Leaders of Broadlawns Medical Center in Iowa are vowing that a revolt among staff psychiatrists won't harm patient care, although they acknowledge that they'll have a challenge in replacing the doctors amid a statewide psychiatrist shortage. Four psychiatrists and the mental-health program's director announced in February that they were resigning from Broadlawns, which is Polk County's public hospital. They expressed anger over administrators' attempts to implement productivity standards, which they said could harm patients.
The Florida Supreme Court says patients have a right to check records on past mistakes made by their doctors and hospitals, no matter how old those files are. The justices rejected an appeal from hospitals claiming that right should apply only to records created since November 2004, when voters adopted a "patients' right to know" amendment. The high court also ruled parts of a law limiting patient access to those records are unconstitutional.
You don't have to be a political junkie like myself to have noticed a lot of talk about change in recent coverage of the Democratic and Republican primaries. It's what voters say they want in exit polls, it's what the candidates on both sides of the aisle are promising, and it has been one of the central themes of the 2008 presidential election.
Today I leave for the AMGA annual conference in Orlando where two of the keynote speakers, former Senator Bill Bradley and former Speaker of the House Newt Gingrich, will discuss what all this talk of change means for the healthcare industry. The duo will explore each of the parties' healthcare platforms and discuss how the potential presidential candidates "plan to reshape the future of the U.S. healthcare system." I'm sure at the forefront of many physicians' minds will be the looming 10 percent cut to Medicare fees and whether the presidential election will finally bring a permanent fix to a payment system that has been held together by Band-Aids for several years.
Too often it seems political discussions about healthcare focus on everyone involved except the providers who make the entire system work, so it will be nice to hear politicians address physicians and administrators directly about issues that concern them.
Why don't politicians speak about physicians' concerns more often? Part of the reason may be that physicians simply don't vote at the same rate as the general public. Physicians have other tools, such as behind-the-scenes lobbying, for influencing policy, but votes are politicans' lifeblood and that's often what they respond to. The behind-the-scenes work may not even be as effective now that the AMA has been banned from discussions about the upcoming Medicare package and its accompanying payment cut.
However, many politicians do work to offer tangible solutions to providers' problems; they just often get lost in the political horse races and the broader political discussions about healthcare reform. Earlier this week, for example, Gingrich and Senator John Kerry spoke about the proposed Medicare Electronic Medication and Safety Protection Act, which will offer incentive payments to physicians who invest in e-prescribing. The event didn't make headlines, but the bill will help address the cost barriers that prevent many physicians from adopting the new technology.
Staying on top of issues like this and filtering out political pandering is particularly important during an election year. We'll keep you updated about the changes that politicians are proposing, as well as day to day changes occurring on the ground in medical practices and hospitals across the country. Attending a conference like AMGA gives me an opportunity to speak face-to-face with physicians and practice leaders about the struggles they face on a daily basis and the innovative solutions they've developed to overcome them.
Senior Online Editor Rick Johnson and I will be reporting live from AMGA over the next couple of days, so check in regularly to find out what Bradley, Gingrich, and your colleagues have to say about what's changing--and what isn't--in healthcare.
Physicians are not getting the sleep they need to function at their best and current work schedules may contribute to their inadequate sleep, according to a survey released by the American College of Chest Physicians Sleep Institute. The survey found that most physicians sleep fewer hours than needed for peak performance and nearly half of physicians believe their work schedules do not allow for adequate sleep.
I have been closely following "concierge medicine" ever since the first practice opened in 1996 in Seattle. Although there is no official count of how many such practices exist, my personal files include 222 practices operating with their own names, and 624 physicians practicing in these or in practices with the doctors' names. There are many others who have concierge patients paying extra for specific services, such as same-day access, e-mail consultations, and risk or disease management packages, as well.
The initial concierge practices were all in primary care specialties--family practice, internal medicine, pediatrics--but there are a growing number that are in secondary specialties: 45 by my count, including "addiction medicine," cardiology, dermatology, general surgery, gynecology, and oncology just to name a few.
