What is Healthcare and Who Deserves it?

Today’s news if full of commentary about work requirements for Medicaid. Is work a prerequisite for healthcare or is health a prerequisite for work?

Not to complicate things, but can we even agree on what healthcare is? I don’t think we can, and it largely falls back on what we want to share in paying for.

A patient with an ugly skin lesion can have it removed if it might be cancer or if it bleeds or causes pain. If it is just ugly, it’s considered cosmetic, and insurance won’t pay for it.

A man wants a vasectomy, while another one regrets having one and wants it reversed. Is one procedure more medically necessary than the other and more deserving of societal cost sharing?

Even the most esoteric medical procedures, like freezing embryos or cloning children, could be called healthcare, but may not have society’s support when it comes to being necessary or desirable.

And, even as we speak, what about abortions? Are they healthcare or not?

In many ways, I think life was simpler practicing medicine in Socialized Sweden. The Government paid and the Government made the rules. Here, the Government makes some rules, the insurance industry makes others; the Government pays for some people’s care and the insurance industry pays for others. And the insurance companies all have different rules.

Since healthcare costs twice as much in this country as anywhere else in the world, it seems painfully obvious that we need to talk about what the purpose of healthcare is and, from a moral perspective, what we have a right to expect our fellow countrymen/women (if not citizens) to pay for.

It is remarkable that such an enormous slice of our budget and our life so much lacks definition and almost seems to be taboo to openly try to debate.

If we look at other aspects of cost sharing in our society, can we draw any useful parallels?

If a high school senior wants to repeat his senior year because he had so much fun, should he be able to do it for free? (Just a hypothetical example, I don’t know if anyone would really want to.)

If a child calls the fire department every time she smells smoke from the family barbecue, should the town charge the family or stop sending a fire truck?

If an amateur sailor capsizes every weekend and always calls Marine Patrol, should they keep responding?

In social policy terms, the word entitlement is used to define programs like Medicare and Medicaid. I think that is an unfortunate and very loaded word. Contrast that with another word that I personally keep coming back to: Stewardship.

It is time for a serious conversation about balancing stewardship and entitlement in healthcare. At least as long as it is not all self-pay: Taxes or insurance premiums both imply we want someone else to pay for some or much of what we think of as our personal healthcare.

My Triple Aim of Medication Assisted Treatment for Opioid Addicted Patients

My second foray into Suboxone treatment has evolved in a way I had not expected, but I think I have stumbled onto something profound:

Almost six months into our in-house clinic’s existence, I have found myself prescribing and adjusting treatment for about half of my MAT patients for co-occurring anxiety, depression, bipolar disease and ADHD as well as restless leg syndrome, asthma and various infectious diseases.

Years ago, working in a mental health clinic, we had strict rules to defer everything to each patient’s primary care provider that wasn’t strictly related to Suboxone treatment. One problem was that many of our patients there didn’t have a medical home or had difficulty accessing services. Another problem was that primary care providers unfamiliar with opioid addiction treatment were uncomfortable prescribing almost anything to patients on Suboxone.

This time around, the majority of my patients come to our clinic for all of their health care, or decide after being in our program to establish as primary care patients. I am the PCP for a good portion, and as the Medical Director for my clinic I not only have access to their medical records, but I am thoroughly familiar with my primary care colleagues’ preferences, practice styles and personal clinical strengths and weaknesses. That allows me to know when it works best to steer patients toward separate appointments for, say, their anxiety, and when it works better to establish a treatment plan right then and there as they become increasingly stable on their Suboxone.

Being involved in our group sessions, seeing clients on a weekly basis, even if briefly sometimes, and sharing impressions in post-group debriefings with my substance abuse counselor, Behavioral Health Director and our dedicated MAT coordinator has given me a profound insight into the personalities and circumstances of my Suboxone patients. The sheer depth of my insight from our comprehensive approach has allowed me to initiate life changing medication treatments for a large handful of patients beyond merely Suboxone.

Through a new grant we will soon also have a case manager, who will help our patients navigate their way back into mainstream society.

It’s funny: I had pictured Suboxone treatment as a carve-out niche in my practice, but it has become the most comprehensive, integrated thing that I do.

