Re: triage designers assume most problems should go directly to specialists

[Guest guest]

I have a really hard time believing that the National average is

70% of visits result in referral. But we have to look at whom we are

referring to also.

Every diabetic needs a “referral” for an eye

exam. A lot of older people see a podiatrist for foot care. Many of

my patients like chiropractors and many plans require “referrals”.

I have to refer for radiology, yearly mammograms. Are blood tests

considered referrals? All my patients over 50 get referred for

colonoscopy. Persistent esophagitis gets referred for EGD. But do people

need colonoscopies ever 3-5 years like gastroenterologists like to say? I

also now refer for suspicious skin lesions as my malpractice says I can’t

biopsy without surgical coverage.

So if you count all those referrals for procedures I don’t

and can’t do, then yes, referral rates sound high. But for each of

those referrals, I have probably treated 3 other conditions. Statistics

taken out of context. But on the other hand, I have seen really busy

medical groups, even gotten records that it seems they do just triage and refer

to the “specialist” for the problem rather than manage anything

themselves. Question is, can they “go back” to

managing things themselves if paid more. Or would they just keep doing

the same thing and just make a lot more money.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Pierce

Sent: Sunday, March 28, 2010 11:29 PM

To:

Subject: triage designers assume most problems

should go directly to specialists

Am I bothered by this due to my biases as a primary care physician or have

we forgotten that primary care can be comprehensive?:

" Our first product we’re making answers the following questions when

you’re in a medical bind and may need professional attention:

When should I take care of this?

Who should I see? (specialist, generalist, retail

clinic, etc.)

How much should I expect to spend?

Since overworked primary care physicians refer about 70% of

their visits to specialists, if we point you to a specialist instead of a

primary care doctor, we’ll automatically be “correct” (in

terms of the consumers experience) 70% of the time. Why should people, when

spending their own hard earned money, waste money on a primary care doctor

visit just to get a referral that will happen anyway 70% of the time? "

From: How

would you fix the access problem?

I love teaching patients how to care for themselves and avoid overutilization

with self triage. We used to do a lot of this in overloaded military

clinics. However, if these folks are assuming that sending 70% of medical

problems to specialists is appropriate then that's pretty sad.

Maybe I'm just overreading this and they're just designing for the

dysfunctional system we now have. In a system with primary care

physicians working in overloaded, rushed clinics, it may make sense to replace

them with midlevels and a program that triages most problems to a specialist.

[Guest guest]

Excellent observation, Kathy!

That might make perfect sense.

Tim

Malia, MD

(phone / fax)

www.MaliaFamilyMedicine.com

www.SkinSenseLaser.com

Malia Family Medicine & Skin Sense Laser

6720 Pittsford-Palmyra Rd.

Perinton Square Mall

Fairport, NY 14450

-- Confidentiality Notice --

This email message, including all the attachments, is for the sole use of the

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disclosure is prohibited. If you are not the intended recipient, you may not

use, disclose, copy or disseminate this information. If you are not the intended

recipient, please contact the sender immediately by reply email and destroy all

copies of the original message, including attachments.

triage designers assume most problems should go

directly to specialists

Am I bothered by this due to my biases as a primary care physician or have we

forgotten that primary care can be comprehensive?:

" Our first product we’re making answers the following questions when you’re

in a medical bind and may need professional attention:

• When should I take care of this?

• Who should I see? (specialist, generalist, retail clinic, etc.)

• How much should I expect to spend?

Since overworked primary care physicians refer about 70% of their visits to

specialists, if we point you to a specialist instead of a primary care doctor,

we’ll automatically be “correct†(in terms of the consumers experience)

70% of the time. Why should people, when spending their own hard earned money,

waste money on a primary care doctor visit just to get a referral that will

happen anyway 70% of the time? "

From: How would you fix the access problem?

I love teaching patients how to care for themselves and avoid overutilization

with self triage. We used to do a lot of this in overloaded military clinics.

However, if these folks are assuming that sending 70% of medical problems to

specialists is appropriate then that's pretty sad.

Maybe I'm just overreading this and they're just designing for the dysfunctional

system we now have. In a system with primary care physicians working in

overloaded, rushed clinics, it may make sense to replace them with midlevels and

a program that triages most problems to a specialist.

[Guest guest]

Well, if the point is to drive the system into the ground, this would be a good intervention. Specialists are an integral part of any health system. Their role is crucial and valuable when there is an effective primary care foundation. We're in the mess we're in because we lack an effective primary care foundation.Gordon

Am I bothered by this due to my biases as a primary care physician or

have we forgotten that primary care can be comprehensive?:

"Our first product we’re making answers the following questions when

you’re in a medical bind and may need professional attention:

When should I take care of this?

Who should I see? (specialist, generalist, retail clinic, etc.)

How much should I expect to spend?

