Physicians’ perspective

Driving forces / Health care practitioners / Opinion/commentary/analysis / Physicians' perspective — No Comments
12
Jul 10

Retail clinics: good enough, enough?

Colorado-based Dr. Marc Ringel avers that they just may be in this public radio interview (7/10/2010, station KUNC, Colorado).

Audio clip is available at the top of the article.

Dr. Ringel sums things up this way:

As we proceed into the brave new world of post-healthcare reform, where there will be lots more people with health insurance but no more primary care doctors to attend to them, we’re no doubt going to have to receive a greater share of outpatient medical services outside the traditional setting of the doctor’s office. Retail clinics will certainly be in the mix.

We should be no worse for this change of venue, if we can keep our eye on what’s good enough care.

Driving forces / Physicians' perspective / Reports, white papers, studies, presentations — No Comments
26
May 10

Primary Care Visits: A Field Test of Value

http://blogs.wsj.com/health/2010/05/24/how-much-would-you-pay-for-a-primary-care-visit/tab/comments/

How do you find out what value people place on a primary care physician visit? You could try asking them, as a small group of Missouri physicians recently did.

….On the day of the events, no insurance was accepted. Care was provided only to the uninsured, who were asked to pay what they could afford. Laboratory tests were provided at cost, and patients who needed additional services were referred to various public resources….most valued it enough to pay something…

….None of the participating physicians collected enough money to make the concept financially viable over the long term, mainly because payments didn’t match a typical day’s collections from insurance and co-pays. Yet most say they want to do it again and enjoyed having one day free from insurance paperwork.

“I couldn’t afford to do it every day and feed my family, but I will probably try and do it once a year,” said [one Maine physician]…

Frankly we’re not convinced the pay what you can docs really looked carefully enough at how close what they made was to their net from treatment of insured patients. Did they, for example, discount for the costs they avoided for
a) collecting patient payment data
b) reviewing, confirming, and transmitting that data for payment
c) reconciling payments on receipt with submitted charges, etc?

Anyway, the Wall Street Journal Health Blog picked the story up (5/24; paid subscription required)

Driving forces / Opinion/commentary/analysis / Physicians' perspective / Retail clinics: field reports / Strategic initiatives — No Comments
19
May 10

Docs Embracing The Convenient Care Concept

Judging, that is, from two items freshly available on the internet.

First this from a May 18 posting in Postgraduate Medicine: Embracing The Convenient Care Concept.

The five Drexel clinicians (three are physicians, at least one is a registered nurse) who authored this piece address the controversial status of retail clinics among physicians this way:

This new trend in delivering health care has been mostly, if not totally, ignored by the medical school practice plans, with the exception of the Mayo Clinic in Minnesota, which has developed several “express care” clinics as stand-alone facilities. As a medical school practice plan and a division of general internal medicine, we could continue to keep a blind eye toward this new trend in primary care medicine or embrace the concept. We aim to develop a new convenient care model integrating our College of Medicine practice plan in partnership with our College of Nursing graduate nursing program to form a stand-alone clinic within a bustling business district in downtown Philadelphia….

….Although organizations such as the American Medical Association and the American Academy of Pediatrics initially voiced concerns over quality of care and disruption to the continuity of care, … retail clinics have exceeded expectations and proved that they can perform well, both in terms of patient satisfaction and in quality measures….

The second is a Washington Post guest editorial written by San Francisco-based emergency room physician Jennifer Brokaw:

Keeping routine medical care out of hospital emergency rooms (5/18/10; free registration may be required).

….[N]on-emergency care delivered in the ER costs almost five times more than in a doctor’s office or clinic.

There are four ways we can steer minor emergencies away from the ER.

First, establish more offices and clinics that are not based in hospitals (and do not carry hospital overhead). The recent trend toward low-cost, retail- and pharmacy-based clinics has been a relative success for what these facilities offer: quick evaluation and treatment for simple problems. They have been found to cost less than one-fifth of what an ER costs for the same complaint….

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4
May 10

Where Do Doctors Learn The Price of Care?

Turns out more than a handful have become well-acquainted with the role of cost in clinical decisions at the East Harlem Health Outreach Partnership, which is a free (for patients) clinic run by students of Mount Sinai School of Medicine, according to this 5/3/10 New York Times story: Teaching Physicians The Price of Care (5/3/10.

