The Renewed Interest in House Calls Includes a Please for the Familiar Physician

It may not be a full-scale “back to the future” movement, but by every indication the return of the physician house call is a small but growing phenomenon in primary care medicine. In part, this revival is expanding because of the “Independence at Home Demonstration”, an ACA-generated test program studying the effectiveness of treating chronically ill people at home, primarily those with limited mobility.

Early reports and common sense are telling us that this now rare but once common practice can play a role in significantly reducing healthcare costs while also improving the quality of care for many frail elderly and chronically ill patients.

Despite the fact that Medicare changes have made house calls more readily billable, it’s still a practice model that simply isn’t economically viable for the significant majority of practitioners, at least not yet. But even if you’re not reaching for your black bag and heading for the car, don’t fail to understand what else is at play. In fact, if you listen carefully, you’ll hear within the house calls comeback a clearly expressed plea for the familiar physician.

That’s because physician home visits represent less hurried and more satisfactory encounters for patients and physicians alike. There’s an opportunity to truly connect with people and as a consequence, the potential to develop a stronger patient-physician bond.

It’s tough to create a true home-like setting in our exam rooms, although a little attention to detail and comfort always helps. What we can do, however, is re-invent the exam room experience, through a physician-led team care approach that lets doctors focus on their patients once again, and not on a keyboard.

It’s an opportunity to strengthen relationships with patients, increase staff and patient satisfaction, improve the overall financial picture and restore much of the pleasure you may have lost in the practice of medicine. Transforming the exam room isn’t the same as a house call, but it just might be the best of both worlds.

Simply put, an Emergency Health Record (EHR) is a digital version of a patient’s paper chart. According to HealthIT.gov, it’s a real-time, patient-centered record that make information available instantly and securely to authorized users. Providers typically utilize EHRs to access patient information, document care, e-prescribe, view lab and test results, and enter orders.

IDC Health Insights conducted a study that looked at the current state of ambulatory provider’s use of EHRs. They reported that providers transitioning from paper records to EHRs share similar goals: regulatory compliance, improving the quality of care and qualifying for meaningful use incentives.

While the adoption of EHRs has been widespread, the majority of providers using them are dissatisfied.

Most office-based providers find that their productivity decreases with the implementation of EHRs. Contributing factors include, but are not limited to, inadequate training, staffing and support, poor usability, inappropriate form factors and user interfaces.

Unfortunately providers have faced several stumbling blocks along the way. Productivity has been jeopardized as a result of providers spending an increased amount of time documenting data and thus costing them their availability to see patients. Furthermore, EHRs may seem cumbersome to new users and often act as a barrier to providing quality care to patients.

This Fall, RAND Corporation published a report that presented the possible culprit behind provider’s stress. Typically providers experience job satisfaction when they believe they are providing high-quality healthcare. They begin to feel unhappy and stressed when circumstances, like adapting to a new way of providing care through EHRs, gets in the way.

The same study brought to light that provider’s feel EHRs are a distraction from face-to-face interactions with their patients and requires provider’s to spend too much time performing clerical work; it also degrades the accuracy of medical notes by encouraging the use of general templates.

While it is not an easy road to pursue, providers recognize the value of EHRs. Those reaping the benefits of EHRs report that there has been a reduction in the number of charts lost or missing, the ability to access medical charts and work remotely, as well as incentive payments.

Judy Hanover, Research Director at IDC Health Insights states “Success and productivity with EHR will become even more important as EHR installations become the building blocks for care management, patient engagement and patient-centered medical home operations under accountable care.”

Financing companies are offering doctor’s offices financial incentives for recommending financing options to patients who may not be able to afford products or procedures.

This is not a new idea; the ability for patients to open a credit card or receive a loan for medical procedures was first seen for cosmetic surgeries and elective surgeries. Unfortunately many older American’s find themselves with their backs against the wall because their care, even the most basic kind, are not being covered by Medicare or private insurance.

The New York Times recently wrote about an elderly woman who went to see her dentist for a problem and later found out she needed a partial denture. She was floored when she received the bill – $5,700.

Empathizing with her, the dentist office offered her a solution – a line of credit.

At first thought, it doesn’t necessarily sound like a bad idea. However, patients and doctor’s offices are being deceived.

iCare Financial of Atlanta, a financing company that offers an assortment of financing plans through doctor’s offices have experienced a 320% increase in enrollment over the past three years. They appeal to providers by showing patients vanishing from their waiting rooms because of the inability to pay for procedures.

The efforts that physicians and other medical personnel put forth to build meaningful relationships with their patients are diminished by offering these forms of payment. Interest rates are typically over 25% and increase automatically, often times the rates are retroactive, meaning they are applied to the patients’ original balances, rather than the amount they still owe and there are additional fees if payments are made late.

