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Saturday, May 22, 2010

Further observations on the episode based model of patient care

I am playing catch up today, dealing with tasks which I simply could not shoe horn into my week's activity. One of those tasks is completing notes on patients who had visits to see me yesterday. They were all complicated, presenting to me because they had problems which were not amenable to common diagnostic or treatment pathways. Virtually all of them will require treatment outside the bounds of standard practice.

Theoretically I could deal with all of the work involved in their care while they were in my office. However, there are time and resource constraints. Let me list all of the tasks which need to happen to complete an episode of care and prioritize which ones must get done and when.

1. Check in including co-pay collection and verification of insurance
2. Rooming
3. Nursing assessment - vitals, meds
4. History - new or interval
5. Physical exam
6. Assessment and synthesis of information
7. Generation of plan which ideally includes some sort of procedural element
8. Patient education
9. Check out
10. Documentation of all of the above
11. Communication with patient in the interval before the next visit

I pose the question, which of these items can be done poorly or not at all and not put immediate payment in jeopardy.  The way I see this the only thing which absolutely must be done are items 1, 2, 7, 9, and 10. Granted there needs to be some sort of history and physical documented. It does not have to be particularly accurate or include any useful information. Everything else can be stinted.

In the episodic care model, the ideal business practice is to make any patient requiring any sort of care between visits unhappy in order to stimulate their desire to seek care elsewhere. If the problem at hand at the time of a visit cannot be complete dealt with in the time frame of the brief visit, the activity outside the time frame of the office visit is volunteer work. Not everyone is cut out for volunteer work.

So here I am on Saturday morning doing my volunteer work. Sometimes it requires that we actually do a literature search to identify the rationale for a particular therapy. You cannot always review the relevant portions of the medical record when your patients are landing in your waiting room like planes lined up for landing at O'Hare international airport. That is relegated to your volunteer time or it never gets done. The sanctions for doing a mediocre job in managing complexity is you are relived of the responsibility of managing complexity. Some sanction.

The episodic model rewards only one thing...volume. You get paid for volume and not penalized in any appreciable form for the absence of quality. Volume is easily measurable and quality is not, particularly in the outpatient realm. I think that Clayton Christensen hit the nail on the head when he saw the parallels between the steel industry and health care. We are basically engaged in the manufacture of re bar steel. There are no specs on quality, for the most part it gets buried so no one can check,  and we just need to generate it by the ton. Occasionally the quality is so bad that someone gets burned, like the occasional parking garage collapse brought on by substandard re bar support. However, this is so rare as to be a non-issue from a business model standpoint.

Let me review the enhanced assessment of the episodic care model. Essential elements in red:


1. Check in including co-pay collection and verification of insurance - this is obvious based upon Sutton's Law
2. Rooming - no face to face encounter, no payment 
3. Nursing assessment - vitals, meds -as little as possible. They might find something you have to deal with.
4. History - new or interval. See #3 above
5. Physical exam - WNL - we no look, we no listen
6. Assessment and synthesis of information - why bother except for identifying high margin CPT opportunities
7. Generation of plan which ideally includes some sort of procedural element - whether the patient derives value or not 
8. Patient education - why bother
9. Check out - another opportunity to collect cash
10. Documentation of all of the above - Non patient specific templates are the best. They are not required to contain any information useful to patient management, only billing. 
11. Communication with patient in the interval before the next visit - to be avoided like the plague. If they have issues which require this, invoke strategic incompetence and send elsewhere.

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