Reducing Fragmentation and Patient Care NOW not Next Year

I do not recommend doing this, but today I attempted to listen to two Webinars at the same time. One was also tweeting the discussion and the other had very detailed slides which made it easier to follow but as studies show, we are not really capable of that kind of multi-tasking. The topic of the first suggested it would discuss Primary Care and its future. However, what the expert proposed was a “How to” plan for bringing more customers into a healthcare system. This was boiled down to a recommendation that these system open small clinics, run by NPs, in competition with drug store and grocery store clinics of similar ilk in order to funnel patients into the listeners’ systems. The other Webinar was a discussion by three mobile health leaders (mHealth) on the future use of their products in the global mobile health arena (wow, that rhymed).
It’s is a good idea to know what is going on in the minds of healthcare system development teams and as I listened to the expert’s remarks I could not help but ponder on what, in my humble opinion, would build the kind of “team loyalty” that hospitals and other healthcare systems are dreaming of. What is it that patients want? I agree that they need healthcare access in their busy lives at more convenient times of the day than traditional physician offices offer. What my patients tell me (and what people tell me at cocktail parties) is that they would prefer access to their very own providers, those individuals who know them best. No insult intended to NPs because they are essential to the healthcare team, but they are physician extenders, not physician substitutes. What about developing systems that give patients greater access to their own providers? This would really engender loyalty to a healthcare system, especially one in which physicians are employees, more and more the norm these days. I believe mHealth can do that. What if you could access your physician after hours via Skype? Or text your doctor just for a quick conversation about whether you should seek immediate care or be seen the next day? Gee, what if the physician had access to their schedule and could book them on the spot?!? What I’m advocating here is a “concierge” type practice without the concierge price. Of course there would have to be some sort of reimbursement procedure to give already overworked primary care doctors the incentive to take care of patients in this way but wouldn’t that be a cheaper investment than opening the equivalent of “Little Clinics” everywhere?
Along with the cost, the second complaint I routinely hear from patients about their medical care is its fragmentation. From a patient and a primary care perspective, no one on the health care team is talking to each other. In fact, frequently the word “team” is a misnomer. Using tools like Doximity¬†physicians can employ a HIPPA compliant platform to discuss cases and improve care. Of course the phone always works, but with the ability to ask questions and respond in a timely but convenient fashion, doctors and other providers like NPs, PTs, etc. can reduce the fragmentation patients feel from their healthcare team.
Of course I realize that ACOs (Accountable Care Organizations) are supposed to be developing this kind of care. But does the bureaucracy that surrounds these systems bother anyone else but me? Do we really have to wait for the lumbering movement of government sponsored programs in order to improve communication, fragmentation and access to care when the technology is already here today? 
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Physician Employment Regrets?

Six years ago I left private practice and never looked back. I traded my autonomy for restful nights, a 401K plan (which I’d never had the money to fund), a regular paycheck (no more doing without at least once in January, February and March, and the disappearance of staffing issues. While I am occasionally frustrated by the “Dilbert” corporate environment, I work for a system that has a strong patient-centered mission and they have been reasonable and kind to me.

How did doctors get to this point? There are so many factors it becomes an interesting mind game to see if I can remember all the headaches that my partner and I wrestled with for the sixteen years we suffered through it. About six years into it we decided our theme song was Chumbawamba’s “I get knocked down but I get up again…” It didn’t help that we were both mothers with two young children when we started out. Neither of us were willing to sacrifice our time with our children so we refused to work eighty hours a week, thus our salaries looked more like teacher’s pay BUT without the retirement benefits and summers off. Then there were the staffing issues. We always kept a key group of loyal individuals who worked for less than they could have, I suppose because they thought we were doing well by our patients. But there were always problems that made you want to tear your hair out–one employee was rude and chronically late, one did not want to work evenings (we were open two evenings a week), one had a child that was ALWAYS sick; there were raises deserved that we couldn’t afford to pay, there were people who needed to be fired that we didn’t know if our documentation was good enough. It never seemed to end.

Our out-sourced billing advisor also helped us with accounts payable and we got very good at creative bill paying. Of course our staff’s paychecks came first and they never did without except for our nurse practitioner who allowed us to postpone her pay four or five times. We made that money up to her but my partner’s and my pay was lost forever. Bonuses? Who are you kidding. We went to plenty of coding classes but had no clout with insurance companies to maximize our reimbursement. We did not see too many patients without insurance but those we did seemed to have problems paying our bills. We learned early on to collect co-pays at the window before being seen, or we might never see that money as well. These were the kinds of issues that keep you up at night. At the worst, when my business partner and I thought we were going to have to declare bankruptcy, I remember having what psychiatrists call EMA (Early Morning Awakening–a classic depression symptom). At 4:30 or 5 I would give up and go downstairs to meditate for thirty minutes to an hour trying not to think about telling my children that we were losing their home. Sigh–those were the days.

So now I am an employee in a big hospital-owned group. Just a little cog, but it is sooo much better for my patients. They get my full attention when I am in the room, my brain is never worrying about bills being paid, staff being disruptive or sleep being lost. When I go on vacation, I get paid and if I am sick then I am only worried about how to get well. No, I’m not always happy with how the administration does things and sometimes the corporate bureaucracy, legalese and slow-to-change atmosphere makes me crazy. But my life is much easier so I try to keep my complaints to a minimum–as I tell my daughters when dealing with husbands and children “Choose your battles. They aren’t all worth fighting.”

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