These specialty practices usually offer the same immediate access, longer appointments, and a proactive health focus as primary care concierge practices. Some also offer home visits. Specialists usually limit their practices to a smaller number of patients--150-300 compared to the more typical 500-600 patients for primary--and they more often deal with patients who already have a chronic condition to be treated.
Like their primary care concierge counterparts, the specialty care practices often attract patients who are not affluent, but who are willing to pay extra for proactive management of their risk conditions or chronic diseases, rather than waiting for the negative consequences of both. Anyone in the middle-income category can usually forego enough discretionary expenditures to afford $100-$200 a month in retainer for better health.
Why concierge medicine is spreading Virtually all of these specialty concierge practices converted from the traditional practice model, rather than starting out as concierge operations. They cite the same reasons for converting as their primary care counterparts:
having too many patients to give the time and attention each deserves
wanting to provide a more holistic/proactive approach rather than just sickness care
wanting time to deliver the kind of quality and service patients need
burnout because of too many patients, emphasis on "billable procedures," and a focus on episodic, rather than continuous, care
hassles of dealing with insurance companies and third-party reimbursement systems, with resulting huge overhead costs
While physicians recognize the pain of switching practice models and forcing most of their former patients to find another source of care, physicians also realize that attempting to start from scratch would be far more difficult. Without a large practice to draw patients from, most physicians wouldn't have enough patients from the beginning to make the practice viable.
Many concierge physicians have converted gradually, offering a retainer option to all while retaining traditional-pay patients, or offering patient-paid fee-for-service as well as retainer to be sure they have enough patients to survive. But most seem to have eventually converted entirely to retainer-based payment, since this simplifies practice management and enables the most complete holistic health management.
A solution, rather than a problem? The specialty practices tend to be subject to the same kinds of criticism about the unfairness of it all and the "abandonment" of former patients. But unlike primary care, where there is the possibility of a severe shortage, most secondary specialties aren't experiencing significant shortages, experts say. And with continuing expectations that the market for concierge practices of all kinds will be severely limited, there have been fewer dire predictions that a few physicians moving to concierge medicine will deprive patients of access to needed care.
In fact, many gurus are arguing that Americans are over-treated by specialists. When specialists only gain income by delivering procedures and specialty-specific treatments, specialists become subject to the "law of the hammer." Every patient they see tends to look like a nail, and the procedures they've been trained in is their hammer, and the only tool they have. With the option of gaining income from continuous, proactive healthcare, specialists will be less dependent on reactive sickness services income and more likely to have time to focus on proactive alternatives.
As a result, there could be strong arguments that the conversion of many specialty practices to the concierge mode, with attention to proactive risk and chronic condition management, would be a good thing for patients and payers alike.
In fact, the concierge model may already represent the kind of "medical home" approach that many insist is the most important healthcare reform needed to solve the cost crisis. And since it can be adopted in secondary specialties as easily as in primary care, with far less concern about depriving patients of access, it may be that the conversion should be encouraged, rather than criticized.
Scott MacStravic, PhD, has semi-retired to a life of freelance scholarship, consulting, and writing after 35 years as a health systems executive and professor of strategy and marketing. He has authored 10 books and 750 articles about a variety of marketing and strategy topics. He may be reached at scottmacstra@earthlink.net.
Working as employees, hospitalists give up a certain amount of control and autonomy compared with physicians in private practice, which can cause unrest if not addressed. It can be distressing for physicians to feel responsible for producing results to which they are deeply committed while lacking the capacity to deliver on that mandate.
Address four areas of autonomy/control to improve hospitalist retention:
Task control. Hospitalists generally lack control of many daily tasks due to a variety of external factors, such as the shortage of specialists, limited hospital resources (e.g., lab, radiology, etc.), daily interruptions, and excessive workloads.
Organizational control. As employees, hospitalists have less control over operations and business decisions than they would in private practice. Representation on key hospital and medical staff committees gives hospitalists a voice at the table and can go a long way toward easing concerns about organizational control.
Physical environment control. Give hospitalists adequate office space and freedom in the design of workstations, hospital rooms, etc.
Resource control. The hospitalist medical director should have a major influence over program budget, and rank-and-file hospitalists should have representation on a compensation committee and the ability to influence elements of their own incentive plan.