Last week, a patient who has seen me for more than 20 years called my office for an appointment. She signed up for one of the new HIE insurance plans but we are not a provider on that plan. She is a healthy woman, rarely needing my services and expected her new insurance to be her backup in case she became seriously ill. She was willing to pay cash to see me but this is unacceptable under Kentucky rules and considered “insurance fraud”. The reason given to her and our legal representative, by the Kentucky Healthcare Exchange (KYNECT), is that if a patient can afford to pay for a routine doctor visit then they shouldn’t need insurance. What? How does that follow? Since when does the ability to pay cash for a single visit mean that a devastating diagnosis and subsequent treatment would not wipe a patient out financially? One would assume lessoning that risk would be one purpose of the new insurance exchanges given that medical bills are the #1 cause of bankruptcies! Insurance doesn’t need to be for routine visits. In fact, the entire basis of the DPC movement (Direct Patient Care) is to cut out the middleman of insurance from routine primary care visits.
Because I work for a healthcare system, my staff could not tell the patient what physicians and healthcare advocates “in the trenches” recommend, which is to hide your insurance status from your doctor’s office. There’s a great article entitled “Insured Patients Can Save Money by Pretending to be Uninsured” from the The Self Pay Patient website that explains how this works to many patients’ advantage.
I wonder, is this solely a Kentucky problem or is this an issue seen across the US? If anyone knows please leave a comment in the section below. In the meantime, if you are my patient and I don’t accept your new KYNECT insurance, well, I’m just sayin’…
1. LaMontagne, Christine. NerdWallet Health. http://www.nerdwallet.com/blog/health/2014/03/26/medical-bankruptcy/
No argument that EHRs began as billing platforms, though I will argue that they work just as poorly with charging as they do for communicating patients’ stories or making better decisions in patient care. After two years our EHR still isn’t used for billing and even if it were, since it has no Natural Language Processing capabilities, the doctor would have to manually enter the correct CPT code.
My rant today is a brief one about how physicians document in an ambulatory EHR. On paper, we documented the patient’s story, any pertinent medical history and/or family history, the physical exam, our assessment and the plan (better known as a SOAP note). This was a short, succinct and usable communication device (assuming you could read the doctor’s handwriting). Today’s physicians, in the hopes of better compensation, pull in every possible bit of information into the note including their great great great grandmother’s penchant for getting hangnails. OK, that’s hyperbole, but it is almost that bad. And then complain that the EHR is a terrible way to communicate and that everyone else’s notes are too long.
Having been the “champion” for the EHR in our system I have a request to make — Hide, or have your assistant hide, all that past medical history. You didn’t put it in your paper note and IT DOESN’T NEED TO BE IN YOUR ELECTRONIC NOTE EITHER. If it’s a matter of training or you don’t know how to take it out, please ask your friendly IT trainer and they will gladly help you.
There, I’ve said it and I feel so much better!
My home and office is full of art work done by the artists I have lived with over the last 30 years. My husband makes wonderful creations out of glass.
My younger daughter paints Georgia O’Keeffe-styled paintings for gifts and designed a beautiful canvas that sits behind my desk at work.
My older daughter designs programs for her medical school class and cards for her grandmothers. As a gift to me she drew a family portrait that captures each family member’s special character.
Surrounded by this talent, about five years ago I began to draw, hoping to do it well enough that my sketches would be recognizable in my journals, especially with travel. It’s been a slow painful journey but recently I began Sketchbook Skool, online classes founded by Danny Gregory, an artist I’ve admired for years. The first class began with an intimidating assignment – draw with a pen. The purpose of the exercise is learning to “live with the line”. Multiple times in the last six weeks I began a drawing and wanted nothing more than to tear it out of the book, get rid of the line and start the sketch over. But I had to persevere and since it was an assignment I kept working with it. Amazingly, as I continued with the drawing it would take shape and become something I really liked. My mistakes were not only livable, many times they were my favorite drawings when finished.
Porch Wall Hanging
There are corollaries to be made in healthcare–perseverance for example, of which most family practice doctors need a healthy dose of every day. But the acceptance of imperfection, is that even safe in medicine? How do you accept, even more, celebrate the difficulties of practicing medicine today, especially in primary care? With drawing it’s a matter of going beyond ignoring the line–it’s using it to “bend” the reality of a picture, thereby creating something that resembles the object but is different, still recognizable but different. The corollary in my practice is helping patients become participants by using tools like social media, whiteboards and smart phone apps. But I’m an apprentice artist compared to the DaVincis of medical care: The DPC movement with physicians like Dr. Robert Lamberts, and models like Turntable Health are “bending” healthcare practice to create better care for patients, and in the doing, taking physician practice to a point where it once again feels like Art.