While medical credit cards and medical loans may be the only option for some patients, it’s not always the best option. Bear in mind that you are the representative for financing companies; whenever there is a problem, patients are more than likely going to blame you.

A chiropractor in Alaska once offered medical cards at his practice, but quickly learned that one missed payment could ruin a patient’s finances and life. When talking with other physicians, he asks them to consider if this is something they would recommend to their friends and family. Usually the answer is no, he says.

The price of medicine follows the same trend as our country’s delivery model of healthcare – broken and health insurance will pick up a large chunk of the bill.

Unfortunately for many, the prices of drugs are too high, another indication of our healthcare system’s crisis. It does not matter how many good drugs are available, if they’re unaffordable, it is of no help to patients.

The ability to afford prescription medications in the United States requires the best insurance, disposable income, and extra time to research how to save money.

Patients are known to scale back on their prescribed dosages to save money. One out of two patients don’t take their medications exactly as prescribed, which leads to additional office visits and further treatment. In the end, untreated diseases cost the culture, as well as the individual much more than the medication does itself.

Did you know? Drugs account for more than 10 percent of our country’s $2.7 trillion annual health bill, even though the average American takes fewer prescription medicines than people in other countries. The price of a typical steroid inhaler in the United States may cost $175, while the same inhaler retails for $20 in other countries.

Generics were introduced as a more affordable option to brand-name drugs. However, the price of generics has increased approximately 5.3 percent and often times are unavailable.

The United States allows pharmaceutical companies and generic drug makers to compete for the price of drugs which leads to the high prices we are forced to pay.

While prescription drug spending has declined due to the recession, it is expected to increase sharply as millions of Americans are becoming insured under the Affordable Care Act.

What mainstream business or product has stayed exactly the same since its creation?

Times change, people change, our needs as a culture change.

Change is undoubtedly hard, especially for the field of medicine which has changed very little over the past several decades.

There is a dire need for disruptive innovation in primary care as well as a reduction in healthcare costs. Patient-centered medical homes (PCMH) have the potential to accomplish these needs and more.

The hope of this new approach is to redirect patients from emergency rooms and hospitals to primary care offices, keep patients healthier and make primary care an attractive field for medical students to pursue.

Within a PCMH, a primary care physician leads his team of professionals who take more responsibility in providing care for a panel of patients. No longer do physicians solely handle patients; nurses are much more involved in the process of providing care, maintaining wellness, and patient education.

A cultural shift is most evident when physicians have to retrain themselves how to function within their office setting; they absolutely must learn to delegate certain aspects of care for their patients to nurses and medical assistants to meet the coming demand and improve outcomes.

Transforming a practice into a medical home does not have a one-size fits all price tag. For some it may include hiring new staff, temporary loss of productivity, purchasing an EHR system, etc.

Further upfront costs may include scheduling more office visits, improving patient adherence to prescription regimens and ordering more tests to ensure chronic conditions are maintained. However, all of this is done to ensure that those patients who may be at risk for a heart attack or some other life-threatening condition is closely monitored and treated, thus their care will be cheaper by detecting such conditions early. Protecting wellness and maintaining health are much cheaper than treating disease.

As many skeptics are quick to point out, it is difficult to measure PCMH’s cost-effectiveness. Though it may not generate short-term savings, over and over you hear stories about physicians falling in love with medicine again, greater adherence to prescription regimens, increased use of generic drugs, fewer hospital admissions, and less use of skilled-nursing facilities. It is inevitable as patients see their physician, costs will come down and health will improve.

Utilizing a patient-centered medical home aligns primary care physicians, specialists and hospitals to work together to optimize treatment rather than be in competition with one another.

Undeniably challenges lie ahead, but patient-centered medical homes are the way to building healthcare systems for the future.

A meteorological event known as the Halloween Nor’easter of 1991 or far more commonly as the Perfect Storm was popularized by a best-selling book and subsequent film. It’s now part of our language, used to describe situations characterized by powerful converging forces.

The storm developed when the remnants of Hurricane Grace collided with a low-pressure system off Nova Scotia and a high-pressure system that moved up the Appalachians before turning toward Greenland. It caused severe coastal flooding, wind damage and rogue waves up to 100 feet high.

Tragically, the Perfect Storm also took the lives of 13 people including six crewmen on the fishing boat, Andrea Gail, the subject of the book and film. For many, the book cover visual of that boat’s futile attempt to rise up and over a ten-story wave remains the symbol of this once-in-a-century phenomenon.

But the Perfect Storm was not a surprise. The National Oceanic and Atmospheric Administration and the National Weather Service both forecast a storm of epic proportions. As a result, warnings were issued well in advance. The public was generally skeptical, however, and many took the forecast far too lightly. This lack of concern, based in part on the particularly fine weather all along the coast at the time of the warnings, proved unfortunate for many and fatal for some.

