Tuesday, May 21, 2013

If You Want to Win, You May Have to Fight

“Victorious warriors win first and then go to war, while defeated warriors go to war first and then seek to win.” –Sun Tzu

According to the National Committee for Quality Assurance (NCQA), there are around 33,000 Patient Centered Medical Home (PCMH) recognized entities to date, 5,560 of which are practices. Subtracting this and noting that many recognized entities are Nurse Practitioners (NPs), we can safely estimate that approximately 10% of the 209,000 practicing primary care doctors in the U.S. are working in a recognized PCMH. There are other accreditation bodies, but NCQA is by far the largest and best known, so the numbers above should be pretty indicative, give or take a few percentage points. My estimate is that another 80% or so of primary care physicians practice in unrecognized medical homes. Yes, 80%. Although it is difficult to get exact numbers, perusing the NCQA lists of PCMH shows that a large number of recognized medical homes belong to health systems, academic centers and community health centers.

According to the Office of the National Coordinator for Health Information Technology (ONC), 72% of office-based physicians were using some sort of EHR in 2012, and 66% either demonstrated or are planning to demonstrate Meaningful Use. As with medical home recognition, EHR ownership is also skewed in favor of larger practices, with solo docs in particular, lagging significantly behind.

And then there is the Physician Quality Reporting System (PQRS), with or without Maintenance of Certification (MoC), and the legacy electronic prescribing initiative, and the upcoming Value Based Modifier, all from Medicare. Private payers, and sometimes States, have their own slightly different pay for performance (P4P) programs. And all these programs are layered on top of a thick and knotty web of rules and regulations, specifying medical necessity, need for prior authorizations, medications formularies, the amount of text and the terminology needed to justify payments, and everything comes in as many flavors as there are health insurance plans.

Health systems and large medical groups have dedicated departments and staff to oversee and take advantage of all these programs, better known as quality initiatives, and that’s why they need to collect additional facility fees (and, according to the American Hospitals Association, also because of the “threat of terrorist attacks, recent mass shootings, the aftermath of Hurricane Katrina and the devastating tornados over the past year”). Small practices, on the other hand, have nothing but angst. The vast majority is resentfully struggling to keep the balls in the air in haphazard ways guaranteed to eventually fail, and a small (but growing) minority is  taking their toys and going home to practice cash-and-carry medicine. But here and there, you find the anomalous independent practice that is thriving; still chock full of resentment, but with a smile, because when you outsmart your opponent, it’s satisfying to acknowledge that this was (is) a powerful (dangerous) opponent indeed. So what’s the secret sauce? And is it scalable to all other soon to disappear independent physicians?

Let's begin with the medical home because some solutions are embedded in its concept, and because the brand new NCQA Patient Centered Specialty Practice (PCSP) recognition extends the same model to physicians who are not practicing primary care. First let’s assume that you chose to be a doctor so you can take care of patients, and this is still what you would prefer to be doing, but an extensive and growing bureaucracy along with shrinking payments, is preventing you from providing the care you believe you should be providing to your patients. If your aspirations are different, or if you are one of the few physicians who made the switch to cash pay, what follows will be of no use to you. 

For illustration purposes, let’s look at a solo practice, because whatever works for a solo practice, can be easily extrapolated to a larger group (but not vice versa). The first and most fundamental tenet of the medical home model is the personal physician, i.e. a person with an MD or DO, who is supposed to create a continuous relationship with an individual patient. It is worth noting that primary care practices led by non-physicians are by definition not Patient Centered Medical Homes, regardless of the current push to the contrary. Unfortunately, NCQA is deferring to State laws, and will recognize medical homes without a physician and/or medical homes where a non-physician is substituted for some patients, but NCQA does not dictate that non-physicians should provide primary care. So basically, it’s up to you to implement this any way you see fit. You are not required to hire non-physicians or delegate patient care to other people. PCMH merely asks that you build a long term personal relationship with your patients.

If that’s the case then how about team care, huddles and that sort of thing? To answer this question, I would suggest a small exercise. Exercise #1: read the PCMH standards and substitute the word “staff” everywhere you see “team”. Does it read better now? Replacing the term “staff” with the term “team” is a semantic innovation that is sweeping every business everywhere. It is not limited to health care and it should not elicit visions of an egalitarian system where nobody is in charge. In case you are not aware, every business executive that used to have staff and staff meetings, now has a team and team meetings. Same people, same reporting hierarchy, with added feel good validation for employees, usually in lieu of promotions and salary raises. If this rationalization is sufficient to deter the knee-jerk reaction to the PCMH language for a few minutes, let’s look at the measures associated with this PCMH concept.