Typically my call weekends are light. I don’t get a lot of messages. Saturday there was one remarkable only in my inability to do much for the caller. My associate’s elderly patient was in the ER, sent there by her physician. He is 94 and was falling more lately, had reduced appetite, just didn’t feel well with occasional episodes of shortness of breath. His daughter called because they were “40 patients deep” in the queue and she wanted to know what could be done to improve the chance that he would be seen more expeditiously. I thought about it. I certainly understand why she was concerned about her elderly father sitting on hard chairs in the emergency room with goodness knows what illnesses surrounding him. At the same time it didn’t sound like there was anything emergently wrong, as opposed to urgently. He might have a pneumonia or urinary tract infection, so common in the frail old patient. Was it appropriate to try to push the emergency room to see him ahead of the other 39 people who no doubt also felt that their problems were of utmost importance? I explained to the daughter there was no certainty anything I said would get her father seen more quickly and she responded that her experience was when a physician called things got done. Sometimes that is true if I have knowledge the ER is lacking as to why a patient is seriously ill. But I didn’t really have that. How quickly does one wear out their welcome with the ER if I cry wolf? On the other hand the patient is 94, sounds frail and certainly was at risk to sit in emergency room for several hours. My own mother is not too far from that age so I intimately understand the daughter’s concern. What was the right thing to do?
What would you do?
If you had to deal with a “spousal satisfaction score” on a monthly basis, would this improve your interactions with your spouse? How about a “colleague satisfaction score”? Would you find it helpful to your psyche or would you resent your colleagues monthly critique? Increasingly this is how I feel about patient satisfaction surveys and physician rating sites. How much value are those instruments? Interesting a study from UC-Davis demonstrated an inverse relationship between patient satisfaction and good care. It makes sense, especially in an ER setting with hurried, relatively impersonal care, patients whose expectations are not fulfilled will be unhappy. The classic example in my world is the patient who comes in with a viral upper respiratory infection insisting on a “Z-pack” antibiotic. Seriously, it still happens. Will they leave and go to Angie’s List and give me a bad grade? Did I do the right thing by refusing the antibiotic AND discussing why? Did I try at great length to help them understand the danger? Despite my explanation, were they still upset they didn’t get the med they wanted? Fortunately I am not yet discussing Press Ganey scores in the hospital lounge with my colleagues but we do offer a Target gift card to random patients who take a survey from my office.
Partnering with patients does not imply that we are always satisfied with each other, just as I am not always satisfied with my spouse’s behavior. We work together to improve healthy behaviors, we trust each other to find the best path and we compromise expectations by taking into account factors that impact health. If I am worried about satisfaction, it is easier to hand out that antibiotic script than spend time explaining why a viral illness doesn’t require one. Or give the patient that antidepressant she expects because the TV says she’ll feel better, instead of understanding the reasons behind unhappiness that doesn’t require medication.
In spending enough time with patients to hear their stories, see their body language and listen to the undercurrents in their lives–this might improve my satisfaction scores and ratings, but not necessarily. It will enable me to give the best care regardless of my score. This is my goal. Hopefully, no one will push me toward another.
1. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Fenton JJ; Jerant AF; Bertakis KD; Franks P. Arch Intern Med. 2012; 172(5):405-11 (ISSN: 1538-3679) http://www.medscape.com/medline/abstract/22331982
My children are no strangers of death. They understand the cycle of life and have said goodbye to pets, mourned with their friends who have lost parents and grandparents. My youngest stood by one of her closest friends who lost her younger brother unexpectedly of a heart problem. My girls have know acquaintances who suicided or died in accidents but tonight is the worst. My daughter calls me, sobbing “They found his body”–a friendship forged in high school at the Governor’s Scholars program, a young man–handsome, intelligent, gone missing two days before. A hate crime. My daughter is 2300 miles away. I cannot hold her. I can only cry with her from the distance, feel her pain and wonder how and why this happens.
Tonight I try to calm the vitriol that rises in my own throat, knowing that is not the answer but is of the same poison that killed this young man.
But it is hard.
Many years ago, a wise family practice mentor said to me “One of the nice things about being a physician for many years is that my patients have grown old with me. Unfortunately that means I am losing more of them.” Those words came back to me recently after the loss of my third male patient in six months, all close to my age. Two of them, avoidable deaths but work and inflammation came before healthy habits and lifestyle changes. The third was from a quick and devastating disease that was not avoidable.
The wife of the third man came in for a visit yesterday. We talked a little bit about his disease and its quick progression. She talked about the usual things–their 30 year marriage, children, hopes for grandkids. I told her that I would miss him after our many year patient-doctor relationship. I hesitated, then shared with her that it had been a rough year with patient losses and that he was one of three men that died much too young–at 70 he had been the oldest. She looked at me and said “then you feel the void.”
Obviously, not the same way that she does, but indeed, I feel the void.
As I look to the end of my sixth decade, time is more precious than ever. Having a mother, maternal uncle and maternal grandmother with late onset dementias forces the realization that not only is my time limited on this earth, but my intellect as well. How can I squeeze the most out of the moments? Like most physicians, in addition to my career in medicine there are life enhancing avocations I enjoy such as perfecting my French language skills and improving my sketch art that has joyfully crept into my journals. To those ends I listen to Johan, the creator of Français Authentique and began an online course with Sketchbook Skool. Understanding that exercise is the single most important way to ward off memory loss, time must be found to keep moving. Important relationships are built and remain strong with convivial meals and moments together.