Medical students evaluate patients, choose which drugs are prescribed, arrange care for patients who need to see a surgeon or other specialist and collaborate with a social worker to help those who need social services or assistance paying for medicine. They also sit on the steering committee and are in charge of researching and updating the clinic’s formulary, a stock of inexpensive, cost-effective drugs that are purchased from the hospital pharmacy.

Surely similar models might emerge for providing teaching hospitals’ students about real world health costs via immersion in hospital-supported clinic operations…?

Driving forces / Health care practitioners / Opinion/commentary/analysis / Physicians' perspective / Strategic initiatives — 1 Comment
29
Apr 10

Primary Care Busy-ness: NEJM Article Has Major Media Hotness

So Dr. Richard Baron’s What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice shows up in the Occasional Notes section of the New England Journal of Medicine on 4/27/10, and the watchful editors at the New York Times and USA Today are already busily turning it into News Of More Than Occasional Note.

And rightly so.

So what’s being said?

The NY Times’ Steve Lohr, a health journalist who “gets it”, doesn’t seem to get this one – at least not in his opening lines:

A new study detailing the uncompensated work burden on family doctors points to the need to change how they are paid, medical experts say — particularly as the new health care law promises to add millions more patients to the system.

Really Steve? The thrust of the piece is that doctors need to be paid differently? Or is it rather that they have to practice differently, so there is justification for paying them differently?

You can probably guess what we think, but here’s a passage directly from Dr. Baron’s post that bolsters our confidence in thinking so (with our emphasis):

The work we describe arises from the needs of patients in a society that assigns many roles to physicians — from making diagnoses and providing treatment to ordering tests and filling out forms — and the practice must be organized to respond reliably. How and by whom the work is done is a continuing project of primary care redesign, dependent on both the skills of available nonphysician staff and the extent of information-technology support.

Meanwhile, correspondent Lohr only gets to this concept indirectly, at the very end of his brief report, and then thanks to a quote from Obama administration HIT point man Dr. David Blumenthal (again, we’ve provided the emphasis):

….Dr. Blumenthal said the study showed “the enormous strain” on family doctors, but also “a pathway toward escaping at least some of those burdens: the electronic health record combined with changes in workflow and payment.”

USA Today’s Rita Rubin gives greater emphasis to the “what are primary care doctors actually doing?” aspect of the story – taking it less for granted that what primary care doctors are doing is what everyone thinks they’re doing, and what they ought to be doing – but she still does not delve into the trickier, thornier, more sensitive matter: what if, once what’s going on there is fully sorted out, everyone discovers that other health care practitioners are better situated to do some of those things, in league with a “re-purposed” contemporary primary care physician?

Now there you would have a platform for disruptive innovation.

EXTRA CREDIT: It may seem unrelated at first, but we feel The Data-Driven Life (New York Times, 4/26/10) supplies valuable commentary on the vital issue of applying data to the information-driven business of deciding “what am I doing, is it what I fully intend to be doing, and what might I do differently to do what I intend to do better?”

Dr. Ateev Mehrotra / Driving forces / Health care practitioners / Opinion/commentary/analysis / Physicians' perspective / Retail clinics / Strategic initiatives — Comments Off
9
Apr 10

Is Physician Resistance a Real Barrier to Retail Clinics’ Success?

A 4/8/10 story by Healthleaders Media‘s Cheryl Clark asks the timely question Will Retail Clinics Be a Key Player in Post-Health Reform World? – then proceeds to address a quite different, though related, question.

That question is, how ‘real’ is physician resistance to the growth of retail clinics?

On cursory examination, the positions taken by physician organizations seem real. The Healthleaders Media article notes the AMA’s recommendation that store-based clinics have “appropriate physician oversight on-site”. The California Medical Association offers 3 reasons why retail clinics are not in patients’ best interest, which can be summarized as 1) retail clinicians do not have the requisite competence 2) they aren’t built to share care information with the patient’s primary care doctor 3) their primary purpose is to sell “beef jerky and Gatorade”, not health care, in the words of the CMA’s CEO that the article quotes.

We can leave questions of clinical purpose & competence to more authoritative analysts like RAND’s Dr. Ateev Mehrotra, whose research to date has largely refuted the essentially unsubstantiated assertions of the physician organizations. What we CAN do is ask whether the AMA, the CMA, and their kindred clinician associations are prepared to deal with the issue as people of science rather than politics – that is, to weigh their concerns on the scales of data, of evidence, rather than resort primarily to dismissive remarks in press releases?

