Preventive Care ≠ eye exams for the blind (Part 2 of How our healthcare system is making doctors even more paternalistic)
Following last week's post, here's the story of Shannon*...a patient who has suffered one of the horrible manifestations of diabetes, blindness. She uses the assistance of a wonderful guide dog whom we love to see each time they enter the office together.
This story is an example of how you cannot expect recommended guidelines for preventive services to be 100% true all the time. Here's a little background. It is recommended that Diabetic patients need to have annual eye exams to screen them for diabetic retinopathy and other ophthalmologic manifestations of diabetes that can lead to blindness. Medicare and insurance companies thus judge a primary care doctor's quality care of diabetic patients in part by making sure that the patient has had their eye exam annually. This is proven to the insurance company by the eye care provider submitting a certain CPT code (Procedure code) on a claim and sending that claim to the insurance company. However, for diabetic patients that have already experienced these complications and are already blind, they are still labeled as having a "gap in care" and thus non-compliant. Of course there is no real penalty for the patient except that they will get phone call after phone call telling them to go get an eye exam. But, their primary care provider is actually penalized for this. I'm telling you this from experience with this exact scenario within my own practice with patients being labeled as "non-compliant" for services that were not necessarily indicated. I've had to tell my own patients that they need to go see a specialist that they don't really need to see, pay a copay they don't really need to pay, spend half a day in a specialists office they don't really need to spend, and have an exam they don't really need in the name of "improving quality of care, reducing costs and improving patient satisfaction."
Shannon stopped having the recommended eye exams several years ago after she lost her sight and there was no longer any treatment available to help her. But, her insurance company doesn't really care about that because they are required to report the compliance of their Diabetic patients with their annual eye exams. They were contacting us and Shannon repeatedly to encourage her to get her annual eye exam to screen her for the complications of Diabetes that could lead to blindness...which she already has. It is not preventive care anymore when you are screening someone for something you already know they have! Despite my efforts to talk at length to the insurance company to explain this, they still mandated it. So Shannon and her guide dog spent half a day and a wasted copay getting her eye exam so that she could be told she was blind and there was nothing they could do.
So here's the thing about the value based payment model of healthcare that is being paid for in large part by third parties (insurance companies and Medicare), not patients; patients are loosing their choice of what medical services they want or don't want and yet are being expected to become more engaged in their own healthcare at the same time. I can understand these third parties having to come up with some way to force improved preventive services being ordered and followed through for our country's population, particularly given our healthcare costs are sky rocketing even while overall health is declining. From a population health management perspective, the guidelines that are published by the US Preventive Services Task Force are rigorously studied by Population Health Experts and they are guidelines for a reason - they help large groups of patients be healthier as a whole for reduced costs as a whole. What I fear is being overlooked is that the implementation of this "improved quality of care" is most dependent on quality doctor-patient relationships where it is decided together what services each individual patient needs. In Shannon's case, this requirement did not improve quality of care, it increased costs both to the patient and the healthcare system and certainly did not improve patient satisfaction - the exact opposite of the intent.
This post is not about patients not needing to follow the important preventive services that their doctor recommends. It is about showing the practical implications for you as an individual patient under our healthcare system. I think it is helpful for individual patients to realize that when a third party is paying for your healthcare with limited funds in a value-based payment model, "individualized medicine" is hard to practice (even though everyday more genetic advances are made that make individualized medicine an inevitable way of the future). I find it ironic that part of becoming a "Patient Centered" healthcare system means finding ways to force patients into having preventive services they may not want and limiting choices of what types of diagnostic testing and treatment options are available all while asking patients to become more and more engaged with their own healthcare. I feel that as I have been seeking to improve how "good" of a doctor I am in Medicare and Private Insurers minds, I've become more of a paternalistic provider than I ever have been.
*Shannon's name has been changed to protect her privacy and her story has been used with her permission.