Age forces the recognition that time is the true currency of our lives. When people waste it for you, it is frustrating and angst producing. One of the underlying tragedies of physicians’ daily lives, especially in primary care, is the theft of our time, stolen away by the health care system. We entered medicine expecting to spend our lives caring for patients by spending time with them and researching best practices, not being glorified data-entry clerks and insurance company proxies. The amount of time that governmental regulations, employers, compliance directed mandates, insurance company prior authorizations and administrator volume expectations take from us is demoralizing. I want that time back to spend with my patients, my family, and myself.
After more than two years of listening to the innovative suggestions of individuals who care about creative disruption in medicine, I firmly believe that this time theft can only be stopped when our patients come first–before profits, shareholders, meetings, EHRs, or any other thing on the long list of healthcare “needs” that may serve but should not be served. When patient needs are met, so will my own.
Doctors hate the first of the year. Besides the cold weather, there are a myriad of reasons for that. In private practice one typically goes without a paycheck for two months. That’s a bit of a stressor. Increasingly more frustrating every year is all the changes from pharmacy benefit managers. Finally the physician finds the right combination of antihypertensive drugs, blood pressure is well controlled, life is good! Then the dreaded letter from the pharmacy benefits company arrives, stating that Exforge (or Metoprolol ER or…) is not covered under the patient’s insurance plan. For some reason this year it is extended release medications on seniors’ plans that are not covered, generic no less. The elderly patient, who may be challenged in regard to compliance, now must take his or her medicine two or three times a day instead of just once. No problem, I’m sure the insurance company will send out a nurse to make certain that the patient takes all medications properly. No wait, the nurse is busy sending the patient to the emergency room for a hangnail because she’s worried that pain in the left arm is cardiac. But I digress.
Copy from denial letter
This week a new level of denial has been breached. Now medications are deemed “experimental”. Somehow pharmacy benefit managers have confused off-label with experimental. Why would they do that? Simple: off-label use isn’t excluded on a patient’s insurance but experimental is. In one particular case my patient has a progressive debilitating neurologic disease that is causing pain. The patient already has issues with constipation due to an inability to be mobile so narcotics are not a good option, not to mention that he does not want to be dependent on narcotics for this pain. Amazingly this “experimental” medication was doing a good job of managing the pain for the last year or so.
Not only is the denial of this medication arbitrary and cruel, it is unethical. Off label use of medications is an accepted and necessary treatment choice, particularly with pain, where avoiding narcotics is important for patient quality-of-life and many off-label use of medications is well-studied but not in the drug’s package insert since the medication has long been generic. In the meantime the patient asks ME how to deal with the issue. I recommended that they call their insurance company to begin an appeal process. Frankly a good lawyer might be a good idea as well.
Recently an employee from a nationally known firm based in my city came in for his wellness “physical”. He works 16-hour days from home, rarely leaving his computer. He is a poster-child of poor lifestyle decisions in regard to wellness and wellbeing; in vernacular terms “a heart attack waiting to happen”. Wellness programs are quite the rage these days. I fill out forms on a daily basis documenting patients’ blood pressures, cholesterol values, waist measurement, etc. Employers are hoping to motivate their employees to be healthier.
Rand and Pepsi Company recently published their report of how well this program worked for Pepsico. It contains interesting data. While disease management assistance for employees was successful, the return on investment for the lifestyle management, which includes those yearly physicals and lab draws, was less so. The report created a bit of a stir. I suggest following Khanna On Health Blog regarding wellness vendors and the lack of data to support much of the recommendations that seem to be taken as facts judging by the forms I fill out routinely.
Meanwhile, back to my patient. I don’t care how much you love your job or need your job, working 16 hours a day is not a healthy way to live. As a family practice physician, I would love to make editorial comments on the forms that I’m filling out but there is no option for that. To be fair, despite encouragement by their employers to be healthier, employees may refuse to take the bait. Without knowing the specifics of his company’s wellness policies, or how well his supervisor adheres to them, it’s impossible to know how much is the fault of the company and how much is about the individual.
Being involved in my own company’s Wellness/Wellbeing Committee, what struck me is how creating a culture of wellness must start by changing any ideas of enforcement. “Mandatory engagement” in such programs is an oxymoron but encouraging a culture of self-care makes sense. There are so many things that don’t cost a lot of money that can be the start of culture change: different food and drink options in the cafeteria, access to better choices in vending machines, posting nutritional content of all foods in the cafeteria, putting up signs that encourage stair use, self-tracking contests, employee workout sessions (at convenient times for them), a farmer’s market in the parking lot with discounts supported by the corporation. We need to start from the top—the C-suits and the doctors making wellbeing and self-care a priority. Watching both those populations work 60 hours weeks is not a way to exemplify healthy behavior.