By Matthew Anderson, M.D.
Health Affairs blog, March 17, 2014
Sometime in the past five years — it’s hard for me to say exactly when — I suddenly found myself living in a new home. I must admit I am still a bit disoriented by how this happened. But it did. People keep telling me that everything will be OK but I am not entirely sure.
For example, in my old home we had occasional family meetings; things are different now. We now have weekly (and monthly) meetings. The many new administrators ask us to complete personality surveys. Once we had to figure out what items we should take from a sinking yacht in the South Pacific (hint: the $100 bill will be useful). Another time we had to decide if we were a “Wow” or a “Thinker.” We are asked to figure out how we can do a better job for them. I guess, like all forms of therapy you don’t get better unless you change.
Despite all these meetings there are a series of things I still don’t understand. I am afraid to raise my hand at the meetings and give the impression I’m a bad sport so I have written my questions down. Please, please don’t think I am a Luddite who wants to go back to the old home. In fact, what I dislike most about the new home is precisely the way — even in its differences — it resembles the old home.
1. Is this a home or is it a hostel?
One of the things that drew me to family medicine was the desire to build long-term relationships with families. I went to weddings and graduations; I was asked to be a godfather. I was there when babies were born and came into bedrooms to declare deaths. I could meet my patients on the street. I had families where I cared for five generations. At the time insurance companies didn’t generally dictate to people whom they could or could not chose as their doctors. Patients who liked me stayed and those who didn’t went to other doctors. All of this felt something like a home.
All that has changed now. Pretty much everyone will be on a managed care plan that will limit their choice of providers. If the system runs as intended, decisions about which doctors patients can see will be made every two years by the rational economic decisions of their employers. There will be nothing special anymore about the relationship between the doctor and the patient. As this has been explained to me, it is not really a problem “because you are a member of a team.”
I’ve already lost patients because of this system. And I’ve seen the orphans of other doctors when they come into my practice; they can no longer see their old family doctor because he or she isn’t in their new plan. I console them and then spend time reconstructing their health and social histories. I repeat labs, perhaps even vaccines given by the other physician. It’s hard to see that this makes clinical, emotional, or economic sense. And when will they have to leave my panel?
In a system where physician choice is guided by the commercial interests of employers and insurers, is it really possible to speak of a medical home?
2. Will my old friends still be welcome in my new home?
One of the things that most worries me is “Pay for Performance,” or P4P. Mind you, I don’t think it’s wrong to evaluate physician performance, although I wonder if the metrics being used are the right ones. I am not sure, for example, that the skill that best characterizes me is my ability to order flu shots. It’s also not at all clear that paying doctors for hitting targets actually improves any outcomes. Nonetheless, my income will increasingly depend upon hitting targets dictated by the insurance companies. But to be honest, I am not even sure who generates the targets. It isn’t us. And in this patient-centered home, it is not the patients.
P4P is very worrisome. Many of my patients are not necessarily what we, as residents, used to call “citizens.” Many of them have drug histories, some have done time, a good proportion don’t read or write. They are often skeptical of my brand of medicine, and many are struggling with mental illness. Their insurance status is often precarious; even if they wanted to get care, it is often unavailable to them. Experience would suggest that this group will not have excellent clinical outcomes. Are my old friends now going to cost me money?
It wouldn’t be hard to figure out ways to get this group of people off my panel and to get more “citizens” on it. It would make me look good. It would make the clinic look good. And it’s what the rational economic incentives offered me would dictate. Why, then, don’t I want to do it? Is there something wrong with my attitude?
3. Does Mommy love me or is she just paid to say so?
Recently a patient asked me if he should get a flu shot or not. I told him I was getting flu shot and that I thought he should too. I thought this was the right answer despite my (ever deepening) skepticism about vaccines and their regulation.
Behind my patient’s question was the implicit assumption that I would be providing him with unbiased, expert advice that was not influenced by commercial considerations. I think he would have felt less sure of my answer had he known that part of my salary depended upon his getting a flu shot. Is it fair for me to have given him any advice on this matter without disclosing my economic interest in the answer? I must admit, sadly, that P4P makes me feel more than ever like a poorly paid pimp for the medical industrial complex. And I wonder how I will feel the next time I go see my doctor and ask for his or her advice. Should I ask him if he is being paid to get me to do something Aetna has decided is important?
The problem is that once communication is purchased (in secret) it becomes impossible to trust anyone.
4. Why are we playing computer games during family time?
The moments I used to enjoy most were those when I sat down in front of a patient and we talked. This was the time to enjoy the immense privilege of entering into another person’s reality and engaging with it.
The EMR has fundamentally altered this relationship in ways that I am still struggling with. There is much less eye contact with my patients since I am writing on a keyboard, often sitting crosswise to him or her. Sometimes I even have to sit with my back to the patient. The content of the interview is dictated by a series of menus whose logical progression is unclear to me; I can’t imagine what my patients conjecture.
