity or mortality benefits of the drug. In one study, it was shown to be equally effective as traditional therapies. My translation of “equally effective” is “no better than,” but there’s quite a different emotional response depending on which words you use.
Although the medication is newly approved and heavily marketed, it comes at a cost. A one-month course of treatment costs $335 compared to the “equally effective” older drug which costs $4 per month. It also is associated with higher risk of urinary tract infections and bladder cancer. Having that conversation with a patient you know well and who trusts your advice is very different than with a patient with whom you don’t have an established relationship. It’s hard to provide culturally competent care (one of the new markers of quality) when there’s not adequate time to develop rapport or resources to form an assistive care team.
The newer models of care delivery include Patient-Centered Medical Homes and other structures designed to deliver care in our increasingly value-based models. We’re offering physicians reimbursement for care coordination and increased payments for higher quality. However, it creates a chicken-or-egg cycle where you have to have more staff to form and train a care team to get more money, which you need in order to have more staff, etc. It’s easy for those of us in the IT and policy trenches to think that physicians should just cut their pay to hire staff. Although that might work in a physician-owned practice, it certainly doesn’t work in employed situations.
Regardless of employment status, new medical school graduates are coming out with record debt – another reason not to choose primary care. Most of the new physicians in my community are entering practice with over $300,000 in student loans. Even at a 30-year repayment it’s like having an extra mortgage payment (or two). Many of those new grads opt for employed positions because they can’t take the financial risks required to open their own practices (assuming someone would even loan them the money to do so with that kind of debt). They wind up in a different kind of bind where their hospitals or employing health systems control staffing and expenditures and often create barriers to developing effective care structures.
I know by this point some readers are wondering what this has to do with healthcare IT and why it’s in HIStalk. In the field, I see many practices where work is being shifted up to providers rather than down to support staff due to increasingly complex systems. A recent engagement involving multiple EHRs revealed clinical reconciliation processes that were so confusing that physicians were reluctant to have anyone else perform the task. Even as an advocate for work redistribution, I agreed with them. I saw two different patient portals in use, both of which had serious usability issues and one that had some potential patient safety issues. Although they may have performed well in some kind of laboratory testing event, they were not meeting the needs in the complex realities of the average office.
Vendors need to have clinicians on staff as well as a network of client and non-client physicians to test new products and proposed changes to products. This also goes to other types of users – clinical, financial, etc. We need to see technology vetted in more real-world environments if we expect to be able to revolutionize how care is delivered. We need vendors to be more nimble and use best practices to translate emerging federal and payer requirements to viable code. We need processes and procedures (both vendor and governmental) that allow product delivery in enough time for practices to implement upgrades and features without the rush and chaos we currently see.
Having better systems, processes, and workflows will help mitigate what sometimes feels like an assault on our nation’s caregivers. It might even convince some physicians who might otherwise be motivated to leave or curtail their practices to consider staying. Ultimately, it might even result in better care.
What are your thoughts about the future of medicine? Email me.
Email Dr. Jayne.