Demystifying Medicine One Month at a Time

Tag: saving primary care

The Doctor & The Orthodontist

My daughter chose purple...

I took my daughter to the orthodontist last week to get braces.

There’s a lot about the process that seems better than when I was a kid. Mostly, it’s that instead of having to slide brackets around each of your teeth (yishk!) the orthodontist just paints a special glue on the enamel and places the brace on the front of each tooth. Kids get to pick the color of their braces now, introducing some degree of choice (and therefore control) into what amounts to a victimization of one’s oral cavity.

What really stunned me, though, was the way that her orthodontist organized his practice.

I’ve written before about the concept of “Patient-Centered Medical Homes,” [PCMH] a high-minded concept in which patients see a doctor or her associates whenever necessary, and all information is seamlessly inside a electronic medical record so any and all providers are able to deliver timely, safe, effective, high-quality care.

It’s an idea that is central to health care reform, and seen as a way in which we can contain costs. [Of course one of the big problems with this concept is that patients often don’t understand the name. Survey data shows that there are loads of misconceptions about what a PCMH actually is. Here is one funny look at this phenomenon.]

My daughter’s orthodontist is part of a three person practice. But for each orthodontist, there are three hygienist/techs and at least one office staff member handling billing, care coordination, and administrative issues like computers.

This sounds pretty personnel-heavy, but let me assure you there was constant motion and therefore constant ‘productivity.’

In the hour that it took for my daughter to have her braces applied, there were four different patients seen in the chair next to her, by three different techs and two of the orthodontists.

The examining suite was arranged with eight chairs in a semicircle, and each chair had a computer screen next to it so that the patient’s parents could see their kids’ xrays, projections of what their jaws/teeth would look like during and after treatment, and get educational material. Of course, the techs and orthodontists used the system for entering patient data as well.

In the center of the circle, tech/hygienists were troubleshooting, preparing trays for subsequent patients, discussing aspects of care, etc.

The orthodontists (two present while I was there) literally sat on office chairs and swiveled from patient to patient–washing up copiously between each encounter, and leaving plenty of time to communicate with parents, and work phone calls in between patients.

It was a tour de force.

I was overwhelmed by the efficiency of it all, the professional nature of the encounter(s), and my daughter entering a rite of passage (and how brave she was!) in no particular order.

How much does it cost?

Well, like health insurance, our employee-benefit dental insurance defrayed a significant portion of the upfront cost. What our insurance didn’t cover, we could have financed. We chose to pay the remainder in a lump sum so as not to incur interest on the debt.

But like a capitation model, we’ve payed for the treatment. Under the contract we’ve signed, our daughter can visit the orthodontist 12 times, 24 times or more, however many it takes to get her teeth straight. I’m certain that at a practice like this one they know their business well enough that even with some unexpected hiccups, they will make money on most patients in the long run.

And I’m O.K. with that. They are providing real value for our money. It goes beyond the “product.” It encompasses the feeling that I got by participating in my daughter’s care and seeing how the operation worked. Literally.

Our experience there made me wonder why medicine can’t be practiced this way.

Medicine is too complicated. Our costs are too variable. Our practice flows are less predictable. We’re not just focusing on one part of the body.

But what’s to stop us from, say, asking our patients with diabetes to come to group visits? They could be seen en masse for education and testing, and see the doctor for quick individual consultations about medication adjustment or the need for further consultation. All the providers (docs, nurses, medical assistants, physician assistants, nurse practitioners, dietitians, etc.) could be ‘practicing at the top of our licenses.’

I never smiled when I had to wear this trap.

At the orthodontist’s office, the hygienists and techs all were involved in lab work, preparation, and direct patient care. No one’s talents were going to waste by locking into one repetitive job description. I spoke with one hygienist, and she told me that she enjoyed the different roles in her job. And she felt empowered to make change or to let the orthodontists know if something wasn’t working well. All in all, it seemed a pleasant work place with a real team atmosphere.

I guess seeing it first hand makes me realize that achieving a medical home model can be done in primary care. We just need our medical homes to be more like our orthodontic homes.

Just ask my daughter. Luckily for her, with modern methods, there’s no need for headgear anymore.

Saving Primary Care: Is There Anyone Home?

Dear Readers: This was a pitch for a magazine article, so I apologize if it’s a little too wonk-y. I decided to post it here to see what other ideas you could drum up.

Quick summary: There’s an idea floating around called the Patient-Centered Medical Home–a way to integrate, automate, and improve how primary medical care is delivered in the U.S.

It has the approval of all major medical societies. A ton of money is being spent on a national demonstration project.

It’s never going to work.

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Patient Centered Medical (?Glass) Home?

The Patient Protection and Affordable Care Act (a.k.a “Health Care Reform”) signed by President Obama in March will revolutionize Primary Care in the United States. By 2014 tens of millions of uninsured people will “enter” the system by being granted insurance, either through expansion of the Medicaid program or through mandated purchasing of insurance via state pools or the private market.

This alone will have a profound impact, straining the capacity of our already frayed system. Therefore, embedded in the law are funds to encourage growth and improvement in Primary Care: Incentives to encourage graduates to enter primary care fields (Family Medicine, Internal Medicine, and Pediatrics) and practice in underserved areas (through scholarships and loan forgiveness), and money to re-format the way that Primary Care is practiced and paid for.

The most prominent example of Primary Care restructuring is something called the Patient Centered Medical Home (PCMH). Currently a national “demonstration” project is underway to show us that the PCMH model is a sustainable way forward. The PCMH promises nothing less than greater access to primary care, delivered with improved quality and safety, better data capture and analysis, all with lower per capita costs. Devotees of the PCMH are surging ahead to tie together the twin strands of incentives for transitioning to electronic medical records and improving on the delivery and payment models of Primary Care.

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