Tuesday, August 24, 2010

The Human Centered Health Home: Protecting Patient and Family Doctor Like Neighbors

How do we protect each other in the patient-physician relationship?  What if we try to act like neighbors act?  OK, Good Neighbors, the ones we like.

Let's establish rapport in a respectful way.  Then clarify an agenda for the engagement.  What if we then establish limits for our engagement?  How do we do that?  At the grocery there is a time/ money limit that's understood.  At the doctor's office, most people only pay a small percentage of the initial fee and everything beyond that is free.  There is a huge incentive to want more at those prices.  At the grocery, we would load our cart like it was a holiday if everything after the first $20 dollars was free.  What's to limit the patient from getting excited and wanting more, especially as they realize how knowledgeable their family physician is?

What do good neighbors do?  If my neighbor helps me with fixing my roof, do I ask if he'll fix my car and feed my dog, too?  How do neighbors help each other and set limits in sharing their skills while limiting misuse of each other?  How do they show their love and respect?

How should we protect each others time?  Why are doctors late? Take too much time with some and thereby show disrespect for others?  If our favorite patient in the world is in the waiting room and we know it, do we do better at connecting to the agenda and time constraints of the current patient?  Doctors have tremendous guilt about this issue, and lots of excuses (I'm not exempt from time management problems - sorry, sorry, sorry).  Neighborly patients, how can we share the fix on this?  (Please).

Will technology help us and the neighbors?  Can we refer each other to sites on the Internet that are helpful and maybe cost effective?  Think about this protection issue and let me know your thoughts and feelings about it.


  1. Interesting that you use the grocery store as an analogy. I've been thinking about that very thing. When I need groceries, I make a list and go get everything on my list. The bill is rung up based on everything in my basket. It would drive me crazy to stop at the store and be told that there was a limit on how many items I could buy. Maybe they'd let me buy bananas and tomatoes today, but if I need chicken or oil or anything else, I'd have to return another day.

    That's exactly what happens in many doctor's offices, and it's no wonder it drives patients crazy. Why can't we make a list and have everything dealt with at once, just like at the grocery store? It's not the co-pay; it's the repeated trips that are so difficult. I don't have a problem paying two co-pays if my doctor wants to bill the insurance company for two back-to-back appointments.

    The grocery store can ring up multiple purchases; do insurance companies not allow doctors to bill for multiple problems? If that's the case, maybe signs posted throughout the office could explicitly state, "Under normal circumstances, most insurance companies will only pay for one fifteen minute appointment per day. This distresses the doctor as much as it does the patient, but our hands are tied. Thank you for understanding."

    As for internet usage and pointing people to specific websites, I think that's a great idea. In most business, the majority of the calls are about the same things (over and over and over again). Your receptionist could keep track (for a few weeks, at least) of the most common inquiries, and answers to those things could be on a FAQ page of your practice's website, along with links to familydoctor.org and uptodateforpatients and other sites you find trustworthy.

    My $.02 :)

  2. Thanks for your comments. Indeed, the grocery is a good analogy. You get to pay for each and every item in your basket. The store owner is happy because you pay for each and every item in your basket. If the item is scarce or valuable, you are willing to pay more, reflecting its worth and your assessment of its worth. That's neighborly, mutually beneficial for you and the store owner.

    Physicians would be tickled to be just like the grocery store and just as neighborly, happily accepting full payment for the services rendered to their neighbors.

    We have a flawed business model and don't expect to be paid a full fee for what we do. We are limited by contract to only bill one visit per day and the "pre-negotiated amount" is limited by contract, but not a contract with the patient, our neighbor. Patients don't pay for the whole visit per their contract, usually negotiated by the patient's employer who actually usually is paying the significantly discounted final amount, much less than the physician bills. The patient pays for very little of what is in the "medical basket", but once in the door, they can press to get all they can stuff into the "medical basket" for the one copay.

    The primary care doctors are getting overwhelmed by this flawed business plan and leaving in droves. Medical students are opting to specialize where they don't have the pressure from the financially strapped patients and these hassles from the insurance companies selected by the patients employer to process the claims. Only 8% of the students are now entering primary care specialties, while we need 30% to serve the primary care needs of America. The ER's are already jammed with people who can't find a doctor or whose doctor is overbooked by patients. In my county, 5 2/3 family physicians left private practice in the last 16 months, uncovering more than 10,000 patients to find their health care in ER's or urgent care centers.

    Can we get together as neighbors and find a better business model that de-stresses the primary care system so we can appeal to those in medical training to serve the needs of their neighbors?

  3. Do you think walk-in clinics & NP's are going to become the new norm for "primary care"?

  4. Good question, Stephanie,
    They will have a definite place in the primary care system. Convenience is important for many who have a minor "parts problem" or non-emergent condition. NP's bring caring and Heart (capital H) to the system and work well on teams. They excel in many aspects of chronic disease management and could make the group visit concept workable as a team member/care leader. They are limited to protocols in some states that narrow their scope of practice compared to family physicians who aren't trapped by protocols.

  5. You're right, they are limited. Patients will go to a NP and get sent to a specialist if the patient need is beyond protocol. But maybe then, specialist will have the same problem family drs. are having as far as having to accept less payment to accommodate patients' needs (maybe not at first, but the market may eventually demand it)? What are your thoughts?

  6. Another good point, Stephanie, the market will drive all physicians to make less money. Temporarily, primary care physicians will get more money while other strategies are invoked that will get more people into primary care. Conscripting all the physicians graduating from medical school starting in 2016 could take care of the money concerns for doctors, but that is too radical to happen this soon.
    It is a wild time and creative juices are flowing to try to rearrange health care. Stay tuned.

  7. What we are doing is creating more steps between the specialist and the patient needing specialty care. First we have to go to the NP. THEN we can go to the FP. FINALLY we can go to the specialist. I don't think so. This is not a great model.
    A better model might be NP(s) in an office with one or more FPs / internists. This is a 1 1/2 step model that is less complex than the NP-FP-Specialist model. Might look like this:

    Patient --> NP/FP --> Specialist

  8. Good point, Elizabeth, how do we have the right people, team and model ready and able? The IOM report on the future of nursing seems to address the potential for expanding nursing roles to the limits of their training and licenses. This may lead to better connections between patient and primary care, leading to closer to optimal, less wasteful sub-specialty care. We're in a vortex of change that's unpredictable.