NOSH ChartingSystem

A new open source health charting system for doctors.

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Independent Practices are Being Left Behind in Health Information Technology

At the end my previous post, I began to summarize the plight of solo primary care physicians and how they have to chose between a LOSE-LOSE-LOSE situation.  I’ll go over them again…

1.  Chose or continue to use a non-certified EHR and get Medicare reimbursement penalties – end result: lower net income.

2.  Chose a costly certified EHR, and get possible Medicare incentives to offset the cost – end results: lower net income with increasing overhead.

3.  Chose to not use an EHR and get Medicare reimbursement penalties – end results: lower net income.

There is one other scenario I didn’t mention and that is for the practice to opt-out of Medicare.  If the practice doesn’t already see Medicare patients – this is the no-brainier solution.  However, if the practice sees a significant portion of Medicare or Medicaid patients. the practice will see lower net income either way.

All of these horrible choices don’t really “incentivize” solo primary care physicians to jump on to the health IT bandwagon.  And those that practice the micropractice way, where EHR’s are absolutely vital to their survival, it forces the micropractice to change their practice to become, well, a non-micropractice (high overhead model) or to resort to other sources of funding (monthly membership fees for example) that would exclude patients who would not be able to afford health care with their primary care provider.

Now, I understand the politics of trying to improve health care systems and that any policy maker is going to set policy that impacts a larger group or population of providers rather than cater to a smaller group.  It is true that solo primary care physicians are already  in small numbers and diminishing.  As a small group, are we going to be able to change healthcare?  Probably not.  Most primary care physicians are in larger groups by way of survival  but most do so without being happy with their job and patients are not necessarily happy with the care that they receive in this “hamster-wheel” medicine model where productivity is the only measure.

It’s gotten this way because in the health care cost pie, primary care physicians have to fight tooth and nail to get every small leftover scrap and in the end, the patients have to suffer.   And this dysfunctional, “sick” system has been established from decisions (and every decision since then) made decades ago in the late 1960’s when the US health care system aimed towards higher specialization and focus on treatments and not really about prevention.  Firstly, the money isn’t there, nor is it considered “profitable” to support prevention.  It’s difficult to “measure” prevention because it’s not a productivity defined idea.  It’s difficult to measure success for life habit changes because people are human beings, not widgets or robots.  I believe there are ways to measure it (and some other countries do), but to do so, it would require a 180 degree re-think about how we view health care, how it fits with financing health care in a FINITE framework (not INFINITE) and retooling the medical education system where primary care IS the cornerstone to good health, both for the individual and the public.

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If We Only Knew

Below was a comment I made on a KevinMD blog post; I felt that I should post it as it really encapsulated what I wanted to say in my last few posts regarding primary care physician struggles.

Kristy, very important points and questions. What Dr. Schimpf and Mr. Qamar has suggested really is an adaptation to dysfunctional system, not a fix. By no means, is a direct pay model a viable, sustainable solution to the root cause of this dysfunctional system. It certainly gives breathing room for PCPs who have been suffering for so long (like me) that having a model like this is so refreshing and energizing. However, a direct pay model will not help those that cannot afford it (even $19 a month). I have patients who would like to see me, but can’t, because even though they have health insurance, it’s high deductible and they need to pay out of pocket with funds they don’t have. Ones without insurance, forget it. They’ll come when the problem is so severe that they can’t help themselves via Google, and then it’s too late or the condition needs such drastic, expensive measures to treat that the cost of treatment is so much more than what it could have been had they had easy access to a PCP in a timely manner.

It is all about equal access and the rights of everyone in the country (not just those that can afford it) for health care that really impacts health care expenditures in the long term.

It’s like trying to putting a tourniquet on a severed artery, but without a fix to the severed artery, we’re just stopping the bleeding. Eventually, the bleeding will go somewhere else or cause secondary problems that are just as life threatening as the initial injury.

The fix is comprehensive, starting with basic health care access for all and coming up with solutions to address the primary care physician shortage, both by prioritizing preventative services, increasing the workforce through medical education and restructuring cost allocations so that there is closing of the extreme gap between PCPs (including especially mental health providers) and subspecialist reimbursement rates. Although I’m sure these suggested fixes (or variations thereof) have been proposed before, I believe change in our healthcare system really will only change with a grassroots education movement in the value of primary care.  We have plenty of data from here and from other countries’ experiences to back up our point.

We’re way past the point where primary care physicians can ask for change to the powers that be because the vested interests preserving this dysfunctional system are so strong and entrenched.  My wake up call was when I was in the process of closing my practice, most of my patients didn’t know that a primary care physician gets paid for so little (less than a optometrist!); they felt that the value in their health care from me was so much more than that…they couldn’t understand how I was able to keep surviving on so little for so long.  They kept saying, “If we only knew, if everyone knew, we would all be rooting for you”.  It was too sad, but it gave me hope where our fight has to be directed, where our best efforts for change can be successful.