In some cases when you try to address a behavioral or chronic problem for a patient, the first step is to have the patient keep a log of their current activities and gain awareness of what may need modification in order to effect beneficial change. Let’s try that. Exercise #2:  for a couple of days, keep a piece of paper in your pocket, and note all your activities as you go through your workday, then sit down and mark the ones that have nothing to do with actual patient care, and of those, mark the ones that have nothing to do with your medical education. Now ask yourself why you are doing these things instead of having your staff deal with them. Be honest. Is it that you don’t trust your staff to do things right? Is it that it takes less time to just do it, instead of having to explain everything every single time? Is it that everybody seems already too busy? Or maybe it’s just because this is how it always was?

Now let’s try something a bit harder. Exercise #3:  on that piece of paper you are carrying around, note your activities when the patient is in the room, in other words, analyze your patient care. Write down how much time you spent looking for information in the chart, how many times you had to step out to give some orders or request things from staff, how much time you spent talking about administrative things, or things that don’t require medical training, and how much time you spent collecting and cataloging standard information that has very little to do with the problem at hand (yes, I know, your EMR sucks; write it down). To be clear, this is not intended to shorten the time you listen to the patient or constrict the conversation in any way. This exercise is aimed at identifying tasks and activities that could be done by staff, preferably in advance of your visit with the patient, precisely so it can free a few more precious seconds for the two of you. I don’t need to tell you that seconds add up to minutes and minutes add up to hours and hours add up to missed opportunities. And yes, it is a sorry state of affairs when we must devolve to counting seconds.

The last exercise in our series will help you identify another very common problem. Exercise #4:  go to a couple social media sites where patients rate doctors (Yelp is a good one) and browse through the various comments. This is not to encourage you to submit to patient reviews, but to illuminate a very common problem in the form of a great doctor, but rude, unhelpful and impatient staff. You may be the greatest and most compassionate physician out there, and your patients will appreciate that and stick with you no matter what, but are you OK with staff that either does not know how, or does not care enough to treat your patients well?

After completing these four exercises, go back and read the “care team” measures in the NCQA standards (remember to substitute “staff” for “team”). Do you see anything that may be helpful with whatever problems you managed to identify through our little experiments? We’ll look at some possible answers in the next post. And by the way, if you are still questioning the necessity of doing anything other than keeping your nose to the grind and going faster and faster every passing day, you should note that once again medicine is changing. It changed before and it will most likely change again, and those who happen to practice the art, science and business of medicine during times of great change, are rarely pleased with the upheaval. Some will be decimated in the process and others will survive and thrive. Which one would you rather be?


  1. Margalit,

    I think your introducing the distinction of "staff" is helpful, but not necessarily sufficient.

    I (and I presume NCQA) think of "team" as including broader care contributors that might or not be employed by the physician practice.

    For example, part of a diabetic patient's care team might include -- internist, nurse educator, nutritionist, endocrinologist, health coach -- some of all of which might be employed the PCMH practice.

    Thus, thinking of "staff" as those in doctor's employ is useful, but still it's useful to think of broader team that might or might not be under MD control.

    1. I completely agree, Vince. The broader "team" is or should be an important consideration. However, I find that many docs are perceiving "team care" as a threat to their idea of proper patient care. All I wanted to do here is to clarify that this is not necessarily so.
      I am planning on a follow up post....

  2. From recent physician experience, the term "care team" is unfortunately becoming a bit of a pejorative. Too often, the results have been the insertion of a group of administratively assigned persons from outside the patient's direct care providers that come in carrying clipboards and too often have agendas that are not necessarily patient-centered. A true care team needs to be the choice of patients and the physicians that deserve their trust.

    1. This is what I am encountering as well, and as you know very well :-), there is absolutely nothing in the PCMH model mandating this type of interference with patient care, although some entities are using PCMH as the vehicle by which to embed such disruption (and expense) into beautifully functioning primary care practices. I wish practicing doctors would stand up and take charge and ownership of medical home implementations....

  3. We are so on the same page regarding the need for physician involvement. Physicians will either learn to collaborate and lead the way, or the profession will continue to suffer. It is a choice to either excel or to passively, incrementally wither.