C M Y K E5
HEALTH 03-09-10 DM EE E5 CMYK
TUESDAY, MARCH 9, 2010
KLMNO E5
SCENES FROM THE 21ST-CENTURY DOCTOR’S OFFICE
The women have
access not just to
doctors, nurses and
midwives, but also
to each other.
from the doctor’s point of view. “I’ve
been a family doctor for 26 years, and it
generally takes four or five visits with
me for people to reveal their whole
story,” Kivlahan says of the patients
coming to the clinic. But “in group set-
tings it is much quicker.”
She thinks there’s something to the
fact that in a group appointment, the
doctor is outnumbered. “There isn’t
that power differential there as with a
single physician and a single patient,”
she says. Often it’s embarrassing for pa-
tients to be candid one-on-one with a
doctor about bad health habits such as
smoking or drinking. But in a group,
she finds, patients surprisingly “are
much more ready to talk.” She says this
is true of “even very hesitant patients.”
Kivlahan said group visits generally
haven’t “been recognized from the
health-care-financing standpoint as an
optimal strategy. And that’s probably
why it is being used primarily on the
uninsured.”
Research shows benefits
Positive results are showing in sever-
al studies. One found that women en-
rolled in group prenatal care used the
emergency department less during the
third trimester. A recent review of
multiple studies that appeared in the
PHOTOS BY EVY MAGES FOR THE WASHINGTON POST
Journal of Family Practice found that
Midwife Suz Brown, standing, conducts a group prenatal visit at Providence Hospital. Premature births are down and breast-feeding is up since the sessions began. group prenatal care may reduce the rate
of preterm births, especially among mi-
nority or low-income women. Some
The doctor will see
studies have further shown that group
care can boost breast-feeding rates and
increase general knowledge about what
to expect during pregnancy.
And a 2009 study in the Journal of
you now. All of you.
Midwifery and Women’s Health showed
that participants in the group model
chalked up “significantly more prenatal
visits, increased weight gain, increased
breast-feeding rates and higher overall
group continued from E1 tened to in that setting” — that is, in satisfaction.”
front of everybody else in the group, A 2006 review of nearly 20 studies
care for both patients and their doctors. whose members all have the same diag- published in the Journal of the Amer-
The important question, of course, is nosis. “Patients actually get used to tak- ican Board of Family Medicine called
how group appointments measure up. ing their socks off and having every- group appointments “a promising ap-
The answer seems to be: surprisingly one’s feet checked simultaneously,” she proach” to chronic-care management
well. said, referring to a common check for for the motivated patient. It concluded
Colleen Kivlahan of Herndon, a fami- people with diabetes. Patients who that “there is sufficient data to support
ly physician who has been conducting need a little more privacy with the doc- the effectiveness of group visits in im-
group visits for years, points to research tor are offered a few minutes away from proving patient and physician satisfac-
carried out in Chicago, where she prac- the group. tion, quality of care, quality of life and
ticed earlier. Two groups of patients Providence Hospital in Northeast in decreasing emergency department
were compared: One received tradition- Washington, where Quijada goes for and specialist visits.”
al care, and one attended group ap- her group visits, also reports good re- While there are sufficient data to sup-
pointments. It was no contest, she says. sults. Debra Keith, a nurse-midwife and While the group appointment continues, Brown examines Marilis Quijada, who port all of these findings, what seems to
“The ‘group visit’ folk . . . blew them director of the hospital’s Center for Life says she loves the connection she is forming with the other women. be missing is definitive proof that pa-
away in terms of self-management, OB-GYN clinic, says that since group tients in group settings are actually
knowledge, behavior change, dietary appointments for pregnant women women in two hours and give them ly, this is about empowerment.” The pa- healthier — and have fewer medical is-
and exercise change,” as well as in im- were initiated, the clinic has seen the such good care that they walk away say- tients at the clinic are mostly low- sues over time — than they would if
provements in blood sugar control and rate of premature births drop and ing, ‘I just got the best of it.’ ” income Latinas; some are treated for they received usual care with their doc-
cholesterol levels, she said. (These find- breast-feeding rates go up. free and others receive discounts. Be- tors.