Doctors and CEOs Need Time to Think

I’ve always likened the job of a primary care physician to that of a Chief Executive Officer of a small business. Family doctors manage the “business” of delivering and coordinating care for more than a thousand patients at an average cost, in the United States, of $8,500 per year – an $8-$12 million business. Because the actions or inactions of the PCP impact the need for, and cost of, specialist and hospital care “downstream” from the primary care office, I think of this as “our” business.

Because of this, I subscribe to the Harvard Business Review. I figure doctors must have some degree of common business sense. And in my medical education, the slant of the business education I got was mostly relevant in the context of Socialized Medicine. I think that is helpful and useful in my practice in a medically underserved area, but there’s more to primary care than serving the underserved on a national level.

Reading the article “How CEOs Manage Time” in the current issue of HBR, I was struck by how light the “grueling” schedule of an American CEO is compared to that of an ordinary family practitioner: 9.7 hours of work each weekday and 3.9 hours on each weekend day.

I was also intrigued by the statistic that 61% of CEOs’ time is spent face to face and 24% on electronic communication. Only an unspecified fraction of 15% is spent on reading written reports.

Undocumented as far as both CEOs and physicians, as far as I know, is how much time we spend researching and thinking. A pullout quote rings true for doctors as well:

I do think it is crucial for primary care doctors to consider the value of their time in a businesslike manner. I know our employers do, but I suspect there is much confusion and disagreement about how to make the best use of our time. In simpler times, doctors just saw patients and brought in professional fees commensurate with their efforts.

But in today’s climate, where outcomes data is starting to determine office revenue and where the health of casual or infrequent visitors to our offices affects our bottom line, we need to claim the value of our time – and I feel strongly that we must leverage our knowledge for the biggest possible impact within our organizations and for our patient populations.

That impact will be less and less determined by line worker type activities such as traditional face to face office visits, and more and more by how we guide and coordinate more and more aspects of our enrolled patients’ health care.

We have added layers of staff to do this coordination work, but in many cases physicians have been peripheral, remaining too heavily involved in the traditional physician activities and not lending their medical common sense and “street smarts” to what could easily become a bloated and disconnected layer of bureaucracy.

Just like a CEO can be the originator and spokesperson for a corporate philosophy while making sure there are middle managers who can reinforce the message on a daily basis, we must be able to shape the overarching medical philosophy and the clinical pathways within our organizations. By doing that, we can more safely delegate tasks while also constantly overseeing and officially promoting and supporting the work that is done by care managers, health educators, nurses and medical assistants.

But just like CEOs, we can’t be spending all our time in meetings, face to face encounters and answering electronic messages. We need some time to research, consider and create. And the more our routine tasks spill over into nights and weekends, the less chance there is that we can think creatively and leapfrog our organizations into the next level of healthcare delivery.

Saturday Clinic

I volunteered to work Saturdays. And to do walk-ins. And to take all comers, not just our patients.

It has been an interesting journey.

Some clinics put their newest, least experienced clinicians on the very front line of doing urgent care. Here, it’s the opposite. I’ve got 39 years under my belt and I see everything from sore throats to people who left the emergency room in the middle of a workup because their anxiety kept them from waiting for their CT scan to rule out a blood clot in their lungs.

The waiting room fills up, and it’s just me and a medical assistant.

It’s refreshing and rewarding to see things that can be fixed in a matter of minutes: embedded ticks, corneal foreign bodies, pieces of hearing aids deep inside ear canals, bursitis cases and nursemaid’s elbows.

My very first paychecks as a doctor came from weekend stints back in Sweden while I was still in medical school. At least back then, they had a system where senior medical students could be given temporary privileges as locum tenens physicians with minimal supervision. I worked weekends, Friday night to Monday morning, seeing patients that weren’t sick enough to need the full resources of the emergency room in a hospital about an hour away from my medical school.

Already then, I thrived on not knowing what challenge was next up. Whatever it is, I’ll do my best, I figured. And at that point, the resources of the emergency room were right down the hall.

Here, the emergency room is 20 miles away, but the ambulance is only a couple of miles away and I’m not the stand-in EMT the way it was when I first came here.

Primary Care is turning into a specialty of chronic care and public health. Some of the chronic care we do is really what internal medicine specialists used to do before they all wanted to subspecialize or go into hospital medicine. And much of the acute care we trained for is now being done by emergency and urgent care physicians as well as PAs and Nurse Practitioners.

