Tag: Primary Care

Physicians and “Moral Injury”

A recent article by Simon Talbot and Wendy Dean spoke volumes to us here at Still Point. The article, titled “Physicians Aren’t Burning Out …” takes the idea of “burnout” and replaces it with the concept of physicians suffering “moral injury.”

What this means, the authors argue, is the inherent chasm between, on one side, the expectations and desires of physicians to care for their patients — and, on the other side, the depressingly heavy weight of things that get in the way. These things include insurance companies, the model of corporate medicine, Medicare, coding, EMRs, computers in the consult room … basically everything that stands between the physician and the care she or he has for the patient.

Talbot and Dean levy the cause of this moral injury squarely at “our broken health care system” and, within it, the inability of the physician to “provide high-quality care and healing.”

There’s too much getting in the way.  The corporate mindset, with its attendant emphasis on gobbledegook-like bizspeak, such as appointing employees to act as fungineers in a somewhat sad attempt to artificially construct fun in the workplace, lays a destructive patina over the core of the problem. And, within that model, the core is buried under ever-growing layers of alleged efficiencies and streamlining that only serve to compound the problem.

One such example is the EMR, or Electronic Medical Record, a computer-based system that brings healthcare down to the level of fill-in-the-dots with a thousand mouse-clicks. Although, in the words of Talbot and Dean, the EMRs “are extraordinarily effective at tracking productivity [mouse clicks?] and other business metrics, [they] overwhelm busy physicians with tasks unrelated to providing outstanding face-to-face interactions.”

Exactly. And this leads to immense frustration. Physicians are trained to evaluate, assess, treat, and respond to patients. They are not data entry clerks. Nor are they wanting to dance the salsa down the corridor in a sad-and-sorry corporate attempt to infuse fun in the workplace. Quite simply, most physicians want to look after their patients. And, within the current “broken system” of healthcare in this country, they are “[r]outinely experiencing” the “deeply painful” feelings of “suffering, anguish, and loss” when they are “unable [within that system] to deliver the care that patients need.”

Yes, as the authors point out, physicians are “smart, tough, durable, resourceful people.” And, yes: there are many who have contemplated leaving health care. Not all, however, stay “wounded, disengaged, and increasingly hopeless.” Some, as we have done with Still Point Medical, take the initiative — and the lead — by working hard to create something different, which we believe we have done with the hybrid Direct Care Practice that is Still Point.

Talbot and Dean are quite right. We do not need a “Code Lavender” team to dispense “‘information on preventive and ongoing support'” nor to hand out “‘aromatherapy inhalers, healthy snacks, and water'” in response to crises.  That goes along with the fungineers and other corporate-world travesties. Such measures will not “change the institutional patterns” of our contemporary health care model that “inflict moral injuries” on physicians and patients alike.

We do not need one eye on the balance sheet and the other on the next business cycle, nor must we turn our physicians into data entry clerks, nor do we need the flotilla of coders to turn the practice of medicine into an ever-convoluted system of bean counting or evaluations that chide practitioners for “leaving money on the table” — or those same evaluations delivered with a snide sideways glance at how valued is the practice of “gaming the system” from within its own indefensible constructs. All of this is abhorrent to the honored and honorable practice of medicine.

We met with our CPA the other day. Still Point is a year old and we needed to check our income in relation to having paid the proper amount of taxes. Our projected income is nowhere near what it could have been had Still Point been a corporate medical entity. In fact, it’s probably less than 10 percent. The satisfaction, though, of really touching our patients’ lives, along with a smaller number of patients with whom we can really interact and know, matters to us. Visiting, this past Sunday, one of our patients who had been admitted to hospital is what matters to us. Calling to see how our patients are doing with no other reason than because we were thinking about them is what matters to us.

And it matters to our patients, too.

A medical practice that works away from the concept of “moral injury” is one, the authors assert, “where the wellness of patients correlates with the wellness of providers” and where the best interest of the patient — not the insurance company, hospital, Medicare, medical group, or fungineering supervisor — is what the physician is best interested in.

PHYSICIAN BURNOUT

Physician Burnout: A “Moral Injury”

 Aarón Blanco Tejedor

That’s Not Fair!

What’s “Blue Book” fair? It’s a “fair” price for patients to pay, as determined by The Health Care Blue Book, for their health care.

BLUE PIG

In New Mexico, according to the Blue Book, a “fair” price to see a family practitioner is as follows:

  • 25 minute consultation: $132
  • 40 minute consultation: $178
  • New patient consultation: $256

So what’s the price for our patients at Still Point Medical for these consultations?

  • 25 minute consultation: $60
  • 40 minute consultation: $60
  • New patient consultation: $60

And evening, weekend, or after hours appointment? You got it! $60

Still Point Medical. Medicine. Done differently.

We hope to see you soon!