Years after I read the Perfect Storm and later saw the movie, I began noting parallels between that event and the state of primary care medicine. In a number of ways, the perfect storm is the perfect metaphor for the extraordinary circumstances we are facing. Among the more direct comparisons are multiple forces coming together at the same time and a lack of concern (not universal but common) among both the medical profession and the general public. Like the storm warnings, many of us are aware but skeptical.

In fact, it seems that most people just can’t imagine the need to get over that 100-foot wave before it crests.

A marked difference between the literal perfect storm and the figurative one is the fact that the weather event was the result of three major systems while the storm darkening the skies over primary care physicians is coming from at least nine major forces. In a theme I developed in The Familiar Physician: Saving Your Doctor in the Era of Obamacare, I plan to describe and share my thoughts on those forces in upcoming blogs, beginning tomorrow.

As part of developing and writing my recently published book, The Familiar Physician: Saving Your Doctor in the Era of Obamacare, I spoke with Paul Grundy, MD. Dr. Grundy is the Global Director of IBM Healthcare Transformation, a champion of the medical home and the founder of the Patient-Centered Primary Care Collaborative, an advocacy group of more than 1,000 stakeholders including major employers, health plans, primary care professionals, technology firms, pharmaceutical companies, policymakers and consumer organizations. In his work on behalf of IBM Dr. Grundy evaluates health care delivery models around the world.  As a result, he has the opportunity to look at best practices, government policies, private initiatives and supportive resources in countries with very high functioning health care systems in terms of quality care and fiscal sustainability.

He described an encounter with government health officials in Spain who had played an important role in that nation’s current health care system.  Commenting on the obvious effectiveness of their efforts, Dr. Grundy inquired as to how they got started.  “We hired some American consultants,” he was told.

Dr. Grundy went on to tell me his belief that “We have had the answers for years in America, but have been unwilling to change.”

I share that belief.  Although I have not had Dr. Grundy’s unique exposure to a wide range of different health care systems, I think that the combination of well-trained and highly-skilled practitioners, state-of-the-art facilities, exceptional teaching resources, advanced research and progressive technology available in the U.S. is unequaled anywhere in the world.

There’s no question that we’re part of a global economy with a level of interdependency that simply didn’t exist even a decade ago. But at the same time I don’t think you’d find much disagreement in the assertion that America remains the world’s leader in the area of innovation, and health care is no exception.

Once we move past the polarizing debates and vested interests that create an obstacle to discovery and change, the potential exists to re-engineer a health care system that can be presented to the world as a model of clinical, social and human advancement.  I may be a little biased, but I also think that particular health care system will be built on a strong primary care medicine foundation.

Across the country, doctor’s offices are responding to the effects of burnout and limited time by offering shared medical appointments. Many doctors who facilitate these appointments believe it will solve the physician shortage we are experiencing in America, which is worsening as a result of increased healthcare insurance enrollment. Shared medical appointments are unique in that they are a combination of support groups and group therapy.

A more efficient way to use already limited time

Some doctors are advocating for shared medical appointments because they believe it is a more efficient way to use their time, which is already very limited.

“Rather than repeating the same advice about lowering blood pressure, or keeping glucose levels in check to eight patients individually, shared appointments allow physicians to see up to a dozen patients with similar symptoms at a time.”

Typical shared medical appointments consist of 10-15 individuals, who meet together in an open forum setting, for up to 90 minutes at a time. This is in contrast to the traditional appointment, where patients spend between 15-30 minutes with a nurse and provider collectively.

No additional financial burdens of implementing group-style appointments

Many think these appointments would be more costly based on the simple fact that patients spend more time with a provider. However, health insurers treat shared medical appointments just the same as traditional doctor’s appointments for an individual.

Shared medical appointments are not new; when they first were studied in 2005, the percentage of practices offering these unique appointments doubled within five years. The popularity of these appointments has been due in large part to costs remaining unaffected.

Patient’s privacy is no longer private

As more individuals are eligible for health insurance, providers are undoubtedly going to be feeling more strained; hence why shared medical appointments are relevant to improving America’s healthcare system, right now.

However, these appointments are not for everyone.

Non-believers in this model feel it is an inadequate solution. Some already avoid doctor’s offices because of embarrassment and shame; they most definitely will not share their personal problems in front of a group.

This is a legitimate concern; a patient’s private information, concerning their health, is now being made public to a group of strangers. Depending on the practice, exam rooms may be available for individualized care, as needed.

On the other hand, believers in this model feel they gain in-depth information and are assured about their health or are motivated to act because of hearing another person’s experience.

Bruce Moore, a teacher in the Ohio prison system who gets his annual physical with six other men at the Cleveland Clinic says, “When I see my stats up there on the board during group, they are my responsibility. I have to look at them and say what am I doing right and what am I doing wrong.”