The American College of Physicians says healthcare-sector stakeholders should physician burnout and stress to help improve patient safety in ambulatory settings.
“Emotional exhaustion, which is linked to standardized mortality ratios among intensive care units, may affect cognitive and physical ability to perform tasks and diminish memory and attention, lessening ability to attend to details and process highly technical information; mental detachment and deficiencies in personal accomplishment may cause individuals to neglect duties or complete seemingly minor but crucial patient safety activities,” the authors continued.
The paper’s authors backed the National Patient Safety Foundation’s recommendations that organizations should try to improve working conditions and staff resiliency. The foundation has said that programs should include fatigue-management systems, and bolstering communication skills, including regarding apologies and dispute resolution.
A British study suggests that keeping primary-care practices open for more hours, particularly on nights and weekends, cuts visits to hospital emergency departments for non-life threatening illnesses and injuries, reports Medical Economics.
Researchers at the University of Manchester, in England, determined that practices that extended their hours beyond the British standard of 8:30 a.m. to 6:30 p.m. had a 26.4 percent reduction in patients seeking local emergency department visits for minor problems.
“The difference amounted to 10,933 fewer ER visits in a year. For every three additional primary-care slots booked, one visit to the ER was avoided.” said Medical Economics in summarizing the study.
But are longer hours practical for most primary-care practices? Nitin Damle, M.D., president of the American College of Physicians and an internist in Rhode Island, told Medical Economics that they are.
“We have had after-hours and Saturday morning hours for 15 years,” he says. “We find it helpful to patients, and it seems to decrease ER use modestly along with providing continuity of care.”
This column by Yul Ejnes, M.D., an internist and a past chairman of the board of regents of the American College of Physicians, says medicine needs a “Quadruple Aim” instead of the “Triple Aim”.
The “Triple Aim” is a concept developed in 2007 by Donald Berwick, M.D., and the Institute for Healthcare Improvement (IHI). Its three dimensions are “Improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.”
Then in 2014, to Doctors and Christine Sinsky published a paper in the Annals of Family Medicine titled “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider.”
Dr. Ejnes notes that “{T}hey very effectively made the case that our ability to achieve the triple aim is jeopardized by the burnout of physicians and other healthcare providers. They proposed adding a fourth dimension to the three in the triple aim: ‘the goal of improving the work life of healthcare providers, including clinicians and staff.”‘
“{E}fforts to achieve the triple aim have in many cases made things worse for providers. The added workload related to performance measurement, EHR use, greater documentation requirements, and increased access (expanded hours, e-mail, etc.) have had detrimental effects on the satisfaction and morale of members of the healthcare team.”
“It’s not about just physicians, either. All members of the healthcare team are at risk. The ‘Quadruple Aim’ bolsters the well-being of nurses, medical assistants, receptionists, and anyone else involved in providing care to patients.”
So here is Dr. Ejnes’s campaign platform:
“Healthcare leaders should discuss the quadruple aim when they would normally mention the triple aim, and explain to their audiences why that change is so important. (Also, when you hear a speaker refer to the triple aim, ask him/her about the quadruple aim in the Q&A.)
Changes designed to improve how we deliver care should also improve the work life of healthcare providers (and certainly not worsen it).”
The incentive program began in 2011 and was designed to address disparities in Medicare reimbursements between primary-care physicians and specialists. It distributed $664 million in bonuses in 2012, the most recent year that figures are available, to roughly 170,000 primary care practitioners, awarding each an average of $3,938, according to a 2014 reportby the Medicare Payment Advisory Commission.
Although that may sound like a small adjustment, it can be important to a primary-care practice, says Dr. Wanda Filer, president of the American Academy of Family Physicians. “It’s not so much about the salary as it’s about the practice expense,” she explains. “Family medicine runs on very small margins, and sometimes on negative margins if they’re paying for electronic health records, for example. Every few thousand makes a difference.”
Doctors who specialize in family medicine, internal medicine and geriatrics are eligible for the bonuses, as are nurse practitioners and physician assistants.
