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Production Pressure: How Health Care is Changing

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Production Pressure: How Health Care is Changing

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Production pressure: How health care is changingYesterday evening, at a routine follow up visit with my doctor, the changes in health care finally hit home. I got to see how it is impacting a caring, skilled physician first hand…and how it will be affecting me and my family. My usually upbeat, positive doctor said she just couldn’t do it anymore. After 26 years, she still loves medicine and her patients, but she can no longer go along with all the changes that are coming her way…decreased reimbursement, electronic medical records, and feeling that she has less and less control over running her practice and treating her patients the way she knows is right.

She told me she had considered becoming a salaried physician with a hospital practice…until she realized that after the first year, her salary would be based on “patient performance”. This meant that if patients did not do well, either by their choices or due to complications, her salary would be decreased because the patients cost the insurance company and the hospital more money. She said this is already in place in many places in the country. How can this be? How can anyone even begin to think that this is reasonable or fair?

In order to balance the huge planned decrease in reimbursement for treating her patients, she would have to figure out how to see even more patients for even shorter amounts of time. She’s already seeing up to 29 patients in a single day. How can she see even more, and yet continue to provide skilled, safe care to her patients? She enjoys spending time with her patients to provide wonderful care because she listens. Spending even less time with her patients was not an acceptable alternative to her. We know that the pressure of getting patients in and out the door (production pressure) can lead to omissions, missed diagnoses and wrong diagnoses.

Her decision, based on several years of serious thought, is that she is joining a company where she will basically provide “boutique” concierge medical services to a select few of her current 2500+ patients. In order to continue to have the opportunity to be treated by my terrific doctor, I will have to pay a pricey annual fee…over $1,600.00…that will not be covered by insurance. My husband will also have to pay the same fee. Apparently there are no family discounts with these boutique plans. We already pay a lot for our health care coverage. This means that in order to keep seeing our current doctor, our healthcare costs are about to increase by 30%!

According to an article in the NY Times on 1/27/2013, NY City’s public hospitals are already embarking on a “radical” program for its salaried physicians. “Instead of granting automatic pay increases, it will pay them based on how well they reduce costs, increase patient satisfaction, and improve the quality of care.” Sounds good…right? However, this plan does not have any way to deal with circumstances beyond the physician’s control…even if they provide the appropriate care.

An example the article noted was in the Emergency Department (ED). The standard will hold the ED doctor responsible for reducing the time between deciding to admit the patient and when they leave the ED. However, the patient can’t leave the ED until there is a room available and clean, the nurse on the admitting unit accepts the patient, and there is staff available to transport the patient. These variables, and many others, are out of the doctor’s control. Yet their salary will depend on meeting the time standard. Many hospital administrators are well aware of the production pressures in the ED and are making it a priority to get patients to their ultimate destination sooner.

Other indicators include:

 How well patients say their doctor communicates with them (how can you fairly and consistently measure that? Patient satisfaction scores after a hospital admission are currently affecting reimbursement too.)
 How many patients with heart failure and pneumonia are readmitted within 30 days (why were they readmitted? Were the patients non-compliant? Did they have unavoidable complications? Did they get the proper education before they left the hospital? Many hospitals have launched major patient education initiatives for patients with these medical conditions.)
 Whether doctors get to the operating room (OR) on time (I guess his other patient who had an unexpected emergency will just have to hope he/she will be OK while they wait so the doctor won’t be late to the OR for someone else)
 How quickly patients are discharged (better make sure that you meet all the landmarks and have no complications).

This model looks to decrease complications. This is a wonderful goal, but unfortunately even with the best care, patients have unexpected problems that require additional care.

Where does patient responsibility come into this model? Should a physician be punished because patients exercise their right to decide what recommendations they choose to follow? My doctor shared that she recently spoke with one of her long-term patients who simply decided that he didn’t need to take his blood pressure medication any longer. His reasoning was that his blood pressure was fine when he checked it on the local drug store blood pressure machine. Should my doctor be held responsible if this man has a bad outcome because of his poor decision?

Our current system definitely needs “fixing” but penalizing good physicians is not the way to go. Rewarding good physicians is certainly fair, but the indicators used to measure whether they are doing a good job are unfair if the items tracked are out of their control.

My fear is that as increased requirements and decreased reimbursements continue to be forced on physicians, many will choose to be less accessible to their patients, or just leave medicine. (My own doctor kidded saying that she was going to become a scuba instructor.) Doctors may also opt not to participate in any insurance plans; cash only for all of us, even if we are fortunate enough to have health insurance.

There is a lot of fixing needed for the current healthcare system. Legal nurse consultants and medical malpractice attorneys see the results of the weaknesses. When bad outcomes occur, increasingly we have to look at the larger system and the pressures placed on providers and patients.

There are no simple answers for dealing with the many complex issues in our health care system. In seeking to achieve access to quality healthcare it is my hope that skilled physicians don’t become less available to all of us, costs for access to healthcare don’t continue to increase, and our choices for healthcare for ourselves, our families, and our employees don’t decrease. As legal nurse consultants and medical malpractice attorneys, we could see firsthand an increase in poor outcomes as pressures are placed on the health care system and providers to do more with less.

Jane Heron MBA RN is a legal nurse consultant at Med League.

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