Wednesday, July 27, 2016

Rural Care: A Primer For Washington Officials, Columnists and Economists.

Earlier this week, physicians in small private practices and rural areas breathed a collective sigh of relief.  There is a possibility the implementation of changes to physician reimbursement (known as MACRA) could be delayed.  Thank you, Mr. Slavitt, for listening.  I am grateful to Orrin Hatch (R-UT) and Ron Wyden (D-OR) for keeping our rural needs in mind.  We have a window of opportunity for rural health care to survive but we must communicate our needs as physicians and patients’ loud and clear. 
Whether in reference to health care or public education, trying to increase quality while simultaneously decrease costs is an unrealistic proposition.  Physicians in rural areas simply have fewer resources at their disposal.  Adding insult to injury, Medicare payments to rural physicians are dramatically less than those of their urban counterparts for equivalent services, a point driven home by the fact 470 rural hospitals have closed in the past 25 years.  Does it cost less to stitch up a laceration in a remote Alaskan village than in New York City?  I doubt it.  The expenses incurred obtaining supplies may be even greater for remote locations.
In order to set primary care physicians up for success, it is imperative those in charge understand our challenges.  Rural physicians are alone, save for our spouses running our medical practices while we see patients.   For physicians to be successful, additional revenue would be necessary to meet the expensive health IT burdens placed on us by this new payment model.  Creating “virtual” groups to consolidate reporting will still require provision of a “virtual” assistant because it is more administrative burden than we can handle.  Our profit margin is too narrow to accommodate additional employees.
I am not convinced time and money spent implementing new technology does anything to improve patient care; I am fairly certain, however, conversations with my patients provide considerable value.  Can you not extract the information from claims, like private insurance companies already do?  If we have to hire an additional employee, who is going to pay them? The solution is relatively simple; shift the burden of data collection from small practices to elsewhere or increase reimbursement so meeting your demands becomes feasible. 
Preserve what we have in rural America until you have more clarity where we are heading in the future.  According to a report on Rural Participation in the Medicare Shared Savings Program, rural providers already deliver value and quality within our existing infrastructure.  Adjusted for lower volumes, Medicare spending per beneficiary is 3.5% less.  Physician spending is 18.4% lower overall compared to our urban peers. We have strong personal relationships with our patients, operate at the top of our capabilities, and keep care local whenever possible.  I fail to see the problem with our old-fashioned style of practice. In fact, maybe you should use us as models of efficiency or cost-containment for larger conglomerates. 
Being in a small or rural practice is extremely challenging.  In rural America, 75% of exchange consumers had incomes less than 250% of the federal poverty level.  Every family in my practice who obtained insurance through exchanges met criteria for Medicaid, known in Washington State as Apple Health.  24% of rural children live in poverty.  We are surrounded by Health Professional Shortage Areas (HPSA’s) and Mental Health Professional Shortage Areas because primary care physicians are spread entirely too thin.   The elderly and poor in rural areas deserve access to quality health care.  What happens to those people if small practices cannot keep their doors open as a result of overreaching government mandates? 
According to the National Rural Health Association, 10% of physicians practice in underserved areas despite the fact 25% of the population lives there.  One-third of automobile accidents occur in rural areas, however two-thirds of the deaths from these accidents occur on rural roads.  Rural residents are more likely to die from injury due to delays in care.  I have direct experience, recently providing road side care after an accident while awaiting EMS arrival for 15 minutes. Delays are related to increased travel distance and personnel limitations.  
Extrapolate for a moment what could happen if numerous small practices closed in rural areas.  Can you imagine if one third of strokes occurred in rural areas, but two-thirds of stroke deaths were rural due to significant delays in receiving timely treatment?  It makes no sense to cripple our livelihood when we provide lifelines to underserved and disadvantaged populations.
Rural residents have fewer resources, significant geographic obstacles, and the acuity level of their medical problems is far greater.  These detrimental conditions drive tremendous health disparity.  We need to spend our time healing, comforting, and having conversations with patients, instead of reporting their medical problems and immunization status to non-physician statisticians. 
For physicians in small or rural practices with scarce resources and deteriorating infrastructure, it will require significant investment for us to undergo meaningful transformation.  Either learn more about the challenges small or rural practices face, provide waivers (like No Child Left Behind did) for exemptions, invest in our infrastructure, or leave solo physicians and our practices alone.  Do not try to fix what I am not convinced is broken.    

