If You Lot Desire To Win, You Lot May Bring To Fight

“Victorious warriors win kickoff in addition to thus become to war, piece defeated warriors become to country of war kickoff in addition to thus try to win.” –Sun Tzu

According to the National Committee for Quality Assurance (NCQA), at that topographic point are about 33,000 Patient Centered Medical Home (PCMH) recognized entities to date, 5,560 of which are practices. Subtracting this in addition to noting that many recognized entities are Nurse Practitioners (NPs), nosotros tin safely guess that roughly 10% of the 209,000 practicing principal attention doctors inwards the the U.S.A. are working inwards a recognized PCMH. There are other accreditation bodies, but NCQA is past times far the largest in addition to best known, thus the numbers higher upward should live pretty indicative, give or receive got a few percent points. My guess is that some other 80% or thus of principal attention physicians do inwards unrecognized medical homes. Yes, 80%. Although it is hard to larn exact numbers, perusing the NCQA lists of PCMH shows that a large number of recognized medical homes belong to wellness systems, academic centers in addition to community wellness centers.

According to the Office of the National Coordinator for Health Information Technology (ONC), 72% of office-based physicians were using some kind of EHR inwards 2012, in addition to 66% either demonstrated or are planning to demonstrate Meaningful Use. As alongside medical abode recognition, EHR ownership is also skewed inwards favor of larger practices, alongside solo docs inwards particular, lagging significantly behind.

And thus at that topographic point is the Physician Quality Reporting System (PQRS), alongside or without Maintenance of Certification (MoC), in addition to the legacy electronic prescribing initiative, in addition to the upcoming Value Based Modifier, all from Medicare. Private payers, in addition to sometimes States, receive got their ain slightly dissimilar pay for surgical physical care for (P4P) programs. And all these programs are layered on top of a thick in addition to knotty spider web of rules in addition to regulations, specifying medical necessity, demand for prior authorizations, medications formularies, the amount of text in addition to the terminology needed to justify payments, in addition to everything comes inwards every bit many flavors every bit at that topographic point are wellness insurance plans.

Health systems in addition to large medical groups receive got dedicated departments in addition to staff to oversee in addition to receive got payoff of all these programs, ameliorate known every bit character initiatives, in addition to that’s why they demand to collect additional facility fees (and, according to the American Hospitals Association, also because of the “threat of terrorist attacks, recent volume shootings, the aftermath of Hurricane Katrina in addition to the devastating tornados over the past times year”). Small practices, on the other hand, receive got zero but angst. The vast bulk is resentfully struggling to move along the balls inwards the air inwards haphazard ways guaranteed to eventually fail, in addition to a little (but growing) minority is  taking their toys in addition to going abode to do cash-and-carry medicine. But hither in addition to there, you lot detect the anomalous independent do that is thriving; notwithstanding chock total of resentment, but alongside a smile, because when you lot outsmart your opponent, it’s satisfying to admit that this was (is) a powerful (dangerous) opponent indeed. So what’s the surreptitious sauce? And is it scalable to all other presently to disappear independent physicians?

Let's get alongside the medical abode because some solutions are embedded inwards its concept, in addition to because the create novel NCQA Patient Centered Specialty Practice (PCSP) recognition extends the same model to physicians who are non practicing principal care. First let’s assume that you lot chose to live a MD thus you lot tin receive got attention of patients, in addition to this is notwithstanding what you lot would prefer to live doing, but an extensive in addition to growing bureaucracy along alongside shrinking payments, is preventing you lot from providing the attention you lot believe you lot should live providing to your patients. If your aspirations are different, or if you lot are i of the few physicians who made the switch to cash pay, what follows volition live of no utilisation to you. 

For illustration purposes, let’s await at a solo practice, because whatever industrial plant for a solo practice, tin live easily extrapolated to a larger grouping (but non vice versa). The first in addition to most primal tenet of the medical abode model is the personal physician, i.e. a individual alongside an MD or DO, who is supposed to create a continuous human relationship alongside an private patient. It is worth noting that principal attention practices led past times non-physicians are past times Definition non Patient Centered Medical Homes, regardless of the current push to the contrary. Unfortunately, NCQA is deferring to State laws, in addition to volition recognize medical homes without a physician and/or medical homes where a non-physician is substituted for some patients, but NCQA does non dictate that non-physicians should render principal care. So basically, it’s upward to you lot to implement this whatsoever agency you lot consider fit. You are non required to hire non-physicians or delegate patient attention to other people. PCMH simply asks that you lot create a long term personal human relationship alongside your patients.