And Public Health is a very different thing from what doctors of my generation trained for. I still feel it is better suited for nurses than doctors. I didn’t attend medical school for 5 1/2 years and do two residencies just to blindly follow rules; I trained to know when rules and guidelines do and don’t apply.

Doctors are trained to identify the exceptions from the rule, which is a useful skill on the front lines. Which migraine is really a brain tumor? Which asthma attack is a foreign body in the trachea? Which rash is a sign of leukemia?

I worked hard today, but I don’t feel drained; I feel energized, because I cured a few people, and closed a few cases. Chronic care with no acutes wears on you. The extra work I do may seem like a burden to some, but I find it rejuvenating. It brings a healthy balance to my work week.

Self-Driving Cars are Like Most EMRs

Drivers are distracted klutzes and computers could obviously do better. Self driving cars will make all of us safer on he road.

Doctors have spotty knowledge and keep illegible records. EMRs with decision support will improve the quality of healthcare.

The parallels are obvious. And so far the outcomes are disappointing on both fronts of our new war against human error.

I remember vividly flunking my first driving test in Sweden. It was early fall in 1972. I was in a baby blue Volvo with a long, wiggly stick shift on the floor. My examiner had a set of pedals on the passenger side of the car. At first I did well, starting the car on a hill and easing up the clutch with my left foot while depressing and then slowly releasing the brake pedal with my right forefoot and at the same time giving the car gas with my right heel.

I stopped appropriately for some pedestrians at a crosswalk and kept a safe distance from the other cars on the road.

A few minutes later, the instructor said “turn left here”. I did. That was the end of the test. He used his pedals. It was a one way street.

Three times this spring, driving in the dark between my two clinics, I have successfully swerved, at 75 miles (121 km) per hour, to avoid hitting a moose standing in the middle of the highway. Would a self driving car have done as well or better? Maybe, maybe not.

Every day I get red pop up warnings that the diabetic medication I am about to prescribe can cause low blood sugars. I would hope it might.

Almost daily I read 7 page emergency room reports that fail to mention the diagnosis or the treatment. Or maybe it’s there and I just don’t have enough time in my 15 minute visit to find it.

For a couple of years one of my clinics kept failing some basic quality measures because our hasty orientation to our EMR (there was a deadline for the incentive monies to purchase EMRs) resulted in us putting critical information in the wrong “results” box. When our scores improved, it had nothing to do with doing better for our patients, only clicking the right box to get credit for what we had been doing for decades before.

Our country has a naive and childish fascination with novelties. We worship disrupting technologies and undervalue continuous quality improvement, which was the mantra of the industrial era. It seems so old fashioned today, when everything seems to evolve at warp speed.

But the disasters of these new technologies should make us slow down and examine our motives. Change for the sake of change is not a virtue.

I know from my everyday painful experiences that EMRs often lack the most basic functionalities doctors want and need. Seeing a lab result without also seeing if the patient is scheduled to come back soon, or their phone number in case they need a call about their results, is plainly speaking a stupid interface design.

I know most EMRs weren’t created by doctors working in 15 minute appointments. I wonder who designed the software for self driving cars…

Getting it Right

There are many days in primary care when you feeel like you are treading water; nobody gets substantially better as time and disease progression seem to always win over your own and your patients’ efforts.

But sometimes you hit a winning streak. The past few weeks seemed to bring me one diagnostic or therapeutic coup after another.

There was the depressed man who came in smiling and said “I’m shaving again”.

There was the woman who was obviously doubting my assessment that the lip rash she had struggled with for two months was just a simple yeast infection.

I remember another woman with a moist, burning rash in every skin fold of her body. Because she also had some rough patches on her elbows, I suspected she didn’t have yeast at all but a bad case of inverse psoriasis. My seemingly counterintuitive choice of systemic steroids worked like a charm.

I thought back to the man with a stubborn back pain, who couldn’t even tolerate the simple exercises his physical therapist had suggested. Because he admitted to feeling depressed, at least about his chronic pain, I had given him a low dose of duloxetine. The other day, he told me he had felt better already after the first dose; he was spending time with his family again and his back hardly bothered him at all.