Friday, July 22, 2016

15 Ways You Know Mom is A Pediatrician

1.      “Hey, did you know there is an Influenza A and B.  Influenza A makes you really sick. ”  - My  4 year old daughter to the nanny
2.       “Mom, maybe it could be a virus that acts like Mono, but is not actually Mono?”  - My 7 year old son, listening in on my phone conversation about lab results. 
3.       “It is just my eczema.”  - My daughter at 3 when her preschool teacher asked about a rash. They did call and verify her diagnosis.
4.       “Can I bring Pedialyte for snack day?”  - 5 year old son to his kindergarten teacher.  (I am strangely proud.)
5.      “Mom I am not pooping.  (Sigh) I have “firework” diarrhea.” – 3 year old in the middle of the night.
6.      Conversation about rabies the other evening:
“If you get bit by a dog, then you will get rabies.”  - 4 year old daughter
“You mostly get rabies from bats.” – 7 year old son
“Dogs get shots to protect them from rabies.” – 5 year old son
“OK, phew.”  - 4 year old daughter very relieved
“Umm, how about we try to avoid getting bit by dogs?”–Mom preferring prevention strategy  
7.       “Fruit snacks cause cavities,” – my 5 year old on a playdate.  “But it says they are made will real fruit,” said the mom.  “Nope those packages lie,” he said. 
8.      “I hit my head.  I think I might have brain damage.”   I asked, “What’s your name?”  They knew it.  “You’re just fine” I said. 
9.      “Mom, your baby came out of your ‘pagina; my little brother is going to come out of my penis.” –2 year old who thought he was going to give birth to his baby brother? 
10. “I need orange juice because I am eating meat.  It helps with ‘sorption of iron.” Vitamin C increases absorption of iron, useful information for every young toddler.
11. “It is good to have an erection; it means you will not get cancer.”  - one child to another
12. “Mom, I sick.  (Fake cough, fake cough.)  I need some Dimetapp.”  - My 2 year old son faking his illness because he loves purple medicine.
13. Mom, I am having a bad throat day.  It hurts.  I need an X-ray to know what is going on.” – 4 year old daughter.
14. “You don’t need a Band-Aid.  Platelets do that job.” – one brother to another
15. School refusal is a common problem I see in my office.  I asked my oldest what advice he had if a child refused to go to school?  He said, “What?” (incredulous) “You throw them in the car, strap them in, drive to school, dump them out in front, drag them into the building, and leave them there.”  Awesome!


Wednesday, July 20, 2016

Going Rogue

Historically, the word Rogue was a descriptive term for elephants behaving in a dangerous way, often when injured or experiencing separation from the herd.  The expression today refers to a person who is displaying independence or failing to follow an expected script. As the reality of MACRA (Medicare Access and CHIP Reauthorization Act of 2015) looms, the pressure is on small practices to survive.  CMS plans to penalize 87% of solo physicians and reward bonuses to 81% of practices with more than 100 physicians.  It is time for passive resistance, defined as protesting against a law using peaceful methods such as refusing to obey or refusing to leave a building.  I am vehemently refusing to leave the building.

We are entering the era of Big Box medicine; where prices are cheap and quality will be questionable.  CMS will favor physicians at larger conglomerates because they will be able to keep up with overwhelming data reporting demands.  I do not agree that mountains of data are essential to providing high quality care.  Physicians are not in charge of our destiny.   What if we could be?  What if we buck the status quo and refuse to comply?

