Tag Archives: primary care physician

Untapped Opportunity in Healthcare

The U.S. spent $2.6 trillion on healthcare in 2010, with wages accounting for more than half of that sum, making healthcare one of the most labor intensive of all industries. For decades, healthcare leaders and policy makers have worked to reduce healthcare spending. Over that time, it has become increasingly evident that cost-reduction strategies focused on utilization and quality improvement will fall short if nothing is done to lower the cost of labor per unit of service. Unlike other industries in which technology has significantly boosted productivity, healthcare has experienced no such gains during the past 20 years.

At the same time, the U.S. is faced with health professional shortages. For example, there is a projected shortage of as many as 31,000 primary care physicians (PCPs) by 2025, according to the American Association of Medical Colleges.

Healthcare’s overlooked opportunity

How can the industry and individual health organizations bend the cost curve in a meaningful way, particularly at a time when chronically ill and aging patient populations are growing and more consumers have health insurance than ever before? A solution to balancing the demand/capacity equation is through virtual health approaches. In this way, healthcare can not only reach consumers who have been underserved, it can also serve in a better way those who already have routine care.

Virtual health can enable more clinical care work to get done without expanding the workforce, by streamlining work and redirecting clinician time to high-value tasks. Virtual healthcare models can expand clinician capacity in three critical ways: shift tasks and work to patients, replace labor with technology and automate tasks.

Combined, these three levers can streamline clinician work, decrease clinician demand and focus clinicians’ time where their training and experience have the greatest value.

More available time means greater coverage for more patients, without increasing workforce size. The optimal combination of traditional in-person and virtual interactions could also offer the best patient experience and has the potential to create a new standard of care across the entire range of clinical services.

What is virtual health?

Virtual health combines clinical care and professional collaboration through telemedicine, tele-health and collaboration-at-a-distance to connect clinicians, patients, care teams and health professionals to provide health services, support patient self-management and coordinate care across the care continuum.

Specific to physician-patient encounters, virtual health enables live and asynchronous clinical interactions, clinical practice and patient management supported by a wide range of communication, collaboration and cognitive computing technologies along with digital devices and data.

Scenarios to illustrate the opportunity

These three common primary and ambulatory care scenarios illustrate the opportunity of virtual health approaches and reveal both the potential time savings and economic value to healthcare. The industry faces clinician shortages in areas other than primary care, of course, but familiar primary care scenarios serve to highlight the possibilities of virtual health.

The need to palpate, auscultate or take samples for lab tests requires that most diagnostic encounters today remain in-person. However, in any “typical” office visit much of the physician’s time is spent gathering patient information, reviewing the information, considering potential treatment options and interacting with the patient. Often, the patient shares information in bits and pieces at different points in the exam, sending the physician back through the diagnosis and treatment option cycle.

Imagine, instead, if the patient provides information prior to the scheduled appointment. Common consumer devices, such as wearable sensors and digital weight scales, allow the patient to capture and share biometric information prior to the exam, which the patient can submit through a secure portal, with concerns or discussion items for the visit. The portal is also where a “virtual character”-a computer generated medical assistant-can guide the patient through the standard intake questions, such as family medical history and physical. Then, analyzing the combined information with a diagnostic engine, clinical options can be suggested to the physician prior to the in-person exam.

Reducing the amount of time gathering patient information and considering options prior to the exam can significantly streamline in-person encounters. Accenture analysis shows that applying virtual health to annual ambulatory patient encounters can save each U.S. PCP an average of five minutes per encounter. This is a time savings equivalent to as many as 37,000 PCPs-or 18% of the PCP workforce-with an economic value of more than $7 billion annually across the U.S. health system.