MEDICINE DONE DIFFERENTLY

Saving Small Business $$$

The Backbone is Breaking

So often we hear that small business is the “backbone” of the nation. It’s a politician’s favorite catch-cry.

The backbone, however, is breaking under the stress of escalating expenses and crippling costs, despite the glib promises of tax relief. And, one of the most pressing issues for small business owners and their employees is the cost of health care.

We’re not just talking about the ever-rising costs of premiums, which have just risen again by an average of 20 percent (when was the last time earnings went up that much in a year?), but the toll that sick employees and employers can take on a business.

There’s a new trend that takes on both these issues: Direct Primary care partnering with small business. And it’s good not only for the health of small business owners and their employees, but for the financial health of the small business as well.

Here’s How It Works

Employers select less expensive, high-deductible insurance premiums for themselves and their workers. Then, they contract with a Direct Care doctor to provide 24/7/365 access to primary medical care – including visits to the workplace if needed.

Imagine that.

After work. At work. Evenings. Weekends. On the way to work. The Direct Care primary doctor is there when you need her to be.

An employee with a sinus infection. He can call his doctor and receive care that day, that moment, without having to miss work or wait hours at the Urgent Care.

An employer with bronchitis. She doesn’t have to wait to be treated. She can consult her Direct Care doctor by phone and be seen on her schedule. 

An Affordable Investment

Direct care is affordable for small business, especially when we think of time as money. At Still Point, our flat fee rate of $60/month per person (with a recommended employer-employee contribution of 70:30) covers an annual wellness exam and up to six consultation visits per year.

In combination with a high-deductible insurance plan, Direct Care is good for your business. Preventive care – and care when it’s needed – can go a long way in helping prevent more serious medical problems.  Keeping your workers and yourselves as employers healthy is a good investment for them, for you, and for your business.

Look up a Direct Care Primary practice or physician today and ask them about the services they can provide in partnership with your small business.

OPEN

Álvaro Serrano

The Worried Well … and Worse Than Nothing

Kaiser Health News is allegedly an “editorially independent program” of the Kaiser Family Foundation and is not, apparently, affiliated with the health insurance company Kaiser Permanente, despite the similarity in name.

One of the organization’s goals is to provide “trusted information on national health issues.”

Trusted?

Two recent articles published by writers from Kaiser Health News — one by Charlotte Huff and another by Michelle Andrews — appear to bring that goal into question. Both articles deal with the topic of Direct Primary Care, and yet throughout both pieces are insidious threads of bias towards health insurance companies.

The title of Huff’s piece, “Flat-Fee Primary Care Fills Niche for Texas’ Uninsured,” appears to promise information about Direct Care filling a gap — which it does. Consider, though, the use of other phrasing and statements. Above the title, in bold red, no less, are the words A FALSE SECURITY.‘ And, below it, the italicized tagline: “It’s [Direct Care] not insurance but it’s better than nothing … “

Really, Ms. Huff? Better than nothing? Those of us actually delivering Direct Care practice and the patients in receipt of it (at least at Still Point) have a different view, and comparatively it goes something like this:

TRADITIONAL “INSURANCE” CARE

DIRECT CARE

WAIT TIME FOR APPOINTMENT

6 weeks to 3 months

Same day/next day
AVERAGE TIME SPENT WITH DOCTOR AT CONSULTATION

10 minutes

40 minutes
COST/CO-PAY AVERAGE

$30-$60

$60
TIMELY FOLLOW-UP ? Frequent
ACCESS 24/7/365 No Yes
ACCESS TO MY OWN DOCTOR During business hours Yes
HOUSE CALLS What? Yes

So, if same or next day appointments, spending 40 minutes in consultation, having access 24/7/365 to one’s own doctor — maybe even at one’s own home — is considered “better than nothing,” then traditional insurance care in comparison appears to be “worse than nothing.”

The bias continues, manifested by an indefensible untruth. Huff claims that “[p]roponents of the [Direct Care] model, which is also supported … by the American Academy of Family Physicians, say it can provide a safety net for those with limited treatment options.”

No, we don’t. We say, quite clearly, that Direct Care offers a genuine alternative to a system that is struggling to maintain even a modicum of the concept of service and efficiency. It’s not about “limited treatment options,” and everything to do with Americans finally taking charge of their own choices for health care — and, for once, leaving the insurance companies out of the equation.

Insurance companies don’t like this. They, in response, make spurious claims about Direct Care practices such as suggesting patients “worry” that “easier access to [Direct] primary care is ‘good enough’,” that such patients “won’t investigate insurance options,” or that it’s “sort of the illusion that it’s kind of like insurance.” All of these alleged statements and claims are from Huff’s piece.

Bollocks. At Still Point, as at most Direct Care practices, we’re very clear to point out that we are not offering insurance. We also encourage our patients to carry catastrophic or high-deductible insurance (thereby directing patients to investigate their options). As for Direct Care being “good enough,” isn’t what constitutes “good” treatment  up to the medical practitioner to determine for his or her patients? — that is, if the practitioner has sufficient time to fully engage and interact with the patient.