Then there was the woman who had fired the doctor who took her off hydrocodone. She certainly had a fair number of orthopedic issues, but her pain was really everywhere. This, along with tender trigger points and her history of poor sleep and profound fatigueabilty, led me to believe most of her pain was actually from fibromyalgia. On two capsules daily of the lowest dose of gabapentin, she had half the pain and double the hours of useful sleep. She was beaming at me the other day and shook my hand with he power of a lumberjack.

I also remember the man who came in depressed and angry with a tale of how everyone around him was withdrawing because of his pricklishness. He fit the criteria for Bipolar disorder, type 2, and between his new mood stabilizer and low dose antidepressant, he was back at work and back in his relationship.

All these small victories added up and gave me a renewed sense of being an effective catalyst through the basic application of observation, knowledge and, for lack of a better word, salesmanship.

It’s not enough to know what to do. How we present facts and formulate treatment plans is part of the therapy. A half-hearted “you might try this” is a lot less likely to work than explaining the diagnosis, describing the mechanism of action behind the symptoms and the medication and even the history behind the treatment.

I believe I made some very good treatment choices, but I also know that what we disparagingly call the placebo effect is always present to a degree, just like the opposite force, the nocebo effect.

I believe that presenting a medication as a very powerful tool that can both help or hurt, and emphasizing the need for skillful dosing and monitoring, you can create expectations and instill hope that helps build the neurobiological foundation for healing. There is more and more literature on that.

And as a doctor with a recent winning streak, I was at least a little bit emboldened over the last few days.

I remember talking with a new patient with longstanding anxiety, who didn’t want medication but seemed at least lukewarm to cognitive therapy. I explained quite a bit about how it works and what the evidence has shown about its effectiveness compared to unstructured forms of talk therapy. Near the end of our visit, he revealed his original intent: He wanted a letter for his landlord so he could get a dog, because he believed that would quell his anxiety.

I love dogs and I worry about people wanting dogs more for their own needs than the dog’s.

I leaned back, looked him in the eyes and said:

I’ll make a deal with you. You start therapy, and I’ll write you a note.

He was silent for a moment, then answered “okay”.

I was on a roll.

Primary Care Needs a New Business Model

Primary Care visits are never quick; we don’t give much advice over the phone or online; and we prioritize the Government’s and insurance companies’ public health agenda over our own patients’ concerns.

Imagine healthcare as a retail customer experience for a few minutes:

Imagine you’re going to Walmart to buy a bag of dog food, a new coffee maker or to equip a small kitchen in your newly built mother-in-law apartment.

1) You’ve bought dog food there before, so you know exactly where it is. You just want to quickly grab a bag and get out of there.

2) You have a rough idea of where the coffee makers are; you know some brands you trust, but you might have one or two questions before you select one, and if they don’t have one you like, you might get it somewhere else. Or, you might even check their website to see which models they carry.

3) For the new kitchen, you have a list, but know you probably haven’t thought of everything, so you plan to walk down the aisles in the kitchen and home departments. You plan to spend a fair amount of money, so you might be on the lookout for special sales or promotions. But, you definitely don’t want someone else to choose all the items for you.

Can Walmart meet your needs in all these situations? Probably yes.

Now, think about how your doctor’s office works:

1) Can you quickly get in and out if you have a simple problem like conjunctivitis?

2) Are they able to give you information on what your options are for a recurring shoulder dislocation; could they refer you to a shoulder specialist without first waiting weeks to see your primary care doctor?

3) You have lots of issues and try to get an appointment to deal with them all at once; you think of it as a physical, but last time you had a physical, your doctor brought up all kinds of things you don’t particularly see as priorities for yourself.

Here are the existing realities of Primary Care:

We can’t afford to just see you for something quick. Our quality indicators, which more and more will determine how we get paid, will go down if we don’t screen you at every visit and offer interventions for depression, smoking, alcohol misuse, hypertension, weight management, immunization needs and much more.

We won’t refer you without seeing you, and we often hesitate giving you medical advice over the phone. Our providers are not scheduled for anything else besides seeing patients, because the rules of how we are paid still emphasize face-to-face visits over “population management”. So our providers are busy all day long seeing patients for visits that could have been simple but are loaded up with mandatory screenings and interventions and our medical assistants, besides being busy with all our screening questionnaires, are discouraged from giving medical advice they aren’t formally trained to provide.