Equally important, after that initial exam, most of any follow-up visit can be conducted via video for greater patient access and both patient and physician convenience.

e-visits are becoming an increasingly common alternative to in-person office visits to manage patients’ continuing clinical needs. E-visits are asynchronous clinical exchanges completed via secure messaging in which patients submit information, questions and images for physician review and response. E-visits typically take fewer than 10 minutes of physician time. One example where e-visits can be applied is hypertension management. 26% of outpatient physician visits each year are related to hypertension. According to Accenture, if each patient has one in-person annual physical with half of the remaining hypertension-focused encounters converted to e-visits, the time savings could be the equivalent of around 1,500 PCPs-roughly 1% of the workforce- with an approximate annual value of $300 million.

Virtual health can support those with chronic conditions to self-manage their conditions to remain medically stable. As an example, adults with diabetes can use sophisticated mobile technology to effectively manage their lifestyles and conditions, and reduce the need for in-person encounters. Available technologies with sophisticated analytics can track, trend and assess data provided by patients-and medical devices-such as blood glucose levels. The same technology can also offer prompts and suggest a personalized self-management plan-and that plan can evolve as the patient’s health status changes. Further, the information can be made available to the clinical team when needed. The goal is to maximize patient self-care and allow physicians to practice “by exception.” In fact, such FDA-approved technology is available via physician prescription today.

Accenture analysis reveals that a care model composed of an annual physician exam and technology-enabled self-management the rest of the year can save time equivalent to approximately 24,000 PCPs-representing 11% of the workforce-for a value of almost $2 billion annually.

The enterprise-level impact of these scenarios is just as compelling as the industry-level view already described. Consider a large regional health system or independent practice association with approximately 1,800 affiliated or employed PCPs. Accenture analysis shows that an average of five minutes saved across all ambulatory annual encounters can release almost $63 million in physician capacity per year, the equivalent of about 320 practicing PCPs. For a smaller system or clinically integrated network, a staff of about 800 PCPs is more the norm. A five-minute savings across all annual encounters for that organization can release the equivalent of roughly 140 physicians’ time with a value of almost $28 million annually.

Toward a new gold standard of care

Virtual care and in-person care are equally important and complementary, the best mix depending upon the nature of the encounter. The ratio of virtual to in-person will shift over time as technologies evolve to enable more patient self-testing and caring.

The scenarios described are only some of the many ways that virtual approaches can unlock the time and capacity of the highly valuable clinical workforce. The gold standard of care will become the best combination of in-person and virtual approaches that support sound clinical practice, continuity of care and episodic clinical needs as well as continuing care for those with chronic conditions.

This is not a far and distant opportunity; technologies exist now that can help deliver quality care in a more affordable way by optimizing clinicians’ time. The industry as a whole, as well as individual organizations, must act now to integrate virtual care models into everyday clinical practice. Only then will healthcare begin to address the looming cost and labor crises affecting the industry at national and organization levels.

Confessions of Sleep Apnea Man

There are elements of medical care in the U.S. that just plumb confound me. One is the requirement of a prescription for the most mundane of items, particularly when you think about where we could be focusing our efforts.

Please indulge me a moment while I ‘splain the background on this.

I went through a sleep study back in 2002, where I was diagnosed with sleep apnea. Apnea is a condition most identified with snoring, although not all snorers are apnea sufferers. After the diagnosis, I was provided with a CPAP machine, the device most commonly used in the treatment of that particular condition.

Sleep apnea is described as a potentially serious sleep disorder in which breathing repeatedly stops and starts. What it really was, however, was a condition that kept my wife awake at night. I don’t know why the doctors didn’t treat her instead. The CPAP (Continuous Positive Airway Pressure) machine is designed to gently pressurize your airway, keeping it open, providing for a more sound sleep.

Mostly for your wife.

You see, the CPAP literature says the machine is designed to alleviate apnea episodes and reduce potentially fatal risks. The fatal risk it is most likely to alleviate is stopping your spouse from shooting you in the face with a bazooka at 3 am.

I have used the same CPAP machine since 2002, and it has performed very well. I do sleep much better using it, as does my wife. I usually take it with me in my travels, and therein lies the conundrum that has produced this missive.