Fortunately, at most Direct Care practices, practitioners do have this time.

A similar vein of bias-towards-insurance-companies is detectable in Michelle Andrews’ article, “A Pioneer in ‘Flat-Fee Primary Care’ Had To Close Its Clinics. What Went Wrong?” Andrews’ piece breathlessly opens with a classically negative “but” conjunction: “In theory, ‘direct primary care’ should result in better health … [b]ut some analysts say that approach just encourages the worried well to get more care than they need.”

What? To begin, which analysts? The Board Members of Kaiser Permanente or Blue Cross or United, for instance? The corporate bodies of administratively-heavy corporate medical  conglomerates? Proponents of doctors seeing 25 or more patients a day and spending 10 minutes with each, most of it on a computer in order to merely comply with onerous EMR reporting burdens and insurance-driven-and-created “treatment codes”?

And … the “worried well”?  Does that mean the individual who is concerned about his or her health and wants some reassurance or to access some medical expertise? The worried well had better not want to discuss any health concerns in detail with the physician or practitioner. There’s no time. So, let’s only see the really sick. Their complicated concerns can be dealt with effectively in a 10-minute consultation, six of which is spent with a face glued to a computer screen.

Patient? What patient!

Andrews’ article goes on to point out that Direct Care practices don’t accept insurance, which is true. The rest of her statement is absolutely and cringingly false. She claims not accepting insurance “frees the doctors from having to get preapprovals from insurers on treatment and lets them skip the paperwork … .”

If only. Daily, we toil at the “pre-(un)approval game” that insurances appear to play: the “you’ve used the wrong fax number even though this is the fax number we told you to use,” or “this person is not a member, even though last week the person was a member,” or “this is the wrong ICD-10 code for this. Request denied,” or “you need a peer-to-peer and we called once and you didn’t pick up so therefore that option is now eliminated.”

All the while, the hapless patient is waiting for treatment. Then again, perhaps he or she is just among the minions of the “worried well.”

Appallingly, Andrews discusses a hypothetical patient who is referred to a specialist by a Direct Care family practitioner. “That patient,” Andrews instructs us, “who likely has a high-deductible insurance policy … will probably be on the hook financially for the entire cost of medical services provided by the specialist — rather than insurance paying a share.”

Rubbish. Plenty of our patients are referred to specialists and the care is covered by their insurance. And for those who do have a high deductible, it’s not going to matter either way whether they see a traditional family practitioner or a Direct Care practitioner: the high deductible is still the high deductible. Above all of this, though, is the fact that health insurance has become so prohibitively expensive that many times a high-deductible policy is all one can realistically afford.

Nowhere does Andrews mention the possibility of negotating cash payments, either. As a specific example (from our own experience), the cost of an antibiotic co-pay WITH an insurance plan was $17.48. The cost to pay cash WITHOUT using insurance? $3.40.

Yes, really.

Andrews’ article continues to somewhat gleefully outline the demise of a Direct Care practice called Qliance that, inexplicably (given the overarching goal of individualism of Primary Direct Care), was serving 35,000 patients. That’s not Direct Care. That’s corporate medicine, replete with all the problems of a burgeoning, administratively top-heavy gelatinous monolith that cannot respond to individuals in a timely and effective and efficient way because it’s just too damn big.

Direct primary care seeks a small, individualized, and personalized patient base. Often, it’s a bare-bones approach, without the need for a small army of “coders” and “billers” (and here we are reminded of one hospital where the number of billers and coders are higher than the actual number of patient beds).

Direct primary care, at least the way we practice it at Still Point, is very small and people — patients — matter. It’s the same as in the book by E.F. Schumacher, Small is Beautiful: Economics As If People Mattered.  Paul Hawken, in his introduction to that book, points out that Schumacher has made an edifying and heretical observation: “There are inherent thresholds in the scale of human activity that, when surpassed, produce second-or-third order effects that subtract from if not destroy the quality of all life.”

Direct Primary Care is heretical to the interests of mainstream insurance companies because it re-establishes the connection and relationship between the doctor and the patient, without a corporate interjectory to micromanage, deny, reject, and control. It puts power back in the hands of the patients: power to choose, to direct their own health care, and enhance their own quality of life.

It would be nice to see writers such as Christine Huff and Michelle Andrews, with their enormous potential power to really enact significant and lasting change through the media platform of an organization self-tasked to provide “trusted information on national health issues,” at least try to present a realistic assessment of Direct Primary Care rather than insidiously appear to align themselves with an agenda of speaking for the nameless, faceless bureaucracy that has become medicine and health insurance in  this country.

SMALL IS BEAUTIFUL

Nine Köpfer