Tag: BLOG POST

You don’t have to be a member of the infamous Corleone Mafia family to understand there’s a difference between what’s personal and what’s business:

But sometimes the lines are blurred, and distinctions are easier in theory than reality—especially within the provider/patient relationship of primary care.

This relationship can’t thrive without some measure of friendship. Where we need clarity, however, is understanding the difference between professional and personal friendship. We’ll take a look here at characteristics of a healthy provider/patient relationship, consequences of poor boundaries and how professional friendship promotes robust primary care.

The “familiar physician” at work

In my book Lost and Found: A Consumer’s Guide to Healthcare (co-authored with Dr. Paul Grundy), we discussed the impact of the “familiar physician” on patient health:

“Keep in mind that a familiar physician may be the most valuable professional relationship you’ll ever have, seeing you through many of the stages and transitions of your life… Based on a considerable body of research, you’re more likely to live longer, live healthier, and spend less for medical care when you see your familiar physician on a long-term basis. No other single entity in medicine can help you achieve those outcomes.”₁

But it’s not always easy to translate value into practice. And if you’re a provider trying to deliver accessible, relationship-based care to your panel, you’ve got your work cut out for you, particularly when navigating the murky waters of professional versus personal friendship.

A provider’s responsibilities to patients (i.e. what he or she is paid to deliver)—personal connection, timely access and competent medical practice—can’t exist in isolation of one another. The balance of these three areas is essential to the robust primary care system required for our society and to the quality, cost-effective care patients need. And the latter two are crucial for reaching the Triple Aim.

Tried and true

Trust helps people relax, let down their guard and feel safe. That’s the kind of environment patients need, and it’s the most basic element of a strong provider/patient relationship. It develops over time as the patient relies on the provider’s expertise to make the best decisions, and the provider expects honesty and cooperation in return. They become true partners, working together for the patient’s well-being.

Every interaction should be focused on medical intervention while getting to know the context of the patient’s life—family issues, economic situation, employment and stress factors—in order to make the best decisions possible for his or her health. That knowledge of the patient beyond EHR data is critical to the quality of care delivered.

But the provider/patient relationship is also a business transaction, which is where it differs so dramatically from a personal friendship. It must be controlled by normal business parameters in order to protect individual interests and make the practice successful. That’s why we have medical records, quality benchmarks and medical liability for the patient’s safety and why the amount of time the provider spends with patients must be limited to maintain the quality of the product (i.e. medical expertise + time).

Don’t take it personally

Another important aspect of a professional friendship is that it serves a specific purpose—something a personal friendship doesn’t always do. A patient’s purpose for a relationship with a provider is to achieve or maintain health at a reasonable expense and receive help making decisions that will lead to continued wellness in the future.

It can be difficult to keep patient health as the primary focus when a truly gratifying friendship develops. That’s why many providers struggle to keep their interaction within the confines of a professional relationship because they genuinely enjoy getting to know and caring for patients. Those relationships can even become a bit of a refuge for the provider from other stressors. But when personal dynamics take prominence in a professional friendship, they can destroy the very purpose of the relationship and lead to all kinds of bad outcomes. We’ll come back to that topic in a few moments.

Care must be honest and given in the patient’s best interests. Sometimes the most honest, caring thing a provider can do is tell a patient he or she has six months to live. That’s not an easy or enjoyable conversation, but it’s the best kind of care a provider can give to help the patient prepare for what’s to come. Without a strong commitment to act as a practitioner first and friend second, we risk losing the objectivity and candor required for those difficult conversations.

None of my business

During my years as family medicine provider, whenever I had a patient call me his or her best friend I knew that statement indicated one of two things. Either the patient was incredibly lonely and didn’t have much interaction with people beyond the brief and infrequent time with me, or the patient was possibly neurotic and inappropriately focused on what our relationship could provide. Those instances were good reminders of the need for wise interaction with patients to maintain a healthy professional friendship and avoid inappropriate reliance on me.

