Healthcare Integration: Waiting For A Dr. Martin Luther King

Healthcare integration requires today what racial integration required on the 60's: strong leadership.

In one of our physician leadership training modules, we show the video of the 1963 civil rights march on the nation's capitol with the key note speech of Dr. Martin Luther King. It is easily accessible on youtube (search for "MLK's I have a dream").

The video has an incredible personal meaning for me. I remember watching the speech with my dad (he actually took the day off from work!) on our black and white RCA with its never quite focused rabbit ears, looking for faces in the crowd of friends whose parents allowed them to attend. Washington DC at that time was still very much a southern town and my overly protective parents were not willing to risk sending the center of their universe forth to do battle with the rednecks threatening to violently shut down the march.

Most physicians in our listening audience, however, while aware of the speech, have not actually seen or listened to it. (It is always a sobering task to ask for a show of hands from the physicians participants of those who weren't even born in 1963!) Their reaction, while not attached to personal memories of the speech, is no less profound. We then deconstruct the speech focusing on the qualities and traits of leadership. 

Racial integration in the 60's was recognized by the majority of Americans as the only way to fulfill the American principle of equality so eloquently stated in its Declaration of Independence. Integration's implementation, however, had a set of obstacles thought by most too difficult to "overcome". The separate but equal culture of American society had been in place for a hundred years. Federal versus states rights had a set of rigid borders resulting from verbal battle of our founding fathers and an intensely violent civil war. Racism was reinforced by legal statutes and conservative interpretation of Biblical scripture....

Fortunately we had a leader and he, as all great leaders, had a "dream"and the leadership skills needed for its fulfillment.

Healthcare integration is the only way to preserve the unique way healthcare is practiced in the United States in our present (and future) economic, demographic and political environment. ACO's and bundling of payments tied to outcomes and disease management are here to stay. Like the 60's and racial integration, we see the inevitability, but are focused on the obstacles too difficult to "overcome". Physicians are wed to autonomy and distrust group decisions, our reimbursement programs are perverse, our information technology is inadequate, patient care is complex and fragmented, regulatory statutes are difficult to change, ......

The time for racial integration was the 60's, the time for healthcare integration is now. The missing ingredient is a cadre of physician leaders with a "dream" and the leadership skills needed for its implementation.

Want the Ideal Medical Clinic? Collaborate With Your Community

By Pamela L. Wible, MD

Dissatisfied with assembly-line medicine?Dreaming of life off the hamster wheel?

Don't wait for politician-saviors. Convene with your neighbors.

Physicians nationwide are taking a novel approach to healthcare reform: They're listening to citizens. All across America doctors and patients are joining together to create ideal clinics, hospitals, and regional healthcare systems based on the real needs and wishes of the communities they serve. Could the future of American health care begin in your own backyard?

Physician as Public Servant

Americans typically rely on elected officials to uphold the will of the people, and for decades partisan struggles have prevented meaningful healthcare reform. Given current repeal efforts, outcomes are never guaranteed. But now physicians—traditionally confined to our exam rooms—are taking direct action to fulfill community needs.

In 2004 an epiphany led me into neighborhoods to meet face to face with citizens in my hometown of Eugene, OR. I thought, "Why wait for legislation? Why wait for another election? I'm an MD, fully licensed, board-certified in family medicine. What's stopping me from serving the public?"

I began by hosting town hall meetings and inviting ordinary citizens to help me create the clinic of their dreams.

From living rooms and Main Street cafes to neighborhood centers and yoga studios, I met directly with people and listened to their wisdom. Bus drivers and businessmen, housewives and healthcare workers, teachers, college students and folks of all ages gathered to design a new model, a template for the nation.

I asked each participant to imagine walking into an ideal clinic in an optimal healthcare system. Community-members shared their visions; most submitted written testimony. My job was to implement their ideas where feasible.

From nine town hall meetings over six weeks, I collected one hundred pages of written testimony, adopted 90% of the feedback, and opened our clinic one month later. For the first time my job description was written by my patients, not administrators.

A Community Prescription

What do people really want from their healthcare givers? Surprisingly, it’s nothing too extravagant. Here are their top ten recommendations, many in their own words:

1. Real relationships: People want practitioners who are fully present and willing to touch them emotionally, spiritually, and physically. One woman's simple request: "Hug me!"

2. Physician role models: Happy, healthy doctors inspire patients to live happy, healthy lives.

3. Integrative healing: People want all healing arts professionals to be working in concert for their wellbeing. They also want easily accessible, on-site complementary therapies such as massage, yoga, and acupuncture.

4. Sacred space: An ideal clinic is "a sanctuary, a safe place, a place of wisdom . . . a place where we rediscover our priorities."

5. Easy access: Same day appointments offered and everyone receives care when they need it.

6. Relaxed appointments:  Visits are, at minimum, thirty minutes. Patients want to be able to speak uninterrupted and "feel heard, understood, and cared for."

7. Patient-centered care:  One citizen's advice: "Abolish cookie cutter medicine—everybody does not need the same thing."