Since overworked primary care physicians refer about 70% of their

visits to specialists, if we point you to a specialist instead of a

primary care doctor, we’ll automatically be “correct” (in terms of the

consumers experience) 70% of the time. Why should people, when spending

their own hard earned money, waste money on a primary care doctor visit

just to get a referral that will happen anyway 70% of the time?"

From: How

would you fix the access problem?

I love teaching patients how to care for themselves and avoid

overutilization with self triage. We used to do a lot of this in

overloaded military clinics. However, if these folks are assuming that

sending 70% of medical problems to specialists is appropriate then

that's pretty sad.

Maybe I'm just overreading this and they're just designing for the

dysfunctional system we now have. In a system with primary care

physicians working in overloaded, rushed clinics, it may make sense to

replace them with midlevels and a program that triages most problems to

a specialist.

[Guest guest]

I was totally floored when I went to an appointment with my sister. She kept telling me she was wasting her time because she just would end up being referred. The physician wouldn't give an x-ray depite the pain from the fall worsening over past 6 weeks but would send her to orthopedist. She said she examined it and it certainly wasn't a broken bone in the elbow. She hadn't touched my sister for either palpation or for ROM much less neuro since my sister was c/o numb fingers! My sister says she sees someone different every time she goes in and she knew she wasn't going to get treatment and she certainly resented taking time off to be shuffled to the next doctor after waiting almost an hour to see that one!

To: Sent: Mon, March 29, 2010 9:03:12 AMSubject: Re: triage designers assume most problems should go directly to specialists

Excellent observation, Kathy! That might make perfect sense.Tim Malia, MD (phone / fax)www.MaliaFamilyMedi cine.comwww.SkinSenseLaser. comMalia Family Medicine & Skin Sense Laser6720 Pittsford-Palmyra Rd.Perinton Square MallFairport, NY 14450-- Confidentiality Notice --This email message, including all the attachments, is for the sole use of the intended recipient(s) and contains confidential information. Unauthorized use or disclosure is prohibited. If you are not the intended recipient, you may not use, disclose, copy or disseminate this information. If you are not the intended recipient, please contact the sender immediately by reply email and destroy all copies of the original message, including attachments. [Practiceimprovemen t1] triage designers assume most problems should go directly to specialists Am I bothered by this due to my biases as a primary care physician or have we

forgotten that primary care can be comprehensive? : "Our first product we’re making answers the following questions when you’re in a medical bind and may need professional attention: • When should I take care of this? • Who should I see? (specialist, generalist, retail clinic, etc.) • How much should I expect to spend? Since overworked primary care physicians refer about 70% of their visits to specialists, if we point you to a specialist instead of a primary care doctor, we’ll automatically be “correct†(in terms of the consumers experience) 70% of the time. Why should people, when spending their own hard earned money, waste money on a primary care doctor visit just to get a referral that will happen anyway 70% of the time?" From: How would you fix the access problem? I love teaching patients how to care for themselves and avoid overutilization with self triage. We used to do a lot of this

in overloaded military clinics. However, if these folks are assuming that sending 70% of medical problems to specialists is appropriate then that's pretty sad. Maybe I'm just overreading this and they're just designing for the dysfunctional system we now have. In a system with primary care physicians working in overloaded, rushed clinics, it may make sense to replace them with midlevels and a program that triages most problems to a specialist.

[Guest guest]

I am the master of the obvious, but clearly most doctors don't have time to provide comprehensive care. That's where most of us are different, I believe. I wonder how nonphysician providers affect this statistic?Lonna

Am I bothered by this due to my biases as a primary care physician or

have we forgotten that primary care can be comprehensive? :

"Our first product we’re making answers the following questions when

you’re in a medical bind and may need professional attention:

When should I take care of this?

Who should I see? (specialist, generalist, retail clinic, etc.)

How much should I expect to spend?

Since overworked primary care physicians refer about 70% of their

visits to specialists, if we point you to a specialist instead of a

primary care doctor, we’ll automatically be “correct†(in terms of the

consumers experience) 70% of the time. Why should people, when spending

their own hard earned money, waste money on a primary care doctor visit

just to get a referral that will happen anyway 70% of the time?"

From: How

would you fix the access problem?

I love teaching patients how to care for themselves and avoid

overutilization with self triage. We used to do a lot of this in

overloaded military clinics. However, if these folks are assuming that

sending 70% of medical problems to specialists is appropriate then

that's pretty sad.

Maybe I'm just overreading this and they're just designing for the

dysfunctional system we now have. In a system with primary care

physicians working in overloaded, rushed clinics, it may make sense to

replace them with midlevels and a program that triages most problems to

a specialist.

[Guest guest]

I didn;t understand this Was the  statement about wastin g time in primary care offcies written by Jay P a primary care doc? I didnt undertsand the  site... but he does say " overworked primary  c are.. "

 well overworked primary care does indeed have no time t do its workThe residents refer out constantly  I don;t  Order an MRI for everything becasue they are afraid and have no time Notme IT is IMPS and folks  like us who do not refer hardly at all- we  are  not  overworked We close our panels.