As of yesterday morning, mine is the last pediatric practice accepting Medicaid patients who are not newborns in my hometown.  In my county, 50% of the children are on Medicaid.  We have 3 fewer pediatricians than we did five years ago.  For a population of 260,000, 16 pediatricians remain.  Two of those currently practicing (including my father) are more than 80 years old.  Patients wait for months on our waitlist.  They are THRILLED to get in.  Sometimes I cannot believe how excited they are to walk through our door.  There are simply not enough of us to go around.  If this continues, children will not have access to a pediatrician when they need it.  Five years ago, I accepted 20 new patients per month.  Today, I accepted 10 and put 7 on the waiting list.  In ONE day.  The call volume is unbelievable.  This is our future if we do nothing.

The health disparity seen in my office every day is abominable; the need for basic care vast. A nine month old baby pulled off my waitlist after 4 months had eczema so severe he looked like a burn victim.  The thought of children not receiving necessary medical care so they can properly grow, develop, and thrive keeps me awake at night.  Our survival is paramount.

Which brings me to my point.

I am going rogue.  Market forces are on my side.  Physicians have a right to make a living.  A little civil disobedience is in order.  We need to stop following the guidelines and care for patients in spite of a system actively working against us.  If CMS leverages a penalty, I will need my Medicaid patients to pay that amount as an out-of-pocket fee; because it will keep my doors open.  I need to stay in business.  I must pay my staff, buy supplies, and pay rent.  I have four small children and a mortgage.  Those are standard life obligations.

Small practices have lower readmission rates and know their patients better than larger health care conglomerates.  I know my patients.  I know their parents.  Heck, I even know their grandparents.  I am exceptionally effective at keeping children out of the hospital.  My patients prefer my office to the local urgent care or emergency room.  If you wake up and your child is unexpectedly ill, you can walk in and be seen the same day.  If your child splits their head open at school, bring them down and I will stitch them up.  You might have to wait a bit, but the delay is less than at the local ER.  I provide excellent quality and service.

I know my families can afford $3 per visit.  I know they will be willing to pay it.  They already pay out of pocket for no-shows, typed letters, and FMLA paperwork.  They pay out of pocket for photocopies and after-hours nurse calls.  CMS Table 64 shows there are 102,788 solo practices and 123,695 practices with 2-9 physicians.  Can the government really go after almost a quarter million medical practices for disobeying the rules?

Abraham Lincoln said, “Government of the people, by the people, and for the people, shall not perish from the Earth.”  The decision of who provides good quality care should be in the hands of the people, not the government.  The people can vote with their feet and their pocketbooks, paying a small amount to make up for this outrageous government blunder.   Otherwise, many valuable small practices will close their doors.

Primary care physicians are the backbone of the health care system in this country.  A “CMS co-pay” in response to the $3- $9 per visit penalty is the best way to prevent our livelihoods from being destroyed.   We must stop being afraid.  We know health care.  We know our patients.  We trust in our abilities to save lives.  Physicians in solo and small practices will not perish if we let the people decide in whose hands they place their trust.  It is time to be mavericks.  If we work together, stop blindly following along, and put ourselves back in control of our healthcare system, we can passively resist until something changes.  Our health, Our people.  It is time to go rogue.

Thursday, July 14, 2016

Discipline: Draw Your Line in the Sand

Many of us were spanked growing up.  My mom had a wooden spoon in her car.  My dad broke a few on us kids.  We were taught “spare the rod, spoil the child.”  Now we are told spanking is not effective, does more harm than good, and teaches them to use violence.  So what is the “right” way?  There is no right way, but I will share my opinion.  Beware; a lot of trial and error went into this process. 

I have four children and their age span from start to finish is four and half years.  When my fourth child was born, the others were 4, 3, and 18 months.  That summer was the toughest in my life. There will be rough years ahead, but that time will go down in history as my personal marathon.

With regard to discipline, the best place to start is with the goal one has in mind:  to extinguish the offending behavior.  I started putting my oldest in time-out at 18 months.  It usually involved placing him in the corner, turning around, and counting to 5 or 10.  He understood the concept, though some take longer to learn it.  I was so proud of my skills (remember how pride goes before the fall?) 

