Monday, October 11, 2010

Physician Mindset, 2010 – 2014

The Affordable Care Act will start to roll out between 2010-2014. Given the volatile political scene, no one knows what this portends for physicians and patients. The only certainty in the new term is higher costs for all. But the uncertainty doesn’t dissuade a quasi-futurist like me.Whatever happens, the practice landscape will never be quite the same again.

For a piece of writing to be effective, you should choose a a suitable design and hold to it. For today, my design is 11 mindsets outlined in John Naisbitt’s book Mind Set!

1. While many things change, most things remain constant - I do not expect things to change radically or rapidly for physicians. Medicare and Medicaid will continue to be the big payer. Medicare will still pay 20% less and Medicaid 40% less than private payers. More doctors will stop accepting new Medicare patient/ Government will not come to grips with the Sustainable Growth Rate (SGR) for fear of adding to the bloated deficit. It will make annual fixes to quell any potential voter rebellion triggered by a growing physician shortage.

2. The future is embedded in the present – The best chroniclers of the present are newspapers. I read them every day. If you want to read multiple papers, go to the Internet. A good source is Real Clear Politics. Each day it identifies liberal and conservative articles . It also publishes the average of the big political polls. Right now conservatism is in the ascendancy, and the chances are high the reform bill will change in the early going. So don’t make any radical plans based on the present.

3. Focus on the score of the game - In politics, we keep score by watching daily polls. Today, the poll averages indicate Republicans will take 50 of 100 Seats in the Senate , 245 of 435 House seats, and 31 of 50 governor ships. These Republican gains are iimportant because Democrats advocate government solutions while Republicans favor market-based approaches – health savings accounts, shopping for plans across state lines, and malpractice reforms. Watch the polls. Don’t leap too quickly to embrace Democratic priorities – installing EHRs (electronic health records) and rushing to form AC0s (Accountable Care Organizations). But investigate these options. They may come with either party in control.

4. Understanding how powerful it is not to have to be right – Here I would not worry too much about being politically correct. It is, course, politically correct to be on side of “patient-centered care.” More times than not, patients still listen to physicians as the last resort. And it is politically correct to believe the Internet will correct all ills and mal-performances . Don’t believe it. The Internet can’t track the billions of patient-doctor interactions, and data alone will never be a useful tool for separating good from bad doctors.

5. See the future as a practice puzzle – The health system is the most complex puzzle known to man – a whirling Rubik’s Cube with thousands of moving, interactive, people, institutions, and market and political parts, each with its own agenda. Look for the pieces that fit your part of the puzzle. Don’t forget the Internet as an important part of the puzzle for marketing your practice, pleasing your patients, educating them, and tracking them. The Internet is capable of lifting all clinical boats.

6. Don’t get so far ahead of the parade that people don’t know you’re in it – In an interview, Tom Coburn, MD, the Senator from Oklahoma, told me physicians have nothing to worry about with reform if they treat their patients right. I suspect he is right. All health care is local. Most referrals occur by word of mouth. If you have a good reputation in the community, business will be brisk. As Susan Baker Keane, an expert in doctor-patient relationships, noted in her book Managing Patient Expectations, you will do fine if you heed patient expectations.

7. Resistance to change fails if benefits are real
– When you make changes in your practice, make it clear to your staff and your patients why you are doing what you’re doing. If , for example, you are installing a practice web site, tell everybody you are doing it to facilitate patient education, office hours, prescription refills, and understanding of the services you offer. Make the benefits of what you’re doing clear, and people will embrace change. Some reform changes are good , i.e. coveraging the uninsured and those with pre-existing illness. Be balanced in your criticism.

8. Things that we expect to happen always happen more slowly - Almost all change is evolutionary, not revolutionary. Most of the significant reform changes will not occur until 2014. You have time to adjust. But study the changes you seen coming down the pike, and educate your patients, and keep them informed. Study closely your options – ceasing to accept new Medicare patients and going into a concierge practice – before deciding what to do. Some developments – a Supreme Court decision declaring the reform law based on the individual mandate – could change everything.

9. You don’t get results by solving problems but by exploiting opportunities- One problem posed by reform will be additional load of 32 million new Medicaid patients combined the physician shortage. How will you find enough time to see more patients? One way is to have patients create their own patient record by creating their own medical history via the This software – based on the patient’s age, sex, gender, and chief complaint - creates a narrative history that is available to you before the patient enters the exam room. Experience with this approach at the Mayo Clinic and elsewhere indicates you can save 4-8 minutes per patient and see 5 or 6 more patients each day.

10. Don’t add unless you subtract
- For what this means, I recommend reading a book The Successful Physician: A Productivity Handbook for Practitioners. The author suggests these addition-subtraction moves - instruct patient to write top three questions in advance; forbid interruptions; consolidate answering of phone calls and emails; encourage patients to ask questions about minor illnesses by email; have a nurse practitioner or physician assistant handle minor problems; delegate uncomplicated clinical tasks to others; ree-engineer – go into a solo practice with a lean staff, lean IT systems, and a lean space. In other words, add some things,subtract others, anything that makes you more productive.

11. Don’t forget the ecology of technology - Whether you like it or not, information technologies will change everything, and their applications and usefulness and popularities are changing and improving fast. At the very least, get yourself an office computer with broad band access. Consider installing an inexpensive or “free” EHR based on internet-based programs, thus allowing you to have an EHR with expensive in-office installations. Develop an office website. Add visual content, such as pictures of yourself and staff and rudiments of what procedures entail. Think about You-Tube, Twitter, and Facebook. Familiarize yourself with the IPad and e-prescribing. Think about other technologies – a portable ultrasound device for detecting abdominal masses or aneurysms, office dispensing of drugs, a portable cardiopulmonary device for evaluating patient for coronary artery disease and lung function.

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