My unit, now about 13 years old, is somewhat clunky for the frequent traveler. This is especially true when one does not generally check luggage. Somewhat bigger than a large box of Kleenex, the device either must be packed within my carry-on or in its own travel bag. As a medical device, it does not count as one of my two carry-on items under FAA rules, but it is nevertheless bothersome to have to tote a fairly significant extra bag around. Prior to the advent of PreCheck, it had to come out of the bag and be run through the X-ray equipment on its own. Until about five years ago, it even had to be pulled aside by TSA for explosives testing. If TSA was efficient, that would occur while I was having my prostate checked by Two Finger Lou. If not, the testing added a few minutes to every pass through security.

Today, as a government-fingerprinted “Known Traveler” with my very own “Trusted Traveler” ID number (don’t get me started on that), I always fly as a PreCheck passenger. The device no longer has to come out of the bag, so for trips of just a few days I pack it inside my carry-on. Of course, as we all really know, size does matter, and this is an issue for trips longer than just a few days. While I have become a very efficient packer and can get four or five days of clothes into a carry-on with the machine, anything longer requires that the unit be carried separately.

With that in mind, I ordered a “travel CPAP”: a machine about a quarter of the size of the one I have been using. After I placed the order with an online company, it notified me that it required a prescription for the machine to be on file before it could fulfill the order. I have a prescription for CPAP supplies on file with the company, but apparently being able to buy the supplies is different than buying the machine that uses them. According to the FDA, CPAP devices are considered Class II medical devices and require prescription by law.

The issue is that my sleep specialist, whom I have not seen in more than 12 years, changed practices a decade ago, and records no longer exist with the practice where I was diagnosed. Without those records, no prescription will be forthcoming. I frankly don’t know what my options are with the practice. I suppose I could set up an appointment, go through another two-night sleep study, spend a couple hundred in co-pays and have my insurance billed God knows what for the effort, all to get a piece of paper confirming something we already know I have.

All for a machine whose basic function is blowing air.

If we applied that logic here, you would need a prescription just to read my blog.

Can someone in the medical community take a moment to explain this to me, an admitted medical ignoramus? Have these machines been abused in some unimaginable way? Were teens buying these machines in droves to huff air? Are they somehow vital in the making of meth? For Christ’s sake, in the hands of evil men, what indeterminate hell could they unleash?

What aren’t you people telling us????

Someone should tell the FDA that CPAPs don’t kill people; drugs kill people. Maybe the FDA should focus some of its enforcement zeal toward those things that really matter. Perhaps the FDA has heard of the need for a national prescription drug monitoring database.

Unless, of course, I am mistaken, and rogue CPAPs are slaughtering more than the 20,000 people every year who die from prescription drug overdoses.

My solution to this dilemma will, I hope, be found through my primary care physician. I have made an appointment with him for the sole and single purpose of getting that magic prescription. It will cost me $30, and my insurance company significantly more, all to tell the good doc that I’m feeling fine and that there is nothing wrong. I just need one of those air-huffing, meth-cooking, chaos-reigning machines — but a small one to make my travel schedule easier to bear.

There is a chance that he will not be able to authorize one without another complete sleep study, in which event it will represent a colossal waste of resources.

In the absence of a logical explanation, this scenario simply serves to show the ridiculous waste of time, effort and resources in a system where common sense often struggles for its moment in the sun. In a world where we are trying to figure out how five or six remaining practicing physicians are going to treat 350 million people, is this really where we need to devote so much effort? It simply makes no sense to me.

But then again, there may be reasons of which I am not aware. I am sure some medical wizard out there, or a medical-equipment salesperson, should be able to enlighten me and remove my veil of ignorance on the matter. I encourage you to do so, and you don’t even need to be gentle about it.

It certainly won’t be my first time.

Everything That Ails Our Healthcare System … Squeezed Into One 12-Minute Doctor Visit

A few weeks ago I taped the first episode of my new public radio show. I thought I sounded good enough, and the producer assured me that I would sound even better after I got over my cold. This would have been reassuring, except that I didn’t have a cold.