8. Community orientation: Patients want a doctor who is part of the community and "knows everyone by their first name . . . knows patients in a social context."

9. Creative financing: Offer your patients an array of different payment options: Consider monthly stipends for services. Offer sliding scale discounts. Accept donations, bartering, and insurance when possible.

10. Heath education:  "Transition from an acute care delivery system based on intervention to one of continuing education of all possibilities of health and wellbeing."

What Ideal Healthcare Looks Like

By soliciting community input, I was able to design my clinic to best serve my patients' needs. My practice model enables me to spend time getting to know the people I serve.

By following my community’s instructions and indications, I now work in an ideal clinic. Our cozy office is housed in a wellness center tucked into a wooded residential area. Yoga, massage therapy, counseling, and a solar-heated therapy pool with hot tub are available on-site. Before appointments, patients may relax in the hot tub instead of a waiting room. Then a short stroll along a walkway leads to a living-room-style office with overstuffed chairs and pillows.

With no administrators or staff, patients enjoy direct 24/7access to their doctor by phone and email. Appointments are thirty to sixty minutes long, scheduled on weekday afternoons and evenings. Sessions begin on time—guaranteed—or patients get to choose a present from the gift basket. I do accept most insurance plans. Uninsured patients receive a 30% discount for payment-in-full at time of service. Alternatively, patients may trade skills such as massage or donate handmade items to the gift basket.  Nobody is turned away for lack of money.

A Populist Movement

Open since 2005, our model has inspired many other physicians to recapture their dreams and reinvent their careers by collaborating with citizens to design innovative clinics. Hundreds of ideal practices are now open nationwide.

Inspired citizens and loyal patients rally around these novel community-designed practices: Volunteers donate hand-sewn flannel gowns; Citizens mail unsolicited checks; Patients assist with billing and office work. It’s quite amazing what happens when patients and physicians actually work together!

Now hospitals are joining the movement. In October 2010, a hospital system in western Wisconsin—inspired by our clinic—invited citizens to design their dream hospitals. The desires of disenfranchised groups—from school kids and the elderly, to the Amish community and Hmong immigrants—were specifically sought and embraced.

Over one thousand people attended events, sharing heartfelt visions through written and verbal testimony. The hospital even had children submit drawings. Implementation is now underway, and as America's first dream hospital becomes reality, more and more hospitals will follow its lead.

What's they key to delivering ideal health care? Put patients--not politicians or corporations--in charge! Why wait for Washington? Follow Wisconsin.

A Cure for Frustrated Physicians

My parents—both physicians—warned me not to pursue medicine. Today, my colleagues continue to steer young people away from a career in medicine. Why? Here's a partial list of grievances: low reimbursement, loss of autonomy, patient overload, loss of respect, the malpractice crisis, bureaucratic red tape, corruption. At a time when America is in greatest need of primary care physicians, our numbers are decreasing (See Escape From McMedicine)

According to a survey by the Physicians’ Foundation, half of all primary care docs have considered leaving medicine (The Physicians' Foundation Survey, Merritt Hawkins & Associates. November 2008.). Some transition into pharmaceutical or insurance company positions. Others opt for administration or early retirement. In my last employed position at a five-physician practice, four female physicians left medicine to pursue teaching, homemaking, waitressing, and other "more meaningful" careers.

Most who don't escape become victims. Three quarters now believe medicine is less rewarding or no longer rewarding, and claim they are overextended, overworked, or at full capacity. Many physicians—having lost their dreams, their inspiration for practicing medicine—simply function in survival mode.

So what's the solution?

Singer Joan Baez once said:  "Action is the antidote to despair." Physicians are in a unique position to bypass partisan discord and enact real change. I believe it's time to step out of our offices and embrace our communities. I realize doctors don't usually ask for help, but sensible solutions are literally right next-door. I looked everywhere for answers, but it was ordinary citizens in my hometown who came to my rescue. They designed our clinic, saved my career, and helped me find a way out of my misery.

I invite you to talk with your neighbors, to engage with your community, and most importantly, to act on what they tell you!

Resources:
Ideal clinics:  http://www.idealmedicalcare.org/ideal-clinic.php
Ideal hospitals:  http://www.idealmedicalcare.org/ideal-hospital.php

About: Pamela L. Wible, MD is a pioneer of community-designed medical practice. Her model has sparked a populist movement that has inspired the creation of Ideal Clinics & Hospitals nationwide. Her community-designed model is featured in the Harvard School of Public Health’s newest edition of Renegotiating Health Care: Resolving Conflict to Build Collaboration. Dr. Wible's site is at http://www.idealmedicalcare.org

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Concierge Medicine, Social Justice & Sex at 100

Some of my medical colleagues who champion the cause of “social justice” bristle when they learn that I practice concierge medicine. 

They fervently believe that it is somehow more noble to practice Soviet-style medicine in America than it is to take professional responsibility for delivering excellent, individualized medical care to their patients.  One of the benefits of being sanctimonious about private doctors who practice in a capitalist model is that you can blame some of the crappy medicine you deliver on your benevolent, utopian system, which claims to be “fair” to everyone.  How convenient.  But what are the consequences of focusing on clinical algorithms, electronic medical records, and the forced “fairness” that comes down from the Politburo?