Medicare generally pays lower fees for primary-care visits to evaluate and coordinate patients’ care than for procedures that specialists perform. The difference is reflected in physician salaries. Half of primary-care physicians made less than $241,000 in 2014, while for specialists the halfway mark was $412,000, according to the Medical Group Management Association’s annual provider compensation survey.
The impact of the bonus program is larger on practices with a substantial number of Medicare patients. Dr. Andy Lazris estimates 90 percent of the patients that his five-practitioner practice in Columbia, Md., treats are on Medicare.
“When the bonus payments started, it was a pretty big deal for us,” Dr. Lazris says. The extra $85,000 they received annually allowed them to hire two people to deal with the administrative requirements for being part of an Accountable Care Organization and to help the practice incorporate two new Medicare programs related to managing patients’ chronic diseases or overseeing their moves from a medical facility to home.
Next year, if they can’t make up the lost bonus money by providing more services, it’ll mean a pay cut of $17,000 per practitioner, Lazris says.
Although in some practices, doctors try to see more patients to make up for cuts in reimbursements, that is harder for a group focusing on the elderly. “Part of what we do in geriatrics is spend a lot of time with our patients,” he says. “We have to, when someone has five conditions and takes five minutes to get into the room. The basic office visit is 30 minutes.”
The incentive program was an effort to address shortcomings in Medicare’s system of paying providers mostly a la carte for services, which tends to undervalue primary care providers’ ongoing role in coordinating patients’ care. Earlier this year, Medpac proposed that Congress replace the expiring primary care incentive program with a per-beneficiary payment to primary care physicians that would be paid for by reducing payments for non-primary care services. That proposal hasn’t made any headway. Meanwhile, physician trade groups have lobbied unsuccessfully for an extension of the Medicare bonus program.
The expiration of the Medicare incentive program is particularly painful because it comes on the heels of a similar bonus program for Medicaid primary care services that ended in 2014, says Dr. Wayne J. Riley, president of the American College of Physicians, a professional organization for internists.
“There will be some physicians who say they can’t take any more Medicare patients,” Riley predicts.
An attorney for an advocacy group for Medicare beneficiaries says they support the bonus payments and hope that physicians won’t shut them out.
“We don’t have any evidence to show that primary care docs will stop seeing Medicare beneficiaries without the payment bump,” says David Lipschutz, a senior policy lawyer at the Center for Medicare Advocacy.
The vast majority of non-pediatrician primary-care doctors accept patients who are covered by Medicare, according to a national survey of primary care providers by the Commonwealth Fund and the Kaiser Family Foundation. But while 93 percent take Medicare, a smaller percentage, 72 percent, accept new Medicare patients. [Kaiser Health News is an editorially independent program of the foundation.]
Not all primary-care practitioners will miss the incentive program, according to the Commonwealth/KFF survey. Only 25 percent of those surveyed said they received a bonus payment; half didn’t know the program existed.
Of physicians who were aware of and received Medicare bonus payments, 37 percent said it made a small difference in their ability to serve their Medicare patients, and 5 percent said it made a big difference. However, nearly half — 48 percent — said it made no difference at all.
Medscape noted that key factors in favor of concierge care, according to the ACP, are that “physicians can spend more time with patients, patients can see their physicians any time they like, and physicians are more satisfied. Factors against the model include the potential of excluding low-income patients, who may not be able to pay the fees up front, and downsizing patient panels at a time when primary care demand is expanding, both of which create ethical considerations.”
“The paper gives some examples of ways to counteract the potential of exclusion, such as waiving the concierge fee for lower-income patients or having a sliding-scale fee.”
“The ACP includes several recommendations for physicians in the new policy paper, including that physicians should consider the patient-centered medical home as a practice model that has been shown to improve physician and patient satisfaction with care, outcomes, and accessibility, and has been shown to lower costs and reduce healthcare disparities.”
The paper says that telemedicine can broaden access to care, improve outcomes, and reduce care costs, but that risks and benefits must be rigorously evaluated for both patients and physician.
The paper offers some recommendations for successful telemedicine.
