My institution is striving to become more patient-centered, and is making good progress, but has an odd way of showing it sometimes.

Medical institutions have come under pressure to adopt and adapt to a value-based medical economy (selling health care and quality rather than office visits and procedures) instead of the old volume-based (do more, bill more, earn more) system.  This means selling health care rather than office visits and procedures (sometimes called the do more, bill more, earn more approach).  Quality is suddenly in a position to trump volume. This is a good thing - or it will be, if we figure out how to do it right.  Sadly, it is often easier to fix metrics than it is to fix patients.

Review of our patient lists showed many who were officially attached to our system because they had received services here in the past, but who not meeting quality guidelines. One group of patients stood out: those who had not seen in the last two years. That’s right. To no one’s surprise, patients who don’t get any care don’t appear to be getting good care, If they don’t come to the office, we cannot offer them screening or immunizations, check and treat their blood pressure or cholesterol, encourage them to exercise and stop smoking, order their mammograms and do their Pap smears.  Both institutions and individual clinicians are impacted by this. These patients count as part of our ‘denominators’ but have not had the tests or treatments needed to demonstrated that we are doing a good job of caring for them. 

It was immediately apparent that our grades were being lowered by this group of patients, and the organization went into action. Reports were run and patients not seen for a physical in 3 years were identified and sent a letter telling them that if they wished to remain a patient in the practice, they needed to schedule a preventive visit or be made inactive. 

The letter, sent over my isgnature but without my input, included this text:

In order for us to do our job of primary care, it is essential that we see our patients at regular intervals to maintain a relationship, keep current about their clinical status, and be able to make suggestions about how to achieve or maintain health and avoid disease.

I strongly encourage you to call and make an appointment for a wellness visit (physical) in the next several months. If we do not hear from you, I will have to assume that you do not want me to serve as your primary care physician and we will close your account here.

Although the letter was sent over the PCP’s (my) signature, the letter was neither written nor reviewed by the PCP (me) and the lists were not reviewed prior to sending the letters. There had been mention at a meeting that the institution was going the ‘clean up the lists’ but I first learned the details when I got a message from a receptionist describing an upset patient who felt she could not afford a physical but wanted to remain my patient.

Marion R. is 56 and a survivor of breast cancer diagnosed when she found a lump. She underwent lumpectomy, radiation and chemotherapy, and has been ‘No evidence of disease’ (NED) for 4 years. She is still paying this off. She is on anastrazole (Arimidex) through a cancer medication subsidy program, but no other meds. She sees her oncologist every 12 months and is now having annual mammograms. She had not been seen in our office in just under 4 years, not since we made the initial diagnosis and arranged the referrals for treatment. 

I asked my nurse to contact her, apologize for the letter I had not sent or specifically authorized, tell the patient not to panic, and suggest she come in for a quick visit to review and update her health status at minimal cost. (My nurse has more discretionary time during the day than I, and loves advocating passionately for our patients and helping them solve problems. I - and more importantly, our patients - are blessed.)

Marion came in the next week.

She works two part time minimum wage and benefit-free jobs. Her husband is only intermittently employed and spends much of the little money that he earns on alcohol and motorized toys (cars and ATVs). She has no savings or assets and scrapes by on her weekly check, which she supplements by picking up bottles while walking 25 minutes to and from work to save gas money. 

I told her I had two goals for our visit: 

  • See if there are any important health needs to address.
  • Figure out a way to make sure she continued to have access to me as a clinician.

I asked her what her goals were, and she said, “Not to be homeless or starve to death.” No, I objected. I mean, what are your health related goals, things I might be able to help with.  “Not much,” she said. But she said she liked me and trusted me, still remembered that I had been direct and honest with her during our evaluation of her breast mass, and particularly that I had called her a number of times to see how she was doing with her treatment. She wanted to be able to see me ‘if something happens.’

I asked if she worried that something else might happen with her health, something she could prevent?

“No, I don’t worry much about that. For one thing, cancer changed my idea of what matters,” she told me. She added, rather bluntly, “I know I won’t retire. I’m just going to work until I can’t work or until I die. Since I can’t retire and I have no family, to take me in if I get sick, I just focus on paying my bills and getting by. Everyone has to die of something, you know. Whatever it is for me, I only hope it isn’t painful or expensive.”

Wow, I thought. This is the sort of on-the-ground face-to-face granular reality that we PCPs see all day, every day, but is a foreign territory for far too many administrators and bean counters, the ones who are largely responsible for management. This is what wears me out - but also makes me eager to go to work.

I told her that if we had a conversation every two years about her status, which required a relatively brief and tolerably expensive visit, I could bill it as the lowest level preventive visit and  the system would see her as active.  A phone call told us that we were talking about $85 dollars every two years, which she was comfortable with. (In my days as a self-employed physician, I would have offered the full physical and simply written it off, but as an employed physician, that is no longer an option. The system sees that as a problem and doesn’t let it happen.)

We then took 10 minutes and went through the ‘list’ of health care information and interventions:

  • Lifestyle. seat belts, helmets on bike, tobacco (< 1/2 ppd, down from 2 when cancer diagnosed), no alcohol or drugs, physically active. Skinny, no junk food.
  • Colonoscopy:  not affordable and declined, so I gave her hem occult cards which she will drop off and I will develop with logging them in so she isn’t billed.
  • Mammogram: done regularly
  • Pap: no history of abnormals, single partner, declined.
  • Immunizations: current on tetanus (ED visit for laceration at work) and declined pneumovax.
  • Lipids 5 years ago awesome.  
  • No family history of DM, or early CAD. Mostly trauma and alcohol (‘which is why I don’t drink’).
  • Bone density testing (DXA):  risk factors (thin, tobacco, and chemo) but no family history and not 65 and wouldn’t afford bisphosphonates, declined.

I told her that if she had non-urgent questions or concerns, to send me a note in the mail. If she had urgent concerns, I told her to call and talk to triage or my nurse, and that otherwise we should plan to see her again in 2 years.  She got decent care, all she was willing to purchase and more, and was very appreciative. 

Now, I recognize the need to look good to the reviewers. Hell, my institution cuts my pay if my patients don’t meet quality the institution’s criteria by agreeing to a set of preventive tests and treatments. I know and suffer under the impact of patients whose incentives are not aligned with mine. But if we are going to call ourselves patient centric, then the patients’ values and preferences take precedence per both mine and the institutions. Full. Stop. 

Perhaps, I thought, the letter should not say ‘Buy the standard package sell if you want to remain in our club.’ Perhaps it should say, instead ‘We want to be able to be on your team and help you stay healthy and meet your health care goals. In order to do that, we need to have some regular contact. Please give u a call so we can work out a way to do this.’


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