Physician Patient

Archive for January, 2017

ACA repeal will prove good for psychiatric practice (January 2017)

Saturday, January 28th, 2017

ACA repeal will prove good for psychiatric practice

By: Lee H. Beecher, MD DLFAPA, FASAM As a psychiatrist who ran a solo private practice for more than 40 years, I welcome the demise of the Affordable Care Act (ACA). Why? Because so many of the ACA’s requirements have worked against the best interests of my patients.

The reality is that patients want much greater power in a U.S. health care marketplace. Patient power will, or at least ought to be, an important objective for health care reform at all levels of government. The 2016 elections make it clear that citizens want to be personally invested when it comes to shopping for their health care insurance and engaging health care professionals of their choice. That means we as professionals must advocate for price transparency for our professional services, and give our patients much greater power to say where money goes to pay for their health care.

One ACA requirement that really turns off patients and clinical psychiatrists is government and third-party mandates that a patient’s clinical notes must be put on an electronic health record (EHR). (The federal program that incentivizes physicians to use EHRs was part of the HITECH Act passed in 2009 and was strongly reinforced in the ACA which passed in February 2010.)
Patient data privacy and confidentiality are essential to gaining and maintaining patient trust when doing psychotherapy and outpatient psychiatry, and more than 40% of U.S. clinical psychiatrists today are in solo or small group independent practices. They make patient data privacy and confidentiality a hallmark.

Unfortunately, the ACA does not support independent solo and small group psychiatric practices. Frustrations tied to the ACA’s current overreliance on payer-”provider” contracting in the private and public sectors are the reason for the growing interest in the Wedge of Health Freedom. The Wedge is a voluntary program conceived by the Citizens’ Council for Health Freedom to advance a “new vision of health care for patients and doctors” by eliminating third parties who “manage” medical care dollars and “medical necessity.” I know from the last 10 years that a direct pay (cash) practice experience is a necessary option and alternative to managed care for patients and doctors. Patient demand is spurring The Wedge concept, as Twila Brase, a registered nurse who serves as president of the Citizens’ Council for Health Freedom, hassaid.

“The right to pay cash, the right to accept cash, and the right to discount prices must be protected within the wedge of freedom,” Ms. Braise said in a 2014 presentation before the Association of American Physicians and Surgeons. “I’m asking you to engage your patients.”

To ensure continuity of care, patients need to have both access to competent professionals of their choice and discretion/control of how those professionals are paid. That is missing in the ACA.

The emphasis on patient (consumer) choice is one of many positive aspects of the ACA repeal legislation proposed in 2015 by Tom Price (R-Ga.), an orthopedic surgeon who has been nominated by President-Elect Donald J. Trump to be the next secretary of the U.S. Department of Health & Human Services. Health savings accounts (HSAs) are key, as are the use of indemnity (catastrophic) insurance offerings based on the costs of care. To incentivize insurance companies to develop and market insurance products appropriate to the demands and needs of all people, including young and healthy enrollees, federal and state laws involving third-party insurance, Medicaid, and Medicare must change. And they will.

Expanding high-risk pools can be accomplished only with help from the states. (Minnesota is now debating resurrecting a version of the 1976 high-risk pool called the Minnesota Comprehensive Health Association). New and innovative programs for Medicaid recipients allowing them to shop for care using debit cards is an interesting proposal. Financial “skin in the game” for patients (even when such discretionary money is provided by taxpayers) will empower patients to shop for services and coverage with real options for them if presented with diversion if they show up at emergency departments with needs for nonurgent health care services or primary care. Other appealing proposals involve primary care programs linking care access through concierge or direct-pay arrangements with patients.

Everyone with Internet access knows that he or she can purchase almost anything online. Other than legal considerations (often state-imposed sales taxes), there are no boundaries or constraints to most Internet purchases. If someone wants a product or service and has the money to buy it from a vendor anyplace in the world, all it takes is a few keystrokes, and, voila, the items are on the way! Soon, in fact, may drop your “stuff” off via a drone on your front steps. So how is health care or the purchase of a doctor-patient relationship different from other “stuff” we buy online? And how, fundamentally, is the insurance that pays for health care different from other forms of insurance? Can we envision after a patient’s vetting and risk assessment that an Amazon drone might drop off an insurance contract or policy?

An important question and proposal for ACA replacement legislation is the opportunity for consumers to buy health care insurance across state lines. Competition based on coverage and price will drive down the cost of health care insurance for buyers. But there are serious obstacles to making interstate health care insurance a reality, such as state regulation of insurance, state licensure of health care professionals, and lack of a stomach by medical professionals for more “provider” networks.