Non-compliant...sounds like something you don't want your insurance company labeling you as, right? I find this term so interesting because today's consumers of healthcare no longer go to see their doctor for absolute directives about what they should do to be healthy. There is no longer a desire, especially among millennials, to see a paternalistic doctor who authoritatively enters the room to give commands to the patient which the patient then obeys without question. Of course it makes sense that patients don't want that. After all, it is the patient's body, health, finances and lifestyle that these directives from the doctor affect, so why should they be blindly followed without a team-like approach to the patient's health. But yet, non-compliant is a term used with increasing frequency to describe patients who are not obliging with their doctors' directives. Among programs like the Patient Centered Medical Home, doctors, healthcare providers and the healthcare system recognize that patients are more engaged with their own health when we actually involve them with their own care decisions. This means practically within an office visit, having a conversation with the patient about what their diagnosis is, what this means for their lifestyle and treatment options for how this can be managed. It means that patients then are given guidance and education from an actual qualified medical professional about their options for treatment and then the patient decides what they want to do. I've had these conversations with many patients for example about their high cholesterol or diabetes. Some patients, when presented with the health risks they have because of their diagnosis, decide to radically change their lifestyle and diet, loose weight and get their disease states under control on their own. Some patients decide they are not going to do that and would rather take a medication. Either way, the patient has chosen and thus they are on board with the plan... and compliant.
All of that is well and good except that our current healthcare system (one in which patients pay a third party for insurance coverage [Blue Cross, Medicare, etc] and expect this third party payor to foot the bill for the entirety of their medical expenses), is not well suited to allow for extensive conversations with patients to enable their own decision making. Further, we are now shifting to the value-based-payment model which means that doctors will be paid based on "how well they are taking care of patients." It is fascinating that non health-care providers believe they can judge how well I am taking care of patients and then will use that judgement to decide how much to pay me for my services. Value-based-payment models of healthcare are intended to improve the quality of care that patients are given, reduce costs and improve patient satisfaction. But, in order for a third party (someone other than the doctor and the patient) to make a judgement call about how well I am taking care of my patient, it has to be some objective measurement. And if there is one thing I know about medicine, it is that there is nothing in medicine that is 100% black and white and purely objective.
Stay tuned for next week's blog...a real life example of how these changes are affecting individual patients.
A "leave of absence".....what I really mean by that is I have reduced the number of patients I see a week to about half what I used to see and am still working the same number of hours per week.
I've realized that physicians underestimate the toll that seeing our patients daily takes on us. I mean think about it - we listen to the complaints of sick people ALL. DAY. LONG. And, our job is not just to listen, it is to fix them. And, our job is not just to fix them, it is to fix them in less than 7-10 minutes on average. And, in addition to fixing them in less than 7 minutes on average, we are also responsible for:
1. Documenting a complete note about their visit that day meeting all requirements of the insurance company (After all, as the saying goes in protecting yourself from litigation "If it isn't documented, it didn't happen.")
2. Choosing the correct list of diagnostic codes out of a book containing 68,000 choices
3. Ordering the right tests so that we don't miss a medical diagnosis
4. Ordering enough tests to satisfy the patient about whatever they have been googling
5. Ordering only the tests that the insurance company will pay for
6. Refer to specialists as needed but only to whom their insurance company deems to be the "right" specialist
7. Prescribing the right medications for the patient but only the ones that their insurance company will pay for
8. Reviewing "Patient Health Snapshots" (as they are called by one insurance company).
This "Patient Health Snapshot" is a document that we obtain by logging in to the insurance company's website and looking up the individual patient. It tells us what the insurance company thinks the patient needs - such as being overdue for their colonoscopy or mammogram, or needing an eye exam, or receiving certain immunizations, or that the patient's blood pressure is too high, or that they are not getting their medications filled at the pharmacy frequently enough. And yes...this too we are also supposed to address with the patient...in those few minutes.
(Why in those few minutes? Because of the fee-for-service model of healthcare, those are the only few minutes that we are paid for. Work done to take care of patients when they are not in the office is not compensated for. And further, not adequately addressing these Patient Health Snapshots actually means we get paid less. So now, if we are seeing a patient for a rash and it happens that they are also not getting their cholesterol medication filled at the pharmacy because they have heard about statins on TV and refuse to take it, our payment continues to be affected unless we convince them to start taking it. Which all in all means we need to see more patients to meet equivalent reimbursement and now the 7 minutes we did have has decreased even more.)