If that’s the representative thus how well-nigh squad care, huddles in addition to that kind of thing? To reply this question, I would advise a little exercise. Exercise #1: read the PCMH standards in addition to substitute the discussion “staff” everywhere you lot consider “team”. Does it read ameliorate now? Replacing the term “staff” alongside the term “team” is a semantic conception that is sweeping every employment concern everywhere. It is non express to wellness attention in addition to it should non elicit visions of an egalitarian organisation where nobody is inwards charge. In representative you lot are non aware, every employment concern executive that used to receive got staff in addition to staff meetings, instantly has a squad in addition to squad meetings. Same people, same reporting hierarchy, alongside added experience adept validation for employees, commonly inwards lieu of promotions in addition to salary raises. If this rationalization is sufficient to deter the knee-jerk reaction to the PCMH linguistic communication for a few minutes, let’s await at the measures associated alongside this PCMH concept.

In some cases when you lot endeavour to address a behavioral or chronic employment for a patient, the kickoff footstep is to receive got the patient move along a log of their electrical flow activities in addition to gain awareness of what may demand modification inwards companionship to number beneficial change. Let’s endeavour that. Exercise #2:  for a duo of days, move along a slice of newspaper inwards your pocket, in addition to annotation all your activities every bit you lot become through your workday, thus sit down downwards in addition to grade the ones that receive got zero to produce alongside actual patient care, in addition to of those, grade the ones that receive got zero to produce alongside your medical education. Now enquire yourself why you lot are doing these things instead of having your staff bargain alongside them. Be honest. Is it that you lot don’t trust your staff to produce things right? Is it that it takes less fourth dimension to just produce it, instead of having to explicate everything every unmarried time? Is it that everybody seems already every bit good busy? Or possibly it’s just because this is how it ever was?

Now let’s endeavour something a chip harder. Exercise #3:  on that slice of newspaper you lot are carrying around, annotation your activities when the patient is inwards the room, inwards other words, analyze your patient care. Write downwards how much fourth dimension you lot spent looking for data inwards the chart, how many times you lot had to footstep out to give some orders or asking things from staff, how much fourth dimension you lot spent talking well-nigh administrative things, or things that don’t require medical training, in addition to how much fourth dimension you lot spent collecting in addition to cataloging touchstone data that has really petty to produce alongside the employment at manus (yes, I know, your EMR sucks; write it down). To live clear, this is non intended to shorten the fourth dimension you lot psyche to the patient or constrict the conversation inwards whatsoever way. This exercise is aimed at identifying tasks in addition to activities that could live done past times staff, preferably inwards advance of your see alongside the patient, just thus it tin costless a few to a greater extent than precious seconds for the 2 of you. I don’t demand to say you lot that seconds add together upward to minutes in addition to minutes add together upward to hours in addition to hours add together upward to missed opportunities. And yes, it is a lamentable solid pose down of affairs when nosotros must devolve to counting seconds.

The terminal exercise inwards our serial volition assistance you lot position some other really mutual problem. Exercise #4:  become to a duo social media sites where patients charge per unit of measurement doctors (Yelp is a adept one) in addition to browse through the diverse comments. This is non to encourage you lot to submit to patient reviews, but to illuminate a really mutual employment inwards the shape of a dandy doctor, but rude, unhelpful in addition to impatient staff. You may live the greatest in addition to most compassionate physician out there, in addition to your patients volition appreciate that in addition to stick alongside you lot no thing what, but are you lot OK alongside staff that either does non know how, or does non attention plenty to care for your patients well?

After completing these 4 exercises, become dorsum in addition to read the “care team” measures inwards the NCQA standards (remember to substitute “staff” for “team”). Do you lot consider anything that may live helpful alongside whatever problems you lot managed to position through our petty experiments? We’ll await at some possible answers inwards the adjacent post. And past times the way, if you lot are notwithstanding questioning the necessity of doing anything other than keeping your olfactory organ to the grind in addition to going faster in addition to faster every passing day, you lot should annotation that i time once again medicine is changing. It changed earlier in addition to it volition most probable alter again, in addition to those who come about to do the art, scientific discipline in addition to employment concern of medicine during times of dandy change, are rarely pleased alongside the upheaval. Some volition live decimated inwards the physical care for in addition to others volition hold upward in addition to thrive. Which i would you lot rather be?