Clearly, price transparency for health care services and insurance should be a first order priority for health care reform. There are no guarantees when it comes to markets, but it’s very unlikely that health insurance premiums will fall simply because people can buy health plans across state lines. Allowing companies to manage health plans in several states could bring down management expenses so long as there is real competition among insurance companies. That prospect, however, is countered by rampant consolidation of insurance companies, and associated oligopoly and antitrust issues.

In my view, health care insurance should be a contract between the enrollee (recipient) and the insurer rather than a deal that is usually hidden from consumers between “providers” of care and third-party payers.

We do need to get rid of individual and corporate ACA penalties for not having insurance while at the same time, make markets appealing to consumers of all incomes and needs. And people should be able to buy prepaid coverage from health maintenance organizations (HMOs) if people want prepaid care with its restrictions. We should expand HSAs, and encourage price disclosure/transparency for services and insurance coverage via the Internet.

I lobbied for mental health parity legislation for years, and the American Psychiatric Association supported the passage of the ACA in 2010 to ensure access to mental health benefits for Americans. But let’s stop kidding ourselves about the ACA’s real world consequences to the psychiatric care of our patients. Despite hard work over the years to expand parity for mental health services, psychiatric and substance use care at this moment is commonly restricted to managed care behavioral carve-out networks or time-limited programs. Those restrictions grew under the ACA.

In short, we need to create a true health care marketplace and access to insurance protections that enable psychiatrists and other mental health professionals to work for the best interests of our patients rather than the bottom line of health care organizations. Let’s urge our politicians to replace the ACA with measures that encourage and promote voluntary, motivated patients and their families to find quality professional relationships with competent professionals of their choice who are able to provide care continuity and confidential, data-safe practice environments.

Causes of The Epidemic of Physician Burnout

Thursday, January 5th, 2017

Causes of The Epidemic of Physician Burnout
Thursday, January 5th, 2017

At the Jan. 3, 2017 Minnesota Academy of Medicine meeting, Dr. Mark Linzer gave an informative presentation on the work of his team at HCMC to mitigate physician burnout.

It is estimated that significant physician burnout now affects half of US physicians, and it is getting worse. Dr. Linzer cited a recent Mayo study:

Despite a nationwide shortage of physicians, burnout is both a symptom and cause of the critical problem facing organizations wanting to retain and recruit physician employees as “providers” in health care organizations. There are narrowing employment options for doctors outside of such large clinic systems because independent medical practices continue to be bought up at a record pace by hospital-clinic organizations

Mark offered a “demand-control model” for physician burnout in which generic physician stress (pressures on doctors) is counter-balanced by the doctors’ ability to have control of their work environments and the quality of supports which are in place to reduce stress. The model’s reference:

From surveying the doctors at HCMC, two identified reasons for increasing burnout stand out:

1. Time pressure during patient encounters. Not enough quality clinical time with patients, nor the flexibility to adjust their efforts to the patient’s needs.

2. Inputting electronic health records (EHR) now dominates physicians’ outpatient and many inpatient clinical encounters and distract from doing quality patient care.

Dr. Linzer’s recommendations included:
Bringing scribes into the examining room whenever possible. The doctor is then free too interact with the patient while the scribe silently types away (in the background).
Expand the (allowable) 20 minute doctor care visit to 30 minutes.
Add (support) perks like a doctor’s lounge, quiet room, child care services and a 7 hours on, 7 off schedule, rather than one of 12 on 12 off. More time off.
Formal listening sessions sponsored by the organization to hear the gripes and complaints of the doctors.

When asked during the Q and A about the financial drivers of physician burnout?, Dr. Linzer said his he’s convinced his recommendations (in progress) save money for the organization — essentially by improving physician productivity and job satisfaction.

A number of audience members commented on the negative consequences to physicians when they are viewed by their organizations as “providers” (health care workers) rather than physicians (professionals). He agreed that this is a real problem.

Not examined or discussed during this fine talk was the elephant in the examining room, a connection between HCMC’s financial incentives and the mounting stresses experienced by its employed doctors. Many people, including policymakers, are not aware that HCMC as our public safety net hospital-clinic organization is now an Accountable Care Organization (ACO) called Hennepin Health So as with other ACO’s, the organization’s financial incentives must be to reward physicians for spending less money on patient care. How does this square with “increasing physician productivity”?

Also, as a psychiatrist by training, I am very concerned about patients’ medical care data privacy and confidentiality. If an EHR is mandatory in the HCMC system, how can patients be assured of privacy and confidentiality in mental health and substance use interviews and encounters? And, if scribes are seen as the answer to reducing documentation stress for most doctors, what is the effect of having another person in the examining room room during one’s doctor-patient visits?