Disordered or disregarded boundaries can have serious consequences, whether unhealthy dependence develops or a lack of objectivity leads the provider to make faulty decisions. The first casualty is often lack of focus on the primary goal—the patient’s health.

As I’ve worked with practices around the U.S., I’ve observed many providers enter an exam room and spend 10–20 minutes socializing and only five minutes delivering medical care to a patient who’s in terrible health. The patient might appreciate the personal attention, but the interaction doesn’t facilitate better health as effectively as it could—and should.

Poor boundaries can also promote inappropriate behaviors such as control, abuse, relationships of a romantic or sexual nature, or improper prescribing of narcotics because the provider assumes undue responsibility for helping the patient cope with other areas of life.

On perhaps the most practical level, lack of appropriate time boundaries is simply destructive. The provider eventually loses his or her personal life because the workload is unmanageable, staff members get burned out, and financial viability for the practice is threatened.

Balancing act

Lack of appropriate time boundaries is detrimental for patients as well. We’ve become so out of balance as an industry that we’ve emphasized the quality of medical education without making the changes needed to facilitate patient access. Providers in the U.S. have some of the best education in the world, and yet our inattention to time has severely limited access for the patients who need our care. Unlimited time for one patient destroys access for another.

No matter how much trust exists between the provider and patient or how talented the provider is, the relationship fails the patient if timely access isn’t available when it’s needed. And more seriously, unavailable or delayed care can be detrimental to his or her health.

Primary care has become a quagmire because of its struggle to offer personal care within the context of poor business parameters. If we don’t understand the differences between professional and personal friendship, we won’t have the capacity to meet the needs of our patient panels and build financially sustainable practices. That’s why it’s so critical for us to get it right.

Business is business

Our care for patients should always be focused on strategies to improve their health in the context of appropriate boundaries. We can’t be great providers without creating an environment in which patients feel known and safe. That level of relational investment drew me to primary care, and the pleasure of caring for patients over time and helping them experience the best quality of life possible is what made me stay.

But like Michael Corleone in The Godfather, we have to remember that despite our personal involvement with patients, the revitalization of primary care through strong professional friendships must be strictly business.

₁ Lost and Found: A Consumer’s Guide to Healthcare by Peter B. Anderson, MD and Paul H. Grundy, MD with Tom Emswiller and Bud Ramey

There’s one thing we can all agree on when it comes to healthcare: it’s expensive for everyone involved.

UnitedHealth Group’s decision to exit the ACA insurance exchanges next year in most of the 34 states where it offers plans signals a need for continued evolution of payment reform. After suffering financial losses (and a projected $650 million in 2016), the largest U.S. health insurer’s withdrawal indicates growing concern regarding the sustainability of the marketplaces.

Something’s gotta give

It’s evident our healthcare system is desperately broken when you consider a large portion of our population can’t afford the cost of healthcare. The exchanges have helped pay for the cost of insurance premiums with tax subsidies from the government, but they have also attracted a sicker population that uses healthcare services more than the average consumer. That means the payer—an insurer like UnitedHealth—stands to make less or even lose money on the exchanges in comparison to the return available outside of the exchanges. So it’s not surprising that an insurer would choose the free market payer system.

With other payers (including Anthem and Aetna) struggling on the exchanges, it’s easy to imagine that in the future there could be fewer and fewer left in the arena to offer a product (i.e. insurance coverage) to consumers taking advantage of tax subsidies. Either costs for insurance will continue to increase so insurers offering individual plans on the exchanges can be profitable, or the government will have to provide more Medicaid/Medicare access to those who can’t afford insurance. If current conditions persist, there’s a real possibility that eventually no payers will offer coverage on the exchanges.

In the market for a better solution

The wrong conclusion to make here is that a single payer is the answer to the problem. A one-payer system won’t give us the access and care quality required to reach the Triple Aim. If the government ever institutes a single-payer system, this payment structure will be mandated to control costs. Free market principles driving competition in the primary care sector are essential for excellent primary care delivery, and a single-payer system would remove most of this competition.

