Comments on: Follow the money. Then follow the trust.

By: Raymond Ferrier, PT,DPT

Raymond Ferrier, PT,DPT — Sun, 07 Aug 2016 19:12:54 +0000

I cannot agree with you more on the matter of trust. For healthcare practitioners establishing trust is the number one requirement for providing efficient and appropriate care. As a physical therapist I make it a point to take the time to listen to the patient’s story, the problems they experience and their expectations from the physical therapy I will be providing. It is astonishing how much pertinent information I glean from this that is not in the medical record, including –but not limited to- omissions of previous diagnoses & medications and crucial gaps in the patient’s knowledge about their health conditions. Having this information allows me to incorporate and address these issues as appropriate in my plan of care or refer back to and consult with the physician. In addition, I spend a significant amount of time on my actual evaluation, making sure that the patient understands the logic (based on the physical testing) of my treatment hypothesis and differentials. When the patient understands the logic of the treatment plan and its goals, her/his compliance will be exponentially higher and therefore the treatment more effective in less time with fewer healthcare dollars used. To me, those are the mechanics of building the trust elements of making the patient feel heard, showing provider competence and promoting patient understanding and therefore increasing self-efficacy and self-determination.
It saddens me that, given the choices that have to be made within the economic constraints that reality imposes, the current payer logic seems to be focused on increasing the burden of documentation over actual time spent caring for the patient in order to be effective and build that needed trust. For the practitioners it means lower job satisfaction and higher rates of burnout due to the inability to fully make use of the high level clinical skills that they have worked so hard to acquire. Call me crazy, but it seems to me that it is those clinical skills that will make our system more effective and efficient, not the growing stacks of paperwork. For the patient it means high levels of confusion, dis-empowerment, dissatisfaction and less then optimal outcomes. For society it means spending twice as much per capita as other advanced nations, but with middle of the road outcomes.

By: joeflower

joeflower — Thu, 04 Aug 2016 22:56:19 +0000

I agree with you, Dr. Liepmann. Or let’s say I agree, and…

Obviously, saying we need more trusted human contact means we need more trusted humans. However, there are multiple pieces to that, and they add up to: Saying that there are not enough primary care physicians does not mean we can’t have a system with more trusted human contact for those who need it.

Several points:

o Workflow: Much physician time is currently wasted through arguing with insurance companies, difficult EHRs, and so on. If we could streamline the workflows of physicians so that they are spending more of their time on real doctoring, that could well be the equivalent of having, say, 25% more doctors — and the doctors would be happier and even working fewer hours while covering more patients.
o Value: As you say, “Primary care saves money while saving lives.” As healthcare organizations realize that economic logic, that will increase the value of primary care physicians in the marketplace, which means they will be paid more, which will attract more physicians to primary care.
o Nurses: The trusted contact doesn’t have to be with MDs. In fact, at the first and most constant level of contact, nurses and nurse practitioners are probably the more efficient choice. We should be using them more effectively.
o Teams: Much of this work is more effectively done in teams, as has been demonstrated repeatedly.
o Tech: Once established, as I mentioned above, the constant trusted contact can be maintained more effectively with less drain on physician hours through the thoughtful use of new technologies.

There is so much waste and ineffectiveness in the way we currently do things that I believe we can rebuild the system to give patients more trusted person-to-person contact while primary physicians actually make more (reflecting their greater value) while working the same or fewer hours.

By: Peter J. Liepmann MD FAAFP

Peter J. Liepmann MD FAAFP — Thu, 04 Aug 2016 21:28:32 +0000

And how are you proposing to do this without more primary care doctors? (Which means, essentially, more FPs, since most IMs go into hospitalist or subspecialty practice, and most midlevels go into specialty practice because the pay is better?)

Just to meet current needs projected forward to 2025, we need ~50,000 more FPs, while the number is projected to go DOWN by the same number over that time.

We can’t go on paying FPs half what we pay other specialists and expect anything but tragedy and high costs. Primary care saves money while saving lives.

“As we are building out these new networks and touch points, many strategists are madly reaching for tactics that actually reduce the person-to-person human element. It doesn’t work. The experience of multiple pilot programs and repeated studies show that prevention or population health management by robo-call, or call centers with scripts, or text message nags, simply does not work. People do not change their lives and habits based on a message or call from a stranger.”