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Primary Care Physicians Lag in EHR Incentive Payments

In July, the National Center for Health Statistics came out with a report about EHR adoption in 2011.

Then, the Government Accountability Office released a report to Congress in July, 2012 about the percentage of physicians who were awarded Medicare EHR incentive payments in 2011.

So, in a nutshell, 58% of primary care physicians in the US have adopted EHR’s but only 38% of them were awarded incentive payments.

What is the discrepancy?  I have a few theories…

1.  Primary care physicians are using EHRs but are unable to get their system certified for incentives payments.  (Cost of certified products versus non-certified products, unable to afford transition?)

2.  Primary care physicians are using certified EHRs but were unable to manage and report properly to CMS to get the award.  (Overworked and not enough resources, perhaps?  Not enough staff?  All of the above?)

Also, as a interesting note, only 29% of solo doctors have adopted EHRs.  I wonder why…cost, perhaps?

If you connect the dots from the previous headlines together, the solo, primary care doctors are in a rock and a hard place.  Not only are we not getting adequate reimbursements, we’re getting squeezed by external mandates, forcing us to choose between using expensive technology versus no technology at all.  And those that want to use technology (or need to, like the micropractices)are having to choose between using technology and dropping Medicare patients (income loss), keeping Medicare patients with pending penalization (income loss yet again), or suffer net income losses by rising overhead expenditures in the form of paying for expensive, certified EHRs (income loss).  It’s a LOSE-LOSE-LOSE situation.  How often does that happen when you’re in a 3 way lose situation?!


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More problems for primary care

This news headline confirms the upcoming shortage primary care.  What this article doesn’t really talk about is why the shortage is happening.  I think the only inevitable path now is the path towards total implosion of the health care system before someone seriously addresses the root causes of this.  The horse is already out of the barn, but I can’t help feeling that there really should have been clear insight about fixing the health care system but strengthening primary care either before or alongside increased health coverage for everyone (whether it be the Affordable Care Act or single payer).  But it did not happen, and critics of the ACA or single payer will only point out the disaster of increasing coverage causing continued health care cost increases despite increased coverage.  Too bad…

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About Conventionality…

Margalit Gur-Arie recently wrote about the concept of the Patient Centered Medical Homes (PCMH) and debunked some of the worries that this concept may bring to physicians.  In my opinion, NCQA’s approach by setting out the standards as a roadmap is a better way to put forward the idea of the patient centered medical home rather than the Meaningful Use approach for EHRs where you’re having to “prove” that you are using the tools that they literally force you to use at a cost and promising some of that money back.   If this patient centered medical home concept doesn’t get hijacked by other corporate interests, I think there is a good future for revitalizing primary care.  However, I think that there is still a strong underlying culture of thinking there is an infinite amount money to be made in health care, and so the pressure will continue to morph this into something else that loses the essence of the idea.

None of these ideas presented in PCMH are necessarily groundbreaking if you’re already a primary care physician.  There really shouldn’t be a kind of expectation that every practice has to be molded in the same way from coast to coast.  I believe in my previous work as a micropractice family physician, I had all of these goals in mind when I developed my practice and actually acted upon those goals.  The appearance of the practice was certainly unconventional and in the minority (in the midst of large multi-specialty practices), but it doesn’t mean it can’t be done.

Same here with my NOSH ChartingSystem project.  I don’t aim for conventionality; I aim for what is the best way for doctors to be able to use technology to actually help (rather than hindering) do their jobs.  Being a non-certified product certainly is not conventional either, but I’m banking on creating a powerful movement to counter the current conventions about health IT.

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Primary Care Physicians are a Dying Breed

Primary care in the United States is a paltry shadow of what it used to be and nothing like what it is in other developed countries in the world.  I can point to numerous articles that confirm this slow death since the 1990’s:

The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care

More Doctors Giving Up Private Practices

Death of the Family Practice – Doctors Struggling to Survive in Face of Mounting Obstacles

Family Physician Can’t Give Away Solo Practice

I can also point to numerous articles that validate that a vibrant and strong primary care component in a health system improves outcomes and lowers costs for a population:

Greater Reported Patient Access to Selected Primary Care Attributes was Associated with Lower Mortality.

How is a Shortage of Primary Care Physicians Affecting the Quality and Cost of Medical Care?

Primary Care Physician Workforce and Medicare Beneficiaries’ Health Outcomes

Contribution of Primary Care to Health Care Systems and Health

This slow death of primary care has many origins, starting with the disparate incomes of primary care physicians versus specialists.  It’s a negative spiral that only serves to degrade and decrease the number of new physicians into the primary care fields.  In fact, only 5% of graduating medical residents in the United States chose primary care as a profession over the past decade or so.