Frankly, we do not see how the physician organizations CAN take the high road here, even if they want to, because the data they have, that they can access and evaluate, is simply not likely to be as good – as timely, as auditable, as thorough – as the data and analyses that retail clinics can deliver. In support of their position, physician groups have anecdotes, rather than evidence. Until they have evidence, it is difficult to understand how their resistance can be regarded as a “real” barrier to retail clinics growth.

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30
Mar 10

The 70-Year Timeline of “Too Few Primary Care Docs” Warnings

You’ll find it here, in this concise March 29, 2010 Kaiser Health News summary: Primary Care Crisis Has Been a Long Time Coming

Driving forces / Health care practitioners / Onsite clinics / Physicians' perspective / Public policy / Reports, white papers, studies, presentations / Retail clinics / Strategic initiatives / Tactical innovation — Comments Off
9
Mar 10

Macy’s Floats Recommendations for “Primary Care Expansion”

The newly released primary care advancement recommendations from the Josiah H Macy Foundation include a number of recommendations for further investment and action. While the 49 participants and the event leaders produced numerous recommendations concerning primary care organization, financing, education, and leadership worthy of closer inspection, we have quoted our favorites below:

  • ….state and national legal, regulatory, and reimbursement policies should be changed to remove barriers that make it difficult for nurse practitioners and physician assistants to serve as primary care providers and leaders of patient-centered medical homes or other models of primary care delivery. [Conclusion I, Recommendation 2]

  • ….Invest in primary care health information technologies that support data sharing, quality improvement, patient engagement, and clinical care, with the aim of continuously improving the health and productivity of individuals and populations. [Conclusion I, Recommendation 4]

  • ….implement all-payor payment reforms that more appropriately recognize the value contributed by primary care through such mechanisms as global payments linked to patient complexity and accountability for the provision of healthcare services, including preventive services, care coordination across settings, chronic disease management, and 24/7 accessibility. [Conclusion I, Recommendation 5]

Can anyone help me square these proposals with AAFP’s turnabout with respect to its qualified support for retail clinics?

Tip of the cap to Healthleaders Media‘s Janice Simmons for her story on the release of the JHMacy Foundation report.

Driving forces / Physicians' perspective / Regulatory activity / Retail clinics / Strategic initiatives — Comments Off
27
Feb 10

AAFP Hardens Line On Retail Clinics

From the American Academy of Family Practitioners website: AAFP Board Revises Retail Clinic Policy (2/24/10: immediate access)

The AAFP Board of Directors has revised its official policy on retail health clinics to reflect the Academy’s opposition to a growing expansion of scope of services provided by many such clinics. In addition, the Academy has discontinued its practice of entering into formal agreements with retail health clinics that support the AAFP’s desired attributes….

….The four retail health organizations that still hold signed agreements — MinuteClinic, RediClinic, The Little Clinic and BellinHealth Fast Care — have been notified that those agreements will be terminated.

In a letter sent to those companies, the Academy said its decision was not intended to reflect negatively on any retail health clinic company. Rather, it was made after observing the evolution of the retail health clinic model into expanded service lines….

without a trace of irony, the AAFP story continues:

The Academy’s policy urges all retail clinics to abide by the list of desired attributes, which, in addition to a limited scope of clinical services, should include

  • evidence-based medicine,
  • a team-based approach,
  • a system of referrals to physician practices, and
  • electronic health records.

Just to take the easiest point to pick off, we’d like a buck for every percentage point by which the share of retail clinics with EHR in place, and used, exceeds the share of AAFP docs with EHR in place, and used. We’d surely be able to buy the house a couple of rounds – and AAFP doctors are leaders in EHR adoption amongst physicians generally.

What we smell in this policy announcement is the acrid odor of fear. Instead of figuring a way to amplify on retail clinics’ simple, fundamental capabilities -take something as basic as routine identifiers information – and using them to their advantage, the AAFP’s public service solution is, to paraphrase a line from onetime Presidential candidate Sen. John Kerry, to vote against retail clinics after they voted for them.

That kind of health care reform we don’t need.

Modern Healthcare’s Andis Robeznieks reported the story, too, on Thursday (2/25).