Fearful of being fired my first day on the job, I immediately called my primary care physician (PCP) to get some advice on how to sound less hoarse. The doctor’s office promptly scheduled a visit with an Ear, Nose & Throat specialist, only four days later.

The specialist scoped my nose and announced that I had polyps in my sinuses. She said she would schedule me for a CT scan of the sinuses, and offered three alternative treatments, which, she added truthfully, may or may not work.

  1. Steroid-based nasal spray
  2. Steroid-based nasal spray with a three-week course of antibiotics
  3. Day surgery followed by a saline flush for a week

“So,” she asked, about seven minutes into the appointment, “which do you want to do?”

“Um,” I replied. “Shouldn’t we try the most conservative therapy first?”

“Well, you could.”

I begged off the surgery by quite correctly observing that I wasn’t very adept at flushing my nose out, so that I would prefer one of the non-surgical alternatives. “I’m not sure I need the antibiotics because I don’t think this is bacterial,” I said.

“A lot of patients report relief with the antibiotics,” she replied, almost as if she were cast as the “before” picture in an evidence-based medicine textbook.

“Isn’t three weeks a long time to be taking antibiotics?” I asked.

“Yes. Some people say that.”

I opted for the nasal spray. I elected not to schedule the sinus CT scan. Seemed like a lot of cost and inconvenience … and didn’t I just get a diagnosis anyway? So I didn’t follow up on it.

Except that the sinus scan was thoughtfully scheduled for me, as I learned when a scheduler called me the very same day. I ignored my first voicemail from the scheduler, but after the third I realized they really did expect me to show up (that very Friday, no less), and it occurred to me I might get billed unless I affirmatively called to cancel the appointment.

And, that is what is wrong with fee-for-service medicine. Most well-insured people would have gone along with the recommended program, getting the scan, the surgery, and who knows what else.

The bottom line is, in twelve short minutes, this visit encapsulated everything that is wrong with traditional fee-for-service medicine, of the type that someday, with any luck, is going to be replaced by capitated ACOs using patient-centered medical homes, supported by electronic medical records (EMRs), to refer to salaried specialists who don’t get to bill a big chunk of money each time they do a surgery.

Except that this practice is already a designated patient-centered medical home, it already uses an EMR, it is already partially capitated by its major health plan, and its specialists are already salaried.

That is the “punchline,” and explaining a joke often ruins it, but healthcare isn’t a joke so I’ll explain.

Just changing practice incentives may not change the behavior of individual physicians, especially specialists who even in most capitated practices are/will still be paid on the basis of work performed, somehow, to some degree. (In this practice, work performed affects physician salary for the following year.)

Further, patient satisfaction also factors into compensation, and what can be more satisfying for patients than promptness and responsiveness and action? As for the checks-and-balances provided by the EMR, it turns out that the EMR is what expedited the referral in the first place. Years ago it had been noted that I had a deviated septum (like about half the world, as it turns out). That information was duly stored in my EMR, so that my primary care physician had grounds to make a referral at her fingertips, without needing me to see her first.

The coda on this story? To try to overcome this hoarseness, I took the steroidal nasal spray twice a day for a week. Then I read the FDA insert, which listed the following as a side effect: hoarseness. I stopped the spray, and told this story to my producer. My producer suggested tea with honey during each taping, surely the most conservative therapy … and I still have my job.

So domestic policy wonks in the Washington, DC market can now hear me on The Big Fix Saturdays at 4 PM on WAMU 88.5, at least through January 15, when the funding runs out. I’m still a bit hoarse, but thanks to my producer I no longer sound like that guy on Boardwalk Empire whose vocal chords were blown up during World War I.

Postscript: The first episodes have already aired, and while a few people complained, not without justification, about my hosting skills, no one wrote in to say: “This guy sounds like he needs his polyps removed.”