Like many large medical systems we have several EMRs and they don’t talk to one another. During a typical encounter I am switching back and forth on the computer between software A and software B (perhaps even opening C & D), all the while trying to maintain a conversation with someone in English (or in their own language). It may be just my inability to multi-task and I am sure that someday we will have (one) good EMR. But right now it seems to me that the multiple EMR’s are a massive barrier between my patients and me. They feel very unsafe. Wouldn’t it have been better to have thoroughly tested these systems first? Or was this another rational, economic decision?
5. Are there any family secrets left?
In my old home medical information was relatively isolated in a paper chart located in one physical space; I must say I hated running up and down to the chart room and longed for an EMR. But nowadays when I type something into the computer literally thousands of people across the medical center can access it. My notes are sent to insurance companies to provide verification of need. The pharmaceutical companies mine (and have mined) all our prescription data. They know more about what I have prescribed than our EMR does.
I think about this when I go to visit my own doctor who belongs to a different hospital. How many people — either strangers or acquaintances — will now be able to read everything I have told him? It has made me circumspect. Paper charts are so 20th century, but I do wish that there were real protections for patient information including my own. Remember that your colleague or clinic supervisor can — with a few strokes of their fingers — open your EMR. Wouldn’t it have been better to discuss this matter thoroughly first? Or is private patient data just one more commodity to be bought and sold by billion dollar corporations?
6. Everyone tells me how important I am, so why is my allowance being cut?
This is the part that puzzles me the most. At a recent Grand Rounds we were told that everyone thought primary care providers were the backbone of the health care system. President Obama said so. Orin Hatch said so. The ACA said so. The Republicans said so. Even IBM loves family doctors and IBM points out that they are buying the care so they should be able to get what they want.
Yet when I look at my paycheck now it is less today — in real terms — than it was when I was hired in 1995. I worked hard in 1995 and I work hard now. I regularly work two or more weeks without a day off. This is the life I love, but I can easily understand why medical students would decide upon a different career. They see how hard we family doctors work, they hear about our salaries, and they are socialized in a medical culture that values technical expertise and knowing more and more about less and less. It almost seems like all this talk about the importance of primary care is just that: happy talk designed to keep us working. I suspect medical students are smart enough to figure this out and continue to avoid our specialty.
We are not flourishing as a specialty and our leadership is far too busy talking about the promised land of the PCMH.
7. Do I have to go to Church now?
One of the things I like best about medicine is that — despite its very imperfect realization — medicine aspires to be a scientific pursuit based on evidence. But the current crop of Administrators (MD’s freshly minted with their MBA’s or a course at Harvard Business School) subscribe to a different religion: the compelling anecdote dressed up as a case study. Advanced Access came to our clinic five years ago on the basis of a case study series in JAMA. Would we give a new hypertensive drug based on a case series? Why are management decisions not held to the same level of careful scrutiny we give to clinical interventions? Why are we told that P4P will be implemented despite the lack of good evidence “because insurers are paying for it”?
I see that same problem in the enthusiastic and relentless pursuit of better patient satisfaction scores. Patients are constantly reminded that “we strive for five” and managers are rewarded when satisfaction scores are high. This passes for good administrative practice or even as hardheaded business thinking. But basic research principles tell us that if you want an honest answer to a question you don’t begin by suggesting the responses. What would we think of a clinical trial where the Principal Investigator met weekly with his or her evaluation team to review blood pressure readings and told them that he wanted better results? Or where the PI offered money to the research team that could produce the best results? We would consider such behavior highly unethical. Why? Because research strives to produce honest results, not those that favor the hypothesis of the investigator.
When Administrators tell staff to tell patients that we strive for five, what are they doing? Both being dishonest and biasing the results to serve their own interests. This is not science; this is hucksterism.
Of course, it is not really the administrators’ fault. They are good people. I like the place I work because there are so many good people there. The problem doesn’t lie with the people, it lies with the system.
8. Can we get some family therapy?
We are told that the new home is “patient centered.” But what does that mean? Patients certainly weren’t involved in setting it up, nor are they involved in its management. The main way they can provide feedback is via surveys, but these surveys are conducted in a way that biases results. Indeed, by almost any measure the patient seems to be the last one taken into consideration.
9. Can’t we afford a better home?
It may sound like I am a bit homesick but this is not true. In fact, I am concerned that the new medical home has all the defects of the old home: balkanization of information, over-reliance on technology, medicalization, disrupted care, waste, inefficiency, values that favor the privileged, the rigid hierarchies that keep people from working well together, inattention to the needs of patients — except now it’s all electric. It’s like giving steroids to someone on acne. The problems just get uglier.
There was a time when family medicine saw itself as a counter-culture in medicine with a mission to incorporate a different set of values. Our job should be to improve the wellbeing and health of our patients and their communities, not the bottom line of the corporations who thrive off our labor.
Such a dream will not happen until health care is seen as a public good instead of a private commodity. A national health system, it seems, is the only economically rational and humane way forward.