Income Disparities Shape Medical Student Specialty Choice

This graph tells it all (source):

Adding dirt to the wound, there is currently a ‘silent exodus’ of primary care physicians as we speak.  I know of other primary care colleagues who have packed up their outpatient practice and headed for the hills of hospitalist medicine, urgent care, or non-clinical jobs (one popular one is a company that serves hospitals to make sure that they meet compliance with Medicare readmission guidelines, it’s something that you can do from home).

If you think about it, these other avenues I mentioned are really picking up the void that is left behind when primary care had been decimated.  Economically, these avenues are much more attractive to the hapless primary care physician, and it’s doing the work that had primary care really done it’s job in prevention, we wouldn’t have to get to the point of acute, higher-cost care.  It’s another negative spiral.

This whole thing stinks of negative vortexes and the cost of health care conundrum is just a big black hole sucking up everything in its path.  It is a very sad state of affairs for primary care physicians.

I was a victim too – I closed my practice down in 2012 due to the increasing uncompensated demands by insurance and continued decline of reimbursement for my services.  My NOSH ChartingSystem worked wonders for my productivity but it didn’t matter because the greater problem was something that my EHR alone could not solve.   As I had mentioned before on my blog regarding EHR certification, certain laws have made it much, much harder for a primary care physician to survive.  Whether it was intended or not, these policy decisions have continued to push the extinction of primary care physicians like me, especially those who are trying to pave a brave, new path against the current trend of seeing more patients in less time.

Small Practice Evolution: The Medical Micropractice

So now, we’re at a crossroads.  Can primary care be reinvigorated?  Is it too late to change?

I think primary care can be reinvigorated.  In time, we as a society will look upon this time of decline as something that we should never repeat again.  I fear, though, that the kind of change and the kind of vibrancy that primary care can be will not be fully realized in my lifetime (with tears in my eyes).  But with this project, maybe I can bring about the solidarity and voice that is needed to bring primary care out of the ashes towards a better future.


The Adverse Childhood Experiences (ACE) Study Suggests That Focus on Early Treatment and Prevention of Certain Childhood Experiences Can Impact Health Care Costs in the Future

The ACE study was a landmark study involving 17,000 participants surveyed between 1995 and 1997 enrolled at Kaiser Permanente.  The aim of the study was to assess associations between childhood maltreatment and later-life health and well being.

The results and associations are extremely revealing, but also makes incredible sense when you apply this to the idea of controlling health care costs.  For example, the total lifetime estimated financial costs associated with just one year of confirmed cases of child maltreatment (physical abuse, sexual abuse, psychological abuse and neglect) is approximately $124 billion.  The impact of child maltreatment, specifically increases the risk for these conditions (this is not the exhaustive list, here’s more): ischemic heart disease, alcohol abuse, drug abuse, obesity, headaches, smoking (and all the medical conditions associated with it like lung cancer, COPD), teen pregnancy, unintended pregnancy, mental health conditions (depression, anxiety, and much more).

So why isn’t this a major headline and why isn’t more being done to address this?

My answer is that part of this is related to the stigma of abuse in our society.  Although the recent Jerry Sandusky coverage has highlighted that abuse can happen anywhere and doesn’t just happen in lower socioeconomic groups, we as a society have mostly focused on sensationalizing the abuser and the bringing them to justice, but we don’t talk much about treating the victims.  Although there are breakthroughs in the neuropsychological fields regarding recognition and management of childhood trauma, there is much work to be done to really focus on helping the victims on the ground.

The second part of this answer is receiving mental health care also carries a social stigma as well as a significant cost barrier. Compounding the problem is that individuals who have mental health issues, in general, do not have the means to pay for health care, and thus are either uninsured or under-insured.

Do you see the same pattern in the previous post?  Cost is the largest barrier here, yet again.

The lack of prioritization on prevention and early treatment as demonstrated by the inequality of reimbursement rates produces outcomes that are woefully inadequate.  It’s further reflected by our prioritization (or the lack thereof) of mental health interventions compared to other interventions, such as drug intervention.  Not too long ago, the standard belief was that mental health was separate from physical health and their treatments were paid differently (less, of course).  In fact, remnants of this belief still exist, especially for treatment, even though the Mental Health Parity Act in 2008 was an attempt to improve this disparity.

Although mental health providers are bearing the brunt of this unfair system, primary care providers also experience a significant share of the burden.  In my own practice, 60% of my time was spent managing mental health issues, including depression, anxiety, bipolar disorder, chronic pain, addiction, and a large majority of that was related to a past history of childhood maltreatment.  I can also attest that managing adults is much more challenging than children because positive change happens much more slowly.  The neurological plasticity of children is the main reason why early intervention is so crucial and so cost efficient in the future if we actually paid attention (more time for providers to interface with the family and patient), and we directed health care costs towards early intervention that has been shown to work.

If money is indeed the measure of worth to society, society is saying right now that mental health treatment is not valuable to society.  Is that really what we believe?