Today I saw a 99-year-old patient in my office who is on my indigent medical care program.  She pays me $5 per visit, just so that she’s got some skin in the game.  (Quiet…I don’t want my social justice critics to know that I actually see people who can’t afford to pay my concierge fees.)  This elderly woman has diabetes and has been in the ICU twice over the past year with urosepsis, on the sepsis protocol.  Last week she was taken to a local ER at a hospital where I do not practice.  She had a recurrent kidney infection, despite receiving rotating prophylactic antibiotics and intravesicular gentamycin given to her by an expert urologist.  I was never called by the ER physician, because I am merely the patient’s attending physician – a point that is irrelevant to most ER physicians, given that virtually every patient in the ER is now admitted to the “hospitalist team.” 

Instead of admitting this frail, 99-year-old diabetic for IV antibiotics and careful monitoring, the ER physician opted to treat her as an outpatient with generic Keflex.  This would not have been my approach, but I have to agree that it certainly was “cost effective.”  Fortunately, my patient survived this “UTI algorithm.”  The doctor also opted to treat her hyperkalemia with equal efficiency, giving her a single dose of oral Kayexalate, which she promptly vomited after arriving at home.  Luckily, she did not have a cardiac arrest from her hyperkalemia, especially in light of the fact that they did not bother to hold her ACE-inhibitor, which was contributing to her elevated potassium.

As my patient left the ER, the medical team dutifully handed her the ubiquitous, and always helpful, discharge instruction sheet.  This document no doubt met all hospital and governmental regulations for educating people about pyelonephritis and hyperkalemia.  Although my patient is legally blind and cannot read standard print, I’m sure she found this 4 page document very comforting.  More importantly, the purveyors of social justice can rest assured that they followed all of the guidelines set forth by the Politburo and did their duty to deliver the same level of care to everyone, regardless of income, ethnicity or social standing.   

Had my 99-year-old patient been able to read this information sheet, I’m sure she would have found it helpful to know that she should “refrain from having sexual intercourse until after all of her kidney infection symptoms had resolved.”  I don’t know about you, but there is nothing that irritates me more than seeing a non-compliant, centenarian who continues to have sex while being treated for an active pyelonephritis.  The only way to prevent these elderly nymphomaniacs from reseeding their genitourinary tracts is to put it in writing!

What we are now seeing is just the beginning of medicine by administrative committee.  If you think I am misusing the term “Politburo”, just wait until you see what happens under the Department of Health and Human Services in the name of ObamaCare.

Where Will Disruptive Health Care Innovation Come From?

Healthcare is a system that's primed for disruptive innovation.

Can We Build a "Faster Horse"?

Henry Ford is qouted as saying, "If I listened to the people, I would have built a faster horse". Ford's Model T was the disruptive innovation that changed transportation. Clayton Christensen's description of disruptive innovation is that a technology comes along that has the potential to change an industry, often because it's cheaper, more convenient, or more satisfying to the consumer. Early automobiles didn't disrupt the status quo because they weren't a better alternative to horses. But when Henry Ford's business model of mass production to produce an affordable vehicle for the average American worker, the internal combustion engine had found it's place in a disruptive innovation.  

Now think about health care. The status quo is expensive, and often inconvenient for consumers and patients.  The financial incentives of our payment system encourage physicians to produce more services to cover the costs of keeping their doors open, and generating their salaries. Both independent practices and hospital-owned physician groups generally follow the same formulas for financial success.

Most doctors I've talked with do not believe they can be "a faster horse". Most consumers/patients don't want to spend a half-day or more in the doctor's office - away from work, home, or family - for health problems that might not require it. Many patients find the current health care system paternalistic and difficult to navigate with satisfaction. Shortages of primary care physicians are widespread, yet the solutions being discussed call for training more PCPs. Shouldn't we be thinking like innovators, and looking at changes in health care through consumers' eyes?

Maybe our mobile devices (cell phones, Iphones, Blackberrys, IPads, etc) can be the technology that leads to a new business model of both primary and chronic care that allows consumers to have a cheaper, more convenient, and more satisfying experience in getting health information and health care services. If payment reform comes in the package of bundled or global payment for health outomes, I can imagine a system where face-to-face encounters with a physician will be needed only for acutely ill patients, or periodic visits for chronically ill patients. The physician may be leading or supervising a team of health care professionals who provide health and illness information through wireless devices, video screens, remote monitoring technology, and convenient locations (often open 24/7). 

Under a new payment system, the hospital will be the most expensive and often most dangerous place in the health care system. I don't know about you, but I'm like the typical consumer in economist Michael Grossman's Theory of the Demand for Health: I want "health and healthy days" on earth - not time spent in the doctor's office or hospital. I'll devote my time, money, and energy doing things that will keep me healthy, and away from the health care system.

When insurers are purchasing medical groups, and new players to health care like Cerberus Capital Management are acquiring hospitals in the Boston area, you can bet that the opportunity for disruptive innovation in health care is coming.