I used to make home visits, but the time/cost pressure on me in private practice forced me and my group to give that up. We also gave up having in office mammography, nursing home care, hospital care, and hospice care. It doesn’t pay enough to make it worth our while. Now the MA plans pay primary care docs to make home visits to upcode the charts, but NOT the actual physician of that patient, because these home visits have NO clinical use. They are only a way of gaming the Medicare reimbursement system that increases payments for higher risk adjustment created by adding more codes. Just a coding racket.
Coordinating care. When my large network was recruiting specialists, we found that some did not even have a field in their records to note the primary care doctor who made the referral!! How low can the motivation to communicate back to the referring physician go? This answers that! A system that pays by the code for each widget starves coordination of care and makes those services unaffordable to primary care physicians. Think of Maslow’s hierarchy of needs. Primary care docs need food, clothing, shelter. Super specialists doing cataract removals or joint replacements need additional investment vehicles to park their winnings….
Coordination with social services. Same problem: there’s no business case for it in fee for service medicine, and primary care docs are working non-stop all day just to keep the doors open, and have no bandwidth to do anything. There have been many days trying to find the time to go to the bathroom, and lunch went away in the 1980s.
Exchanging records? Sure we can do it, but we’re in the last century sending FAXES for God’s sake! The few interfaces we have are all with reference labs or with our hospital, and they work ONE WAY. The hospital wants us to get their data, but when we offered them password access to our 30000 patients for the ER, they demurred. It seems the standard of care for the ER doesn’t involve finding out what patients are SUPPOSED to be taking, just to do “medication reconciliation” involving questioning the patient and family if available, NOT finding out what the treating physician intended. Given the low level of adherence to treatment, that means that errors of omission are GUARANTEED by the “standard of care” in the ER. Of course, we don’t want to be bothered to provide that data to ERs for free, but if that is the case, how about if SOMEBODY in the system valued primary care enough to make if even feasible?
Fee for service has been beggaring primary care for my whole 38 year career. There’s nothing left to remove. It’s time to have primary care docs and patients take back some of what is the core of medicine: the doctor patient relationship. That’s why I’m involved with SyncMD, the first tool for docs, the first patient centered personal health record system that enables patients to become what they always should have been: the center of the health system. For a long time the insurers became the center, and now the EHR/coders/payers are the center. Let’s get the patient back in the center and build the workforce around them. That will require changing the payment system to reward superspecialist less and primary care more until the balance reaches the rest of the more efficient and higher value systems in the developed world, with around 50% of doctors in primary care and substantially less unnecessary service and waste paying for technology that provides no value. Nothing done to date is making much headway to reduce cost, improve value, or make the primary care doc and patient do the most important functions. The Commonweath Fund survey shows how far behind the US is. I’m trying to point out some of the reasons why, and point towards solutions. Payment reform, changing the focus to primary care and patients, and providing them with the IT tools that work for docs and patients. SyncMD is a start, and a revolutionary one. More needs to be done.