My goal isn’t to debate the value of a single-payer system, but to instead advocate for why robust primary care offers us the only truly viable way forward to achieving the Triple Aim. What payers—the government included—should be doing is incentivizing and rewarding health.

Incentivizing health

Achieving the Triple Aim isn’t as simple as figuring out who’s going to foot the bill. The solution is to create a healthier population, thereby bringing down the overall costs of care. This can only be accomplished by a robust primary care system coupled with payment reform to address the damage done by the fee-for-service model. This payment model promoted sickness rather than health and encouraged both patients and providers away from primary care.

Robust primary care can be boiled down to three characteristics:

• Relationship-based care with a strong provider/patient relationship, leading to increased patient engagement and better, more cost-effective healthcare decisions

• Timely, convenient access to relationship-based care so patients can receive appropriate chronic disease management and aren’t relegated to urgent care from unfamiliar providers

• Excellent quality of care

These attributes will enable us to provide the care our population needs while also driving the costs of care down, thus accomplishing the Triple Aim. We won’t get there by throwing more money at the problem—we’ve already (unsuccessfully) tried that with three trillion dollars. It’s becoming clear we can’t remedy the situation by paying more bills. We must create better health for our society. To do that, we need a strong primary care system with a payment system that incentivizes health and not sickness.

UnitedHealth Group probably won’t be the last insurer to struggle and opt out of the Health Insurance Marketplace—more of that seems inevitable. The likely reaction from consumers will be a cry for more financial assistance. But the government’s real effort should be aimed toward helping to develop a flourishing primary care system throughout the U.S. that can truly serve and improve the health of our citizens.

I remember being part of a group of young physicians in 1982 that was told by a consultant, “You’ve got to be pretty bad to screw up this business opportunity. It’s just too easy to make money because people want your product. Basically anyone can survive in business as a doctor.”

It sounded good, but we received virtually no training for how to run our practices and make them successful from an administrative standpoint.

In my last post, I talked about the great divide between clinical providers and system administrators. These two entities—clinical medicine and healthcare administration—both want to deliver care to patients. But there’s constant friction between their goals and approach.

We’ve all contributed to the problem, and most of us have put little effort into finding common ground. With healthcare (and primary care in particular) at a unique juncture in our nation’s economic, political and social landscape, it’s impossible to ignore the chasm any longer. A good starting point for providers is to recognize our faulty understanding of good business practices and examine what needs to change.

It’s a matter of time

Doctors in the 60s, 70s and 80s didn’t really have to worry about being efficient to survive. When I was told in the early 80s that barring miserable failure in medicine I’d have no trouble achieving financial success, all of the industry’s emphasis was placed on good clinical performance. The assumption was that everything else would simply work itself out.

This belief fostered poor habits and a dysfunctional business model in primary care that set us up for failure. For example, time consciousness in the exam room was considered a lack of patient focus. In other words, if you weren’t providing unlimited attention to your patients, you weren’t giving them a good product (healthcare). This and other poor habits have persisted for decades, and now we’re experiencing the consequences.

As I’ve worked with practices and systems across the US over the last five years, I’ve observed hundreds of primary care providers at work. Very seldom have I seen one who’s able to limit his or her time for the sake of maintaining a viable business model that offers the convenient, same-day access patients need.

One internist told me last year, “If a patient needs me to stay in the exam room for an hour, I’ll stay in the room for an hour.”

At first blush, this commitment sounds admirable. But when style is considered more valuable than efficiency, it ultimately leads to underperformance. Unlimited time for one patient destroys access for another. Patients who can’t be seen by a primary care provider end up at the ER or an urgent care center and generate significant expense, due to unnecessary testing and an emergency level of care for what should have been a routine visit.

The root of this problem is the belief that time boundaries in the exam room aren’t important. This single issue is probably the number one reason primary care doesn’t have the impact it should—and could—have on our healthcare system. That lack of time-consciousness has helped create our current poor access to primary care, which has led to excessive costs across the healthcare industry.