Among them:
“ACP believes that a valid patient–physician relationship must be established for a professionally responsible telemedicine service to take place. A telemedicine encounter itself can establish a patient–physician relationship through real-time audiovisual technology.”
But, the authors say, a physician seeing a patient for the first time via telemedicine should begin a relationship based on the standard of care for an in-person visit or consult with another physician who has a relationship with the patient.
Physicians’ practices are increasingly trying to reach their patients online. But don’t expect your doctor to “friend” you on Facebook – at least, not just yet.
Physicians generally draw a line: Public professional pages – focused on medicine, similar to those other businesses offer – are catching on. Some might email with patients. But doctors aren’t ready to share vacation photos and other more intimate details with patients, or even to advise them on medication or treatment options via private chats. They’re hesitant to blur the lines between personal lives and professional work and nervous about the privacy issues that could arise in discussing specific medical concerns on most Internet platforms.
Some of that may eventually change. One group, the American College of Obstetricians and Gynecologists, broke new ground this year in its latest social-media guidelines. It declined to advise members against becoming Facebook friends, instead leaving it to physicians to decide.
“If the physician or health care provider trusts the relationships enough … we didn’t feel like it was appropriate to really try to outlaw that,” said Nathaniel DeNicola, M.D., an ob-gyn and clinical associate at the University of Pennsylvania, who helped write the ACOG guidelines.
But even the use of these professional pages raises questions: How secure are these forums for talking about often sensitive health information? When does using one complicate the doctor-patient relationship? Where should boundaries be drawn?
For patients, connecting with a physician’s office or group practice on Facebook can be a simple way to keep up with basic health news. It’s not unlike following a favorite sports team, your child’s middle school or the local grocery store.
One Texas-based obstetrics and gynecology practice, for instance, uses a public Facebook page to share tips about pregnancy and childcare, with posts ranging from suggestions on how to stay cool in the summer to new research on effective exercise for post-birth weight gain. Practices have also been known to share healthy recipes, medical research news, and scheduling details for the flu shot season..
“I have people come up to me and say, ‘I follow you on Facebook — thank you for posting this particular article. It helped me and my husband and my family,’” said Lisa Shaver, M.D., a primary-care physician based in Portland, Ore.
But unless they’re already friends, she won’t add patients to her personal account — where, she said, she posts less health information and more cat videos.
Historically, professional groups including the American College of Physicians and American Academy of Family Physicians have advised against communicating through personal Facebook pages. The American Medical Association notes that social media can be a valuable way to spread health information, but urged doctors in its 2010 guidelines to separate their personal and professional online identities to “maintain professional boundaries.”
Finding ways to use Facebook and other forms of social media to connect with patients — even if it may just be through professional pages — fits a trend in which patients seek more equal footing with their doctors, said Zack Berger, M.D., an assistant professor of medicine at the Johns Hopkins School of Medicine who studies patient-doctor relationships and social media. It also follows what James Colbert, M.D., a hospitalist at Massachusetts-based Newton Wellesley (Mass.) Hospital, described as the growing consumer approach to medicine — including the notion that patients should be able to reach their physicians at all hours. Colbert is also an instructor at Harvard Medical School who researches how patients want to fit social technology into their health care.
Email can be particularly convenient method, though it isn’t without concerns. Eva Schweber, 44, emails her doctor from a personal account and sends messages through an online portal — a more digitally secure system that is being adopted by a growing number of practices. The portal, she said, is for discussing complex, specific information. She’ll email her doctor from her personal email for less private concerns: scheduling, filling prescriptions and asking if certain symptoms might warrant a check-up.
“The unsecure email is easier, in that I can do it from my phone, my tablet, whatever,” said Schweber, of Portland, Ore.
In a recent study published in the Journal of General Internal Medicine, almost 20 percent of patient respondents reported trying to contact doctors through Facebook, and almost 40 percent through email. “Patients want to communicate with doctors [in whatever way] is convenient,” said Joy Lee, a postdoctoral research fellow at the Johns Hopkins Bloomberg School of Public Health, and the study’s lead author.