Is there a doctor shortage?

We are said to have a doctor shortage. We have an aging population with more and more chronic diseases, like diabetes and heart disease. The need for skilled and experienced medical providers is continually increasing.

We have no Public Health system to speak of in this country, so the Government, through Medicare and Medicaid, has mandated that health care providers do the things the Public Health system does in other countries.

This is, plain and simple, what is clogging up the works in healthcare today: Too much non-doctor work is crammed into each patient visit, and we can’t charge for giving advice or directing care except in a face-to-face visit.

You don’t need to go to medical school to give immunizations, tell people smoking is bad for you, explain that “low fat” foods cause obesity, or promote regular exercise. You don’t even need to be a doctor, PA or NP to screen for high blood pressure – only to treat it. (Some pundits, in utter desperation, have suggested we send pharmacists to school to learn how to treat hypertension, but there are of course plenty of licensed medical providers who are able and willing to do that if we get freed up from the less-skilled tasks I just listed above.)

Patients and doctors have no control

Now, why are we doing all those things we do if they are so inefficient? Quite simply, whoever pays us has the power to define our work. We call that “Health Insurance”, but that is not exactly what we are dealing with. Insurance, for home, auto or employer liability, has nothing to do with predictable events or minor issues. Your car insurance doesn’t pay for oil changes or tire wear, not even for a minor paint scratch. But somehow that is what we expect health insurance to cover for our bodies. In terms of auto insurance, most people probably figure an insurance job carries an inflated price tag and lots of paperwork. The same is true for health care, which should not be a surprise to anyone.

For example, years ago the overhead cost of insurance billing for each primary care doctor was reported to be $80,000. That, put very plainly, is money that patients and employers are ultimately paying through premiums and deductibles.

And all the mandated screenings are there because Medicare in particular has the right to micromanage doctors’ work because they are paying for healthcare visits, which could be quicker and less costly if patients had control over their healthcare spending.

How could we do better?

We do three things in primary care, each with its own workflow and, really, each with its own economics.

1) We could do our part of Public Health more effectively. Allow us to promote immunizations and other primary preventions outside our already crammed fifteen-minute visits. Pay us a per patient per year stipend to reach out to target populations through mail, phone web or, when appropriate, in person about general health issues. Stop imagining we can do all of it and still treat diseases, acute and chronic, in our measly fifteen minutes. Right now, that is just clicking boxes with little actual substance. Use some of the Government money that should have been spent on a working Public Health system if you want us to step in and do the Government’s work.

2) Make it economically feasible for medical providers to oversee patient care by acknowledging that reading incoming reports, answering phone or web inquiries and coordinating care with specialists and hospitals are essential parts of being a medical home for patients. Such activities should not be unpaid services eked out at the expense of lunch, bathroom breaks or dinner with our families.

3) Allow us to define each office visit together with our patients. It is insulting to everyone involved to have to interrogate someone with a splitting headache, twisted ankle or bleeding laceration about their diet and alcohol habits. I could see many more patients if I could delegate those things to outreach staff or simply not do it every visit. Right now we are made to act as if we will never see that patient again. I was trained to provide care over time, in a relationship based practice. That is proven to be an effective and fiscally sound way to deliver healthcare.

The third task is the only one that makes sense to pay us for on a per-visit basis, whereas the first two deserve their own payment method. Personally, I wonder if the first few hundred dollars worth of Primary Care visits are worth churning through the expensive bureaucratic insurance machinery, or if it wouldn’t make more sense to just allow each patients a set amount of spending at their discretion.

I am not writing about privately financed, Direct Primary Care or Concierge Medicine. Those obviously exist, and may work well for many people, but the healthcare payment options for most Americans are what desperately need fixing.

Only if we acknowledge that Public Health, Population Health and Face-to-Face visits are three separate aspects of health care can we move forward in reforming Primary Care. And only if we recognize and reimburse physicians’ non-face-to-face work fairly will we see the improved customer service and doctor-patient communications we are now only paying lip service to.

(This would also help reduce physician burnout, in case anyone didn’t realize that!)

Where would Google be if we had to make an appointment to sit down with a search consultant and pose our questions, fifteen minutes at a time? It may be an outlandish analogy, but healthcare needs some shaking up…

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