ings were presented at a chronic disease Quijada, 22, who already has one
‘This is about empowerment’
fore the clinic began group appoint- Kivlahan believes that although more
conference but have not yet been pub- child, says she prefers the group model In the group setting, the women have ments for such women, she points out, research is needed, this is a good model
lished.) to the traditional path she followed for access not just to doctors, nurses and “they did not really have the opportuni- from the patient’s perspective: “Pa-
Kivlahan is adamant that group ap- that first birth. Beyond the shorter wait midwives, but also to each other. They ty to participate in their own care. . . . tients are able to talk with other people
pointments should not be mistaken for times, she says, she loves the connec- are taught how to take their own and They don’t even know what blood pres- who share their same condition and get
some sort of support group or hygiene tion she is forming with the other wom- others’ blood pressure and weigh them- sure is, let alone taking it and figuring and give advice, understand symptoms
class. “They’re getting comprehensive en and feels more on top of what’s going selves. Further, over two hours, they can out their numbers, using a scale and fol- and adapt to their chronic conditions in
care in that setting,” she said, which in- on during this pregnancy. go much further into depth on topics of lowing their weight. It is really exciting a manner that fits their learning style.”
cludes thorough medical examinations Before the program started in 2007, pregnancy — working off each other’s for me, as a provider, to see and hear This is better, she says, than “talking
and referrals for lab tests and follow-up patients “were facing wait times of two questions and experiences — than these women, some of them with a only to their doctor about what it is like
with specialists. It’s full-fledged med- to three hours,” Keith recalls. “The phy- would be possible during a 15-minute third-grade education, really taking to live daily with chronic disease.”
ical care. sicians and midwives were totally visit. In fact, the chat about knowing charge of their own health.” health-science@washpost.com
But, of course, it does require some stressed out with the backup because it the signs of labor evolved into a dis- By sharing in the group setting, Keith
sacrifice of privacy, which some people was like a factory of going in and out of cussion — complete with role-playing — says, “they realize how smart they are Mishori is a family physician and faculty
handle more easily than others, Kiv- rooms and seeing patients and trying to about how to tell your husband it is and how much they already know. And member in the Department of Family
lahan says. “Patients know that they’re hurry up.” time to leave for the hospital. that’s a really powerful thing.” Medicine at Georgetown University School of
going to have their heart and lungs lis- Now, says Keith, “you can see 10 or 12 To Keith, that’s the essence of it: “Tru- It can also look like a powerful thing Medicine.
Why not include doctors’ bills in ‘bundled’ hospital payments?
billing continued from E1 From 1992 to 1996, Medicare con- surgeons resisted any attempts to might be tempted to put the hospital’s outpatient physician services, such as
ducted a demonstration project at sev- change their usual patterns; that hospi- best interest first. But professionalism those that I offer my HIV patients. Out-
service” model. It’s a design flaw of our en hospitals for patients undergoing tal did not see equivalent reductions in and fairly simple quality-control meas- patient care often requires multiple
health-care system, and one of the rea- heart bypass surgery. The total fees cost. ures, I believe, could keep performance doctors, laboratory and radiology ser-
sons for spiraling health-care costs. But went to the hospitals, which had con- Patients in the demonstration proj- up to par. vices. Bundling payments for all of
we can patch this flaw without over- tractual agreements with the surgeons, ect expressed greater satisfaction with Also, some doctors complain that them is difficult. To move the idea of
hauling the entire system: We can start the anesthesiologists, the cardiologists their hospital experience than patients bundled payment is reminiscent of the bundled payments forward, Congress
“bundling” payments. and the radiologists. The doctors re- in non-demonstration project hospi- capitation fees that many HMOs imple- must act.