Is it any wonder we're concerned about medical errors, high costs and poor outcomes in our healthcare system? Practicing medicine in America is insane. And as Albert Einstein said "Insanity is doing the same thing over and over again and expecting different results." So, I'm trying to embrace the upcoming changes in healthcare by prioritizing initiatives such as making our practice a Patient Centered Medical Home (PCMH) and preparing our current patient base for the upcoming MACRA shift. It's estimated these projects take 12 months. We need to do them in 6. 6 months of work that I won't get paid for... yet. Hopefully, it will pay off in the year 2019 when reimbursement for MACRA goes into effect. It's now been determined (source here) that on average 20 weeks out of the year are spent within a single physicians practice reporting quality measures...20 weeks is insane. That's not 20 weeks spent taking care of patients, that's half a year reporting to our insurance companies who then report that data to the government about our patients health. Thank goodness I have amazing CRNPs that are helping me with the actual day to day patient care. Without them, I'd be out of business right now. Due to MACRA beginning in 2019, it's estimated that 87% of solo practitioners will begin receiving reimbursement penalties, which will ultimately drive these practices out of business.
So while a lot of non-health care providers try to reform our healthcare system in ways that will probably only make it worse, I've got to take care of my patients, myself and my family. My "leave of absence" effectively means that I'm seeing half the number of patients I used to while working the same number of hours for less pay in order to add in administrative tasks like implementing PCMH and tools to better report quality measures. It's not really the leave of absence I would dream of:) But, it's better than continuing the sleep deprived, burned out, unhealthy state of being I was quickly making a habit of which was likely to just leave us among the 87% that were going to be headed out of business anyway.
In a physicians training, we're trained to put the patient first. Beyond that, we're trained to be heroes that can tackle any problem on our own perfectly. It's not exactly thought of as a positive trait in medical school to have a growth oriented mindset, make mistakes and learn to ask for help. We quickly learn that we have to set aside our emotions to witness horrendous suffering and try to be the one that can help. We realize that we have to sacrifice our own health sometimes to do this, our relationships suffer, our emotions have to be set aside. And when we take that hero/perfectionist component of our training and enter the healthcare system we are working in, it just doesn't work. It doesn't work because it's not possible. It's not possible to do everything that we are held responsible for (that is actually out of our control) in 7 minutes of time with the quality in which we want to do it. It leads to a lot of burned out physicians cynically practicing medicine. As much as I genuinely love my patients, I've realized that without boundaries, these two sweet souls pictured will suffer, not to mention myself and my dear supportive husband. And so, that is why, I am taking my "leave of absence."
A few weeks ago, I had a wake up call given to me by my youngest son, 2 years old. It was my off day. You would think I'd be more relaxed on these days spending a mommy-son day together. But, when you've been up late working the night before (and the night before and the night before and on and on) and you're still depressingly behind on everything needing to be done and are also intermittently answering calls/messages/texts/emails from office staff and patients AND trying to be present with your children, it's an extreme test of mindfulness. That afternoon it was time to go pick up my daughter from school and I'd been delaying my son's nap until we all got home so it wouldn't be interrupted by having to leave to go pick up his sister. So, of course, he's napless and tired and I'm in my usual state of exhaustion. I wanted him to use the bathroom before we left so he wouldn't have an accident in the time we'd be gone. After telling him it was potty time, I went to the bathroom to wait for him to follow me as he typically would do. This time, I waited and waited. It must have been oh maybe 15 seconds, it felt like 10 minutes. We're going to be late, I'm thinking. And for some reason, I just totally snapped. And you have to understand, I don't do that. I'm calm, cool and collected. I can count on one hand the number of times I remember yelling in my entire life. But this time, I yelled. I yelled at my son for taking 15 seconds too long to come to the bathroom. As soon as the words came out, I was already teary eyed. Then I looked up through my tears and saw my sweet son crawling into the bathroom. He looked up at me with a look of fear, confusion and such sadness and said "I was coming. I was crawling. I don't like it when you do that." He wasn't even disobeying, he really was coming, just not fast enough for me. He just was playing a game with his stuffed animals and was pretending to be a baby and crawl with them. And, I didn't have 15 seconds to wait.
I realized in that moment that my life was not working for me or my children. I mean sure there had been signs before but that was the moment looking at my son through my tears that I was convicted.
I've told my husband, who is thankfully also the Practice Administrator at our clinic, that this next few months is an experiment in figuring out if we can survive the next 20-30 years with a medical business under the ACA. Time will tell...
Brooke Uptagrafft, MD
Dr. Brooke is a family medicine doctor.