Then there were two; 18 months apart.  They got along from their first moments together.  I praised the oldest when he was gentle with the baby and gave him extra snuggles when he hugged or kissed his little brother.  I would sit down and read to my oldest when nursing the baby.  I totally had it together! 

Then there were three; chaos began.  Three children in three years sounded like such a great idea, that is -- until it wasn’t.  Every time I nursed my daughter, the boys would fight, throw things, and make mischief.  They figured it out so fast.  “Quick! She is feeding the baby, now is our chance.”  I gave up figuring out who did what.  Instead, they both went in time out.  Right after one of them, my second child pushed an entire ream of paper off a ledge scattering hundreds of blank pages onto the staircase below.  That is when things needed to change for this “rock star” mom (hopefully you are not missing my obvious sarcasm.) 

“Evolve or Die” came next, known as natural consequences.  I spent an hour forcing him to pick up each and every page off the stairs.  If they spilled it, they wiped it up.  If they wrote on it, they cleaned it off.  If they broke it, they fixed it.  If they forgot their coat, they went without it.  (My children have magic internal heaters; they wear shorts year round and NEVER need coats, it must be a superpower.)  If they forgot to pack “cars with eyes” and their brother remembered to do such an important thing, then that child had to live with the consequences of his incomplete packing job even though his tantrum on the ferry was witnessed by hundreds of people (most at least had words of encouragement, but there were definitely some glares.) 

Back then, the happiest moment of my day was the brief two-minute silence I experienced after strapping them all in their cars seats while the car was in the garage before heading out for an errand.   I would go back in the house, take a deep breath, finish one chore, and remember what my life used to be like, back when I was sane. 

Pregnancy number four was a complete and total surprise.   (Consequences from your husband being home during the two minutes they are strapped in their car seats in the garage.)  I was in way over my head at this point.  Along came discipline methods combined with desperation:  anything to make it to stop and yes, even occasional spanking.  Time-outs expanded; my children would occasionally fall asleep in time-out, because I would forget they were there.  If anyone fought, they sat in the corner until one task was completed by me i.e. dinner was made, dishes loaded, or laundry folded. 

As for spanking, here are my personal guidelines:  One, single spank with a wooden spoon, only on the rear end, and never in anger.  Sadly, there have been no more babies for me, but I am still coming up with new discipline methods every day, the latest being the “warning” spank.  The warning spank is employed after one method of punishment fails (i.e. time-out), but before I reach spending-the-rest-of-the-day-in-your-room level.  It is effective without the ‘corporal punishment’ feel of regular spanking.

In summary, time-out, natural consequences, removal of privileges or toys, extra chores, and even an occasional spank all work.  Continually brainstorming and coming up with new ways to stay one step ahead of them remains part of the equation.  Anyone who bites another human or hits mommy goes straight to bed for the night.  When one says they “hate me” at bedtime, I refuse to snuggle them that particular night.  I say, “I love you, but I love myself too and will not snuggle anyone who hates me.  It is my body, my decision.”  I basically make it up as I go along. 

As for my journey, my best advice is to draw your own ‘lines in the sand’ as a parent.   No  one single discipline method is perfect for every child.  Reasons for misbehavior vary.  Do not judge other mothers; it is harder than it looks.  We are all “doing the best we can.” 

Discipline is a little like making meringue, always add some sugar (love) but being firm is still important too.  Parting thoughts to leave you with are about my grandmother, who had 8 children and her hands even more full than mine.  Her truth: “Make them more miserable than they are making you.”  Words I live by.  

Tuesday, July 12, 2016

Dear Mr. Slavitt, Please Come Visit My Office.

On July 7, 2016 Andy Slavitt informed us he wants to focus on primary care.  Below, I have chosen three points to help him with his task:  1. Overwhelming EHR requirements, 2. Defining value based care and, 3. A Solution for a Hurdle of the Care Coordination Model. 