Think about this issue in contrast to notoriously time-conscious lawyers. Lawyers know their business can’t survive without billing clients for any work performed on their behalf. While that approach can certainly be exploited, the principle holds true: viability is threatened by giving away your product without boundaries on time.

Make a move

The point of this critique isn’t to cause offense, but to call attention to poor habits. If you’re like me, I wasn’t aware of my dysfunction in the exam room until I was forced to re-examine my entire delivery model. And while not all the blame rests with providers, we have to acknowledge how we’ve contributed to the problem by not viewing our work with a business-oriented perspective.

The ACA reflects how healthcare is coming to grips with the fact that we can’t spend whatever we want on patient care if the economy is going to survive. Providers must begin to think in the same terms in order for costs to come down. We can’t bridge the gap without protecting critical elements of good clinical care and sustainable business. Both are needed for healthcare to thrive.

Don’t miss the third and final post of this series, where we’ll take a look at how providers and administrators can better work as a team to build self-sustaining businesses with convenient access.

It’s no secret there’s a wide chasm between healthcare and business, and even more so, between clinical medicine and healthcare administration. You’ve likely heard cautionary tales of providers who “went to the dark side” and chose administrative positions over clinical medicine, and there’s certainly no love lost between the two.

We have clinical providers of systems who want to give good patient care, and we have system administrators tasked with developing self-sustaining business that offers a quality product (i.e. healthcare) that consumers want and need.

East is East and West is West, and never the twain shall meet.

Much could be said about the origin of the divide, but essentially it boils down to the false economy developed by fee-for-service and third party payers with deep pockets. This system created extreme wealth but didn’t function like a real-world business. And the lack of normal economic boundaries caused costs to spill over into our population with devastating effects.

The goal here is not to focus on how bad off we are, but to shed some light on how we ended up here and what can be done to bridge the divide and move together toward the Triple Aim. In the following posts of this series, we’ll take a look at what’s needed from providers and administrators to begin the bridge-building process.

Where we are now

Before the ACA, business and the government (as well as the uninsured, in some cases) absorbed the majority of the high costs of healthcare. Now much of the financial dysfunction has shifted to healthcare consumers, making our general population acutely aware of the problem.

This article and other similar stories about life after the ACA further reinforce the gravity of the situation. The issue isn’t just a matter of who pays for healthcare; the problem is that healthcare is simply too expensive for everyone involved in the equation.

Cost creates a huge barrier for healthcare consumers to accessible, quality care, even if they have insurance under the ACA. The ACA made insurance affordable for some, but many still can’t afford healthcare in its current state due to high copays and deductibles.

A brief history lesson

It’s fair to say the dysfunctional relationship between healthcare administrators and providers is a disaster that has been decades in the making. Every system across the U.S. is struggling, but no one really wants to deal with the root of the problem.

Up through the 1980s, virtually no practice was owned by a hospital system. It was so easy to make a living as a doctor in those days that medical schools offered little, if any, business training for practitioners.

When HMOs came on the scene in the early 1990s, private practices became far less viable. Physicians began selling their private practices to hospital systems and became employees of those systems.

The problem is that because doctors weren’t well versed in business, they brought poor habits (and a reluctance to change them) into the more controlled environment of hospital systems. As a result, we started seeing the ramifications of the myths they (and by extension, patients) had come to accept about the care delivery process:

7 Care Delivery Myths

1. If a provider produces quality clinical care, his or her business is guaranteed to survive.

2. The patient’s expectations should control the visit in order for the provider to meet the patient’s needs.

3. Quality care demands a lot of time.

4. A good provider shouldn’t pay attention to time.

5. If it’s not expensive, it’s probably not quality care.

6. Socializing with patients is just as important as clinical effort.

7. If a provider is unable to see a patient, another provider (who doesn’t know the patient) can deliver the same quality of care.

This kind of mentality isolated business and clinical care and put them at odds with each other. It justified providers’ rejection of business norms—like efficiency, competition, and innovation—because they believed this kind of care was what a good provider should provide. But in reality, it came at a tremendous cost to their patients and posed significant problems for administrators.

