A Day in the Life of a Medical Director – Monday Pulse 03.24.08, and perspectives from a few years later
This blog entry retro is from a newsletter of three years ago when I was directing a group of Community Health Center physicians through the strife in diminishing resources resulting from the annual California budget crisis and its ramifications on patient care.
The first part of this newsletter to staff deals with a process to get the point-of-(billable)service staff to coordinate PTO or Planned Time Off for the health center. All employees deserve benefits but in a way time-off benefits for providers can serve as a “double whammy” for the center, as revenue will drop when the provider is off the floor; unless the time-off is coordinated. I was encouraged by my administrative colleagues to encourage the docs to plan vacation and educational time-off earlier and in a more coordinated manner. Without that planning, time away authorized often felt capricious and even worse as favoritism, which can be very destabilizing to morale. The PTO Survey represented an attempt to bring some order or better, predictable process to provider time away from clinic. The process began with a survey and actually became very complicated and perhaps too formulaic as the spring went on.
The second topic in the newsletter deals with the State’s ratcheting down of the Extended Access to Primary Care (EAPC) program. this no longer existent program was a way to support cost for the health center’s uninsured patients. The program allowed some flexibility to spend, and in our site paid for ancillary services, like lab studies and xrays, that the center then purchased, ideally by contract to mollify risk. In terms of an idea of magnitude, we received ~ $500,00o to help support ancillary care at eight different sites of varying size and percentage uninsured population. The program had a history of exhausting itself ~8 months into the fiscal year. EAPC was a program in dire need of clinical management, specifically utilization management. In short, getting physicians to become efficient caretakers of expenses they control. Ethical issues could abound, …”equal care for all patients”, “standards of care”, “CYA defensive medicine”, and the “no margin-no mission” ideology. In any case, in order to change physician behavior you have to begin with data. And in general, they are a very savvy group, leery of administrative data. Never-the-less, I thought we had two good data sets to go forward with, one internal (lab charges)and one external (insurance carrier data), and this newsletter edition served to begin that discussion with my colleagues. Post script, by the summer of 2009, one year later, the EAPC program was de-funded, end of story. Interesting lesson, we probably ted too late with our utilization planning. Please enjoy and comment!
“You can’t always get what you want,… But if you try sometime…you just might find you get what you need!” – M. Jagger
Clinicians’ PTO Request Survey.
Attached to this edition of the Pulse you’ll find a survey querying clinician about their August and December PTO desires for 2008. This information will be used when considering PTO request for the historical short staffing months. This was a recommendation coming forth from the Working Group of providers that met in February. Certainly other factors will also be involved like history of prior recent PTO Holiday-time use and date of requests already received (very few if any have already come in for these months). I will also interoffice a copy to all providers. If possible return these to me or Jon Y. as soon as possible. Again the intent here is for fairness in planning. Reminder will be brought up at our next Clinicians’ meeting.
EAPC Lab Follow-up.
I have had a chance to review the lab utilization data that was presented at the last Clinicians meeting. Additionally, I reviewed the Central Coast Alliance for Health (CCAH) lab utilization data from 2006. The idea was to check trends of note. Terry Gomez and Jimmy Lew also did some investigation involving Quest lab and presented it in their Monthly Kaizen Provider meeting. Here is some pertinent info. From their presentation. The commonest Quest ordered labs, during one four month period in 2007, were in descending order with their EAPC prices: lipid panels ($7.00), TSH (11.00), Comprehensive metabolic panel (1.90), CBC/Hemogram(2.00), HgbA1c(7.00), PAP (21.00), hepatic panel(5.00), GC/CT(17.00), Urine microalbumin (26.00), Basic metabolic (1.58), UA(?), ESR (3.00), H.Pylori breath (25.00), Urine culture (18.00), PSA (5.86), HIV AB (14.00), Stool O&P (5.99 per),CPK (3.74), Hep C (7.60), ALT (4.00), Fecal Globin (9.99). The most interesting note is the variation at each site, but this data contained no denominator, so exact interpretation is lacking. But even in similarly sized clinics the variation is really remarkable and really unacceptable. For example one smaller clinic ordered 25 ALT, AST during the study period, and another ordered 0. Interesting since clearly the cost efficiency would have been to order the CMP instead. I think understanding the price breakdown will in itself begin to educate about lab selection choices. My practice about -statin liver test monitoring will now change now that I know the pricings.
The CCAH data is also interesting about variation. The data is better in that their clinic-by-clinic data is normalized to a rate per 1000 members. For example, let me show you these numbers:
Disease panel variance from norm range for the 6 sites (-47% to +36% from specialty average)
Blood counts “ -23% to +30% “
Urinalysis “ -30% to +82% “
TSH “ -34% to +37% “
HgbA1c “ -22% to+115% “
PSA “ -35% to +100% “
Other Chemistry “ -27% to +301% “
From a pursuit of uniformity standpoint that Total Quality Management approaches seek, this degree of variation suggests waste is occurring somewhere. And looking forward, as the IOM pointed out in its “Crossing the Quality Chasm Report”, a 21st Century health care system needs to pursue waste reduction over cost reduction, because the cost of waste is tremendous, and some begins within the clinicians’ sphere of influence. As we have been discussing here, modern quality experts talk about variation as distance from the mean. The more of the outcomes that are closer to the mean, the more reliable the procedure. One could consider the decision to order a lab as the procedure, so the more lumped together the order rate, the fewer outliers several standard deviations away from the mean, the more confidence we can have that we are being efficient in our practices. The less we are wasting valuable institutional resources. Quality experts believe all improvements begin with the data. One final quick but useful point about variation. Variation can be of two types, special-cause variation, a result of employee error or undertraining, and common-cause variation, that variation that a policy or a technology allows, usually a management decision. The majority of variation is usually common-cause type. I believe this data truly justifies the need for a lab utilization review policy, which should combine both clinical and cost information as described above. Until such a policy/tool is in place I’ll be sharing the data I have with you for consideration with your lab ordering.
To date no feedback is forthcoming from CCAH about our variation in utilization but I do plan on speaking to their Assoc. Med. Director Julio Porro, MD, about his interpretation of acceptable variance from the norm. I’ll try to have the clinic specific data at the next provider meeting to share for educational purposes.
Tamper-Resistant Rx Pads.
As of 04.01.08 Medi-Cal, Medicare and CCAH prescriptions will need to be on tamper-resistant forms as we are presently using for our controlled substances. I have been in communication with Victor Rodriguez from Purchasing and we should be receiving increases numbers of the existing tamper-resistant forms for prescribing. We understand that these pads allow only one drug at a time and their use will be inefficient, because of the many medications some of our patients require. We are attempting to obtain larger tamper-resistant forms for betterprescribing efficiency. Additional options we have for prescribing are for staff to phone in or fax prescriptions on these complicated patients. Certainly the more discussion we have with our staffs and receiving pharmacies should minimize this transition period, and I’ll keep working with purchasing to get these larger pads as promptly as possible.
This will be the final reminder for our Health Disparities Collaborative Diabetes Health Fair on Thursday night at El Sausal School. The fun begins at 6:30PM, come on down if you get a chance, you’ll find a chance to meet and greet some of our collaborating agencies in town and socialize/network about future joint efforts.
For a lttle more on utilization mangement begin here
and review this more global update on Massachusetts’ three year effort at healthcare delivery/cost reform