My change from a traditional practice to direct-care has caused me to challenge some of the basic assumptions of the care I’ve given up to this point. Certainly, the nature of my documentation will radically change with my freedom from the tyranny of E/M coding requirements.
Perhaps the biggest change in my care comes courtesy of the way I get paid. The traditional way to be paid is for service rendered (either at an office visit or procedures done). This means that I am financially motivated to give the bulk of my attention to people when they are in the office. They are paying for my attention, so I try to give them their money’s worth. The corollary of this is that I tend to not think about people who are not in the office to be seen. The end-result is an episodic approach to care that is entirely dependent on the patient paying for an encounter.
There is a huge problem with this approach to care: people live their lives between encounters. Life does not go on hold between office visits for my patients, and the impact of my care is not dependent on what happens in the encounter, but what happens between visits. My ability to help my patients depends on my ability to affect the continuum. If I do a good enough sales pitch for a person taking their medications, and if I consider the life-circumstance which may affect their ability to take the medicine, then I am successful. I don’t learn about the success until their next visit (usually), and I also don’t learn about problems until then. People are reluctant to call with problems they are having with medications, new symptoms, or other important details, often waiting for many months to tell me things I really want to know. Perhaps they don’t want to be “one of those patients who calls all the time,” perhaps they don’t understand what I said, or maybe they’re worried I will “force them to come in” to pay for another office visit. Regardless of the reason, I get very limited interaction with my patients in this episodic care model.
My new practice model allows for, and even encourages interaction between face-to-face encounters. I intend on spending a significant part of my day systematically reviewing records to make sure they are up-to-date, and initiating contact if need be. I will also give them resources to be able to manage their care (or their wellness) without having to pay for each encounter. One reader (of another blog to be left unnamed) suggested that under this system he would get his “money’s worth” by using my service as much as possible. For him that meant coming to see me often, but in the model of care on the continuum it would involve going to the web site and updating records, sending me questions, or watching videos I’ve made on a particular subject. My hope is that all my patients would “get their money’s worth” between visits, and that perhaps this will reduce the need for actual face-to-face encounters. In fact, that is the whole point of what I am doing.
There are some specific types of care that the view on the continuum is significantly better than the traditional episodic approach:
- Pediatric/well care. We traditionally see babies at 2 weeks of age, then at 2, 4, 6, and 9 months of age during the first year of life. After that the care becomes less frequent, to the point that many pediatricians don’t see children in school-age and teenage years more than every 2 years for well care. The reality is, however, that children grow between these visits, and much of the advice given during these visits (“anticipatory guidance”) is forgotten by parents. Care on the continuum means parents have access to the information about a wide range of problems as well as having the ability to ask questions any time they want. Things like “I can’t get my child to sleep in her own bed,” or “Jonny is still wetting his bed” are problems parents will hold off on asking until the scheduled visit. Certainly there will still be scheduled visits for measuring, assessing development, and physical exam (not to mention that the pediatrician needs his baby fix), but these visits are enhanced by what happens between them, allowing problems to be addressed sooner.
- Psychiatric problems. Much of the follow-up care of anxiety, depression, or attention deficit disorder (which are the three staples of psych in primary care) involves assessment of interim symptoms and/or problems. Care on the continuum can happen with monthly (or more frequent) reports of how things are going, how the child is doing in school, or if there are problems with medications. Many people with these problems are reluctant to come to the office, much less talk about new problems. I hope having direct access to my care will give them an easier avenue to give me the real view of how they are doing.
- Controlled drugs. Prescribing and refilling controlled drugs are a huge part of my work stress, and one I wanted to address in my new practice. Traditionally I write refills of these medications and manage them with intermittent office visits. On the continuum I can require a symptom questionnaire before refilling medications, allowing me to address increasing use as it is happening and moving people away from more addictive short-acting drugs to the more effective and safer long-acting drugs.
- Chronic disease. Diseases like asthma or diabetes are much better cared for on the continuum, as a regular log of blood sugars or peak flow readings can be sent to me on a regular basis. I can see early, not waiting for the 3 months A1c, that the sugar is not coming down as expected. I can hear about early symptoms of asthma, not waiting for the patient to come in with a full-blown attack. Adjustments can be made much more frequently without the need for face-to-face care just to hear about symptoms or blood sugar readings.
I keep getting new ideas of how to handle problems differently in this new model of care, but all of them benefit from the fact that it looks at patients before problems pop up, or at least at the time of the problem instead of after a potentially dangerous delay. The waste in our system is, as has been noted often, huge. But the assumption that episodic care is the proper model could be the most costly mistake of all. People are afraid to engage our system because of the cost, and that fear ends up costing everyone by not dealing problems until they are “bad enough.” Care on the continuum seems to accomplish the main goal of my care: keeping people away from the rest of the health care system unless it’s absolutely necessary.
Rob Lamberts is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).