ceived fixed payments for their ser- tals. mented in their short-lived boom in the More than half my income comes
Time for a change
vices; some of the demonstration hos- I believe the best way to have doctors 1970s. from Medicare or Medicaid programs,
In the 1980s, when hospital costs pitals also gave the doctors a share of and hospitals work efficiently together But there is a difference. Capitation and I’m not unusual; if Congress re-
were rising at unprecedented rates, their profits. is to pay them together. The widely ad- fees were fixed sums paid to physi- quires Medicare to bundle payments,
Medicare applied the brakes by chang- Medicare savings in such plans were mired Mayo Clinic, Geisinger Health cians, usually in advance, to provide all many of us will have to figure out how
ing billing rules: Hospital administra- 10 percent higher than expected. Most System, Kaiser Permanente and In- the needed care for an individual. It to work in that system.
tors were required to bundle charges came from shorter stays in the hospital termountain Health can boast of low- was difficult to adjust these lump sums A bill that the House passed in No-
into diagnostic related groups, or and in the intensive care unit and from cost and high-quality care because to the varying level of illness among pa- vember recently mentions pilot pro-
DRGs. lower pharmaceutical costs. The mor- most of these hospitals have salaried tients. And some doctors took the pay- grams involving accountable care or-
Under this payment system, which tality rate was also lower in the demon- physicians, unlike my hospital or most ments, then just delivered less care. ganizations (ACOs), a structure where
still exists, hospitals receive a single stration hospitals. others in America. Bundling would avoid these pitfalls hospitals, physicians and others work
payment for a patient’s entire hospital Interviews with doctors and hospital by paying doctors and hospitals after together and are paid together in bun-
stay: room charges, medicines, physi- managers during this project were re-
Doctors’ objections
treatment was complete and by includ- dles for both outpatient and inpatient
cal therapy, blood tests and more. The vealing. A majority of U.S. doctors earn their ing predetermined quality safeguards care. ACOs not only reduce the cost per
result was greater efficiency: a drop in The hospital staffers were surprised income through fee-for-service pay- — for example, monitoring rates of in- procedure but also the total number of
cost and length of stay with no decline how quickly the physicians were able ments, and most adamantly oppose a hospital infections and readmissions procedures. The Senate addressed ACO
in quality of care. to reduce the length of stay, substitute change in this system. Some worry that due to incomplete treatment. programs in the comprehensive health-
Physician charges, however, are not generic for brand-name drugs and re- in a bundled system they would be- Bundled payments could be imple- care reform bill whose future is cur-
included in the DRG payments, and duce unnecessary testing. The sur- come “slaves to the hospital.” One in- mented fairly simply for common diag- rently unclear.
doctors are still paid separately for geons worked as a team with nurses to ternist at my hospital said, “Who will noses such as pneumonia, heart attack Bundled payments would almost
each visit they make to a hospital pa- implement standardized protocols and look after the patient’s best interest?” and congestive heart failure. They certainly limit my income and, more
tient. checklists. At one demo hospital, the It’s true that a hospital-paid doctor would be more challenging to use with important, reduce my autonomy. But
Most health-policy experts agree health care should be about patients,
that it’s time this changed. Here’s how not how doctors want to be paid. Sadly,
it could work: The doctors and the hos- the payment system is the tail that
pital would receive one payment for a
given treatment, such as an appendec-
Bundled payments would almost certainly
wags the dog in health care.
health-science@washpost.com
tomy or months of cancer care. Doctors
limit my income and reduce my autonomy.
and hospitals would develop a contract Jain is an infectious-disease specialist in
stipulating the fees each would receive But health care should be about patients, Memphis and an adjunct assistant
for specific procedures.
Pilot programs have shown that this
not how doctors want to be paid.
professor at the Rollins School of Public
Health at Emory University in Atlanta.
model works well.
C M Y K E5
Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52