Andy, if you want to fix primary care you must do some field research.  Come spend one day, or even a week at my office or another small primary care physicians’ office.  You need to see what we do on a daily basis and actually understand the view from a small practice perspective. This knowledge deficit is at the core of CMS's problem.  You cannot repair what you do not comprehend. 
Once you understand what we are capable of doing, how we do it, and how it actually SAVES money in the long run, while still providing high quality, then you are ready to tackle Focusing on Primary Care for Better Health.  The bottom line:  you must pay us more for what we are doing if you want to increase our overhead expenses.  Tasking us with additional administrative burden in order to earn extra money is not actually paying us any more for our work.  We would be working harder, not smarter.  Do you understand that?
First and foremost, the largest stumbling block for reducing expenditures of a small practice is addressing the certified EHR. Why do you need all this data?  Your days at McKinsey & Company have hooked you on its necessity to make management decisions, but your background in healthcare insurance and expenses is a far cry from the provision of primary health care or value-based care. 
The EHR mandate has damaged our profession as a whole.  It has been destructive to the physician-patient relationship as well. Technology has not improved safety, efficiency, or patient satisfaction and has only served to increase physician dissatisfaction.  Physicians are overwhelmed, hopeless, and trying to get out of the practice of medicine altogether.  You do not belong between me (the physician) and my patient – move out of the way.  Please.
If you want me to collect mountains of data, then prove it actually increases quality, reduces cost, and decreases our workload before I get on board.  There is very little margin to work with in my office, and if I make a wrong decision, my practice (and many others) will be dead in the water.   Find technology that is useful to both physician and patient while being affordable at the same time.  Stop adding complicated algorithms and programs to increase reimbursement while expanding our administrative burdens.  You will decimate everything decent about practicing medicine.
Second, value will materialize if you pay us more for what we do.  Higher reimbursement allows us to slow down and talk longer with each individual patient.  Make our lifestyle something to which others want to aspire and you will find more primary care physicians wanting to work in smaller areas.  Do not make us depend on a family inheritance or the lottery to prevent bankruptcy.  Primary care physicians, actually ALL physicians, deserve better. 
Have you not realized small practices provide urgent and emergency care, acute and chronic care, plus everything in between?  Care coordination, we already do it!  Winging it when there is NO specialist to refer to at all, we already do! It is value, pure and simple.  You cannot get anything more out of us.  There is nothing more to give.  If primary care is rendered obsolete because we could not keep up with your overwhelming demands, access will be in jeopardy.  Access will be worse than it is right now.  What will you do then?
As to your Collaborative Care Model, supporting mental and behavioral health through a team-based, coordinated system involving a psychiatric consultant, behavioral health manager, and the primary care physician sounds like a dream come true.  My county with a population of 260,000 has NO psychiatrist.  Not one.  Many states all over are experiencing the same provider shortages.  Can you grow psychiatrists somewhere at an accelerated rate, like that clone army in Star Wars, and drop them randomly by plane throughout the United States?  That would be a good start.  They could be raised to believe indentured servitude is their destiny.  I think it could work if you put that on your task list. 
CMS employees have not spent one day inside a small primary care practice.  It is necessary at this point in time that they do.  You talk about encouraging innovations to connect people with primary care.  Here is the thing Andy, primary care physicians do not need innovations to connect people.  We use phones, interact face-to-face with our patients, and chart to document the entire process.  If we were not good at connecting with people, we would not be successful primary care physicians.   
There is a lot of talking as a primary care physician.  It is difficult to quantify the value of face-to-face interaction but it is a crucial part of health care.  If you are feeling socially awkward and experiencing difficulty connecting to people, again, please come visit me in my office.  I will rid you of your communication problems, pronto.  At the very least, please spend some time with one primary care physician in a small community.  It will show you all that can be good with health care.  It will also open your eyes to what you are about to destroy. 

Thursday, July 7, 2016

The Reward of Caring for Foster Children

The more I see foster children in my office, the more my eyes are opened to the ugliness in the world.  Compared to them, my childhood was steeped in privilege. I ache for them to know love and security, not to worry who will tuck them in at night, or whether they will be separated from their siblings. I fight hard to hang onto my foster kids once a relationship is established.  Having the same health care provider as they grow up can lend an element of safety and stability to their unpredictable lives.  Below is one such story, of love and loss. 