Doctors don’t yet seem to share that enthusiasm, Colbert said.
Meanwhile, security questions persist.
Social-networking platforms aren’t usually digitally encrypted, increasing the odds they could get hacked or shared with third parties. The same worries hold true for other, casual forms of online communication such as email and text-messaging.
That means doctors who discuss specific health concerns with patients through those could break the Health Insurance Portability and Accountability Act, the patient privacy law.
“Those concerns are always going to be there,” said David Fleming, past president of the American College of Physicians. “How private is it when we share, when we talk to people? … Once I’ve written it or once I’ve emailed it, it’s gone, and I have no control.”
But because HIPAA was written before email and social media’s ascent, it may not address patient preferences or behavior, Colbert said. With more patients becoming comfortable using personal accounts for health needs, he said, the law perhaps deserves another look.
“Should we allow patients to be able to share or send messages without going through these privacy safeguards if they’re willing to do so? Or do we say that that’s not safe and even if patients don’t care about privacy we need to protect them,” he said. “That’s an open question.”
That public nature is a real worry for such patients as Katie Cardenas, 45, who lives in Garner, N.C. She doesn’t think that Facebook is secure enough for personal medical details. For sensitive information, she’ll usually send messages through a patient portal, the more secure website her doctor’s practice has set up.
Doctors could address that, several said, by using social media in other ways. These include maintaining active Twitter presences and professional Facebook pages for less-tailored health tips. That way, patients can get useful information and a sense of their doctors as people, but privacy stays intact and physicians maintain distance.
At the Minnesota-based St. Cloud Medical Group, patients can follow a public page. Doctors who are part of the practice post updates with safety tips and seasonal health reminders, or use the page to coordinate and publicize small projects, such as a week-long initiative geared to reducing children’s screen time.
Julie Anderson, a family physician who is also part of the practice, sees the value in this option, but doesn’t personally befriend patients on Facebook. Beyond patient privacy, she said, she fears blurring her personal and professional lives, or patients using that access to seek extra care when she’s off the clock.
“I’ve known colleagues that have friended somebody and have had inappropriate questions asked online, in terms of kind of abusing service,” she said. “Or abusing that … Facebook friendship, where they’re asking medical advice and you’re not even their physician.”
Following these recommendations would obviously mean a considerable drop in income for some providers.
“Less frequent screening for some malignancies, as well as starting tests later in life and ending them earlier in old age, may make sense for some adults without a family history or other risk factors for cancer.”
“The notion of high-value screening is a sensible way for doctors and patients to decide whether a particular test for cancer makes sense,” Dr. Richard Schilsky, chief medical officer for the American Society of Clinical Oncology, told Reuters.
He wasn’t involved in the ACP recommendations.
“No screening test is perfect, and most people who get screened don’t have the disease. Most people who do have the disease won’t benefit from screening because the disease is so aggressive that they would have died anyway, or because it is so slow-growing they would never have symptoms,” Dr, Schilsky said.
Bob Doherty, a vice president of the American College of Physicians, notes that if Congress lets Medicare primary-care payments be cut on Jan. 1, it would be the second straight year when such payments to primary-care physicians — and only those physicians — would be cut by double-digits.
“Medicaid payments to primary-care doctors were cut in most states by an average of 40 percent at the start of this year because Congress failed to reauthorize a federally funded program, called the Medicaid Primary Care Pay Parity program that, in 2013 and 2014, raised Medicaid payments for office visits, vaccines, and other primary care services to no less than the applicable Medicare rates.”
Because the elderly vote at much higher levels than do poor people, Medicaid tends to get much harder hit than Medicare in funding cuts.
Mr. Doherty notes that “Republicans wouldn’t sign on {to continuing the primary-care incentives} were varied, but were mostly due to the fact that since Medicaid Primary Care Pay Parity was created by Obamacare, which they loathe and vowed to repeal, they couldn’t see their way to supporting a program created by it. Plus because many of them believe the Medicaid program is fundamentally flawed, they couldn’t see putting federal dollars to prop up its reimbursements to primary-care physicians.”