There’s no such thing as a free lunch

In part to curb this kind of thinking, HMOs and Medicare began trying to establish some kind of connection between the level of clinical care and the cost of care for that level. This was the environment in which the “blank check” payment structure was created. Patients could go to as many providers as many times as they wanted and get any test they wanted—and a third party payer would cover everything. But because of the blank check, the healthcare industry never had much motivation to limit care in order to produce health or fix the lack of normal business parameters.

Fee-for-service and third party payers helped us survive the environment of the chasm for a while. But these factors, along with the continuing poor business practices of many providers, created an economic catastrophe for government, businesses and healthcare consumers. It’s also what ultimately led to our large uninsured and underinsured population.

Bridge construction ahead

There’s more discussion to come on this topic. We’ll look at other aspects of the issue—and practical steps to move us toward resolution—in following posts in the coming weeks.

The important point to realize is that we have to acknowledge the divide between administrators and providers. The problem is evident; now we have to fix it in order to achieve sustainable business and accessible, quality care.

To bridge the gap, we have to protect what’s critical for good clinical care while also protecting what’s critical for business to thrive. And both sides must be involved to bring about a truly successful solution that will bridge their two worlds.

Check out the second post in this series for a look at how providers can help bridge the gap by recognizing the poor business practices we often bring into the exam room.

It may be, but the road leading there has some challenges

As the team-based care model and its focus on care coordination expand throughout the world of primary care, so do the “coordinator” analogies. For example if you like sports, you might view the primary care physician as the quarterback of the team or the coxswain of the racing boat. If your interests run to music the PCP is the conductor of the orchestra. For cinema buffs, he or she is the director of the film.

To extend the analogy, it’s clear these particular coordinators would have a problem if, respectively, the offensive tackle decided not to block, the sweep refused to row, the first violin didn’t want to tune up and the star wouldn’t memorize her lines. You get the idea. Team-based coordinated care only works if everyone involved is open to being coordinated. When it comes to primary care medicine, the coordinated team includes the patient who, if we’re doing it right, is at the center of the whole process. And that’s exactly where we’re starting to see a growing concern.

As individuals and families covered through employee health plans or other forms of public or private insurance are becoming exposed to higher out-of-pocket costs for their health care, we can expect a corresponding increase in non-compliance based on financial pressures. It’s a simple equation. Less comprehensive plans and the higher co-payments and deductibles that go with them mean more and more people will make the decision to forego needed therapies, medications and procedures because they don’t think they can afford their share of the cost.

Given this scenario, what role can physicians play to improve treatment plan adherence in the face of healthcare sticker shock? To start with, we’re not financial advisors so a direct assault on the underlying economic concerns is not going to be part of our repertoire. What can be highly effective, however, is a more open approach to talking about costs before going forward with potentially expensive diagnostic procedures or ordering medications in those instances where it may not be affordable in either the short or long term.

In an excellent article on this subject in the New England Journal of Medicine the authors contend that having this kind of discussion is as important as sharing information on the potential side effects of treatment – with the belief that the anxiety created by financial concerns is a type of negative side effect in its own right. The article goes on to suggest a number of important reasons why a greater degree of transparency and open communication in the exam room has important benefits to patient outcomes, to the patient-physician relationship and to the healthcare system as a whole.

Care coordination is an essential element in the Patient-Centered Medical Home. Likewise, it’s a critical part of the way ACOs are going to work and the foundation of our ability to provide the right care at the right time in the right place.  But without the buy-in, literally and figuratively, of the patient and often the family, without the compliance of the person who’s at the center of all the coordination resources and efforts, the full promise of care coordination won’t be realized.

Talking directly about the cost of care isn’t something we train for and is generally not the easiest kind of conversation to have with patients. Beyond the possibility that they might range from mildly awkward to downright difficult, however, these discussions are becoming part of the way we should orient our view of the whole patient. And if we believe care coordination is the future of primary care medicine, or at the very least, a big part of it, conversations related to potential out-of-pocket costs are something we need to have. There’s that much at stake.