The State Foster Care director asked I take on a patient who had been designated the highest care level, known as BRS (Behavioral Rehabilitation Services).  These particular children tend to have history of heavy trauma and increased adverse childhood experience (ACE) scores.  Being cared for by complete strangers as they move from home to home brings perpetual uncertainty.  Processing life forces these children to work through pain and adversity most adults do not face in a lifetime. 

I will always see a little of this one special girl in every new foster child who walks through my door.   Maleka (Arabic for Queen) was 8 years old when I first met her.  What an odd choice for a little girl with blonde hair and blue eyes, I thought to myself.  Her life story was no different than that of other BRS foster children.  There is always a primary caregiver who could not cope and was addicted to drugs, followed by an older relative who stepped in to help.  That individual gets ill, dies, or can no longer manage and yet another child is thrust into an unfamiliar world.  Each new home is always temporary.  In this particular tale, one home contained adults who were later convicted on multiple accounts of sexual molestation.  She was a victim as was her half-sibling, who was placed somewhere else in the state. 

What a start in life for this brilliant young mind, huh?  By the time she arrived in my office, she was on 8 heavy medications and carried 6 diagnoses including ADD, Oppositional Defiance Disorder, Conduct Disorder, PTSD, Reactive Attachment Disorder, and a Learning Disability.  She had been treated with every major psychiatric medication on the market and then some.  She was on 3 times the maximum dose of anti-psychotic medication and having daily accidents at school, likely due to the sedating nature of the medications.  How could she focus on schoolwork, let alone her bodily needs?  Common for children shuffled from county to county, each new physician adds to the regimen; sometimes forgetting to wean them off of others.

On that first visit, I saw her fear as plain as day.  So many people had harmed her, how could it possibly be any other way?  I took a history, completed an exam skipping uncomfortable parts for now, and decreased the sedating medication by two-thirds.  She seemed intrigued by this physician who seemed different from the others.  Unfortunately, I needed to draw blood and make sure she still had adequate liver and kidney function which destroyed any rapport built that day. 

I was honest and direct, explaining what needed to be done.  “Nope.  Take it or leave it lady.”  It took four of us to hold her down.  Her anger was apparent as she threw punches until she had little fight left.  The tears followed as I tried to reassure her to the best of my ability.  “I will never listen to you,” she hissed.  Before Maleka, when trying to comfort these hurting souls, I mostly felt lost.  She helped me find my way.

After she recovered, I said, “Your name is beautiful.  Do you know what it means?”  She shook her head indicating no.  “Would you like to find out?” I asked.  She nodded.  “It means Queen in Arabic and I think it means you are pretty special.”   She sat straight up and grinned ever so slightly before leaving.

Over the next two years, she returned many times; I always looked forward to seeing her on my schedule.  She weaned down to one medication for ADHD.  She tested into the gifted program and lost 30lbs. once she weaned off the mood stabilizers and sedating anti-psychotics.  She and I fell into a rhythm during her appointments; she always hugged me tightly on the way out the door.  It was as if she knew our relationship was only meant to be temporary. 

Out of nowhere, a long lost relative in a faraway state suddenly popped up on the radar.  The couple wanted to adopt her and her half-sibling.  I was the one who was terrified now; I cannot imagine how this little girl felt.  She was thriving in a wonderful foster home, attending a school she loved, and had a stable health care situation likely for the first time in her life.  I hated letting her go to another unknown place. She and her half-sibling were adopted by that couple and I pray she is thriving.  It has been a decade now and I imagine she will be entering college soon. 

While there will always be cruelty in the world, this story is more about triumph in the face of overwhelming adversity.  With each new foster child I wonder if there will be another who teaches me so much.  To genuinely stand with these forgotten children between their rocks and hard places is something Maleka taught me to do.  Our time together was far too short, but thank you darling child for allowing me into your heart.  Wherever you are, I wish you happiness, health, security, and love.  You deserve everything extraordinary life has to offer.