The standard american doctor office visit is HI how are you  type a little check the chart for bs an insulin an dI NRs and and labs and VS  and say  see you in 6mo.Docs do not talk becasue it would take time That's therm

I guess that is what  he  is decribeding and  that  is what specialists see.And  what America sees.All  t he more reason to form up your own little clot of  docs  in  an ACO and change your piece of the world  I don;t think I refer out 10%.

 

Well, if the point is to drive the system into the ground, this would be a good intervention.  Specialists are an integral part of any health system.  Their role is crucial and valuable when there is an effective primary care foundation.  We're in the mess we're in because we lack an effective primary care foundation.

Gordon

 

Am I bothered by this due to my biases as a primary care physician or

have we forgotten that primary care can be comprehensive?:

" Our first product we’re making answers the following questions when

you’re in a medical bind and may need professional attention:

When should I take care of this?

Who should I see? (specialist, generalist, retail clinic, etc.)

How much should I expect to spend?

Since overworked primary care physicians refer about 70% of their

visits to specialists, if we point you to a specialist instead of a

primary care doctor, we’ll automatically be “correct” (in terms of the

consumers experience) 70% of the time. Why should people, when spending

their own hard earned money, waste money on a primary care doctor visit

just to get a referral that will happen anyway 70% of the time? "

From: How

would you fix the access problem?

I love teaching patients how to care for themselves and avoid

overutilization with self triage.  We used to do a lot of this in

overloaded military clinics.  However, if these folks are assuming that

sending 70% of medical problems to specialists is appropriate then

that's pretty sad. 

Maybe I'm just overreading this and they're just designing for the

dysfunctional system we now have.  In a system with primary care

physicians working in overloaded, rushed clinics, it may make sense to

replace them with midlevels and a program that triages most problems to

a specialist.

-- PATIENTS,please remember email may not be entirely secure and that Email is part of the medical  record and is placed into the chart ( be careful what you say!)Email is best used for appointment making and  brief  questions

Email replies can be expected within 24 hours-Please CALL  if the  matter is more urgent .     MD         ph   fax

impcenter.org

[Guest guest]

I don't know where the stats come from in Jay's blog post but I agree with you that overworked PCPs may indeed refer a high rate of people off to specialists.The point I'm making is that we know that effective primary care is the foundation of high performing health systems. Reading between the lines, Jay is positing a future world with a massive shortage of PCP and proposes an online triage mechanism that can join patients with the appropriate specialist.I've seen some "direct access to specialist" systems in play and have to note that this tends to drive outcomes down and costs up, so I don't have confidence in that intervention. Jay's pretty imaginative, so he's probably coming at this in a new and different way, but I'm skeptical at this point.If effective primary care solves the problem then solutions should be aimed at supporting effective primary care and not bypassing it.If primary care supply is an issue then we should work on enhancing primary care supply.The root causes of these problems are well described in the literature.G

I didn;t understand this Was the statement about wastin g time in primary care offcies written by Jay P a primary care doc? I didnt undertsand the site... but he does say "overworked primary c are.."

well overworked primary care does indeed have no time t do its workThe residents refer out constantly I don;t Order an MRI for everything becasue they are afraid and have no time Notme IT is IMPS and folks like us who do not refer hardly at all- we are not overworked We close our panels.

The standard american doctor office visit is HI how are you type a little check the chart for bs an insulin an dI NRs and and labs and VS and say see you in 6mo.Docs do not talk becasue it would take time That's therm

I guess that is what he is decribeding and that is what specialists see.And what America sees.All t he more reason to form up your own little clot of docs in an ACO and change your piece of the world I don;t think I refer out 10%.

On Mon, Mar 29, 2010 at 9:44 AM, L. Gordon <gmooreidealhealthnetwork> wrote:

Well, if the point is to drive the system into the ground, this would be a good intervention. Specialists are an integral part of any health system. Their role is crucial and valuable when there is an effective primary care foundation. We're in the mess we're in because we lack an effective primary care foundation.

Gordon

Am I bothered by this due to my biases as a primary care physician or

have we forgotten that primary care can be comprehensive?:

"Our first product we’re making answers the following questions when

you’re in a medical bind and may need professional attention:

When should I take care of this?

Who should I see? (specialist, generalist, retail clinic, etc.)

How much should I expect to spend?

Since overworked primary care physicians refer about 70% of their

visits to specialists, if we point you to a specialist instead of a

primary care doctor, we’ll automatically be “correct” (in terms of the

consumers experience) 70% of the time. Why should people, when spending

their own hard earned money, waste money on a primary care doctor visit

just to get a referral that will happen anyway 70% of the time?"

From: How

would you fix the access problem?

I love teaching patients how to care for themselves and avoid

overutilization with self triage. We used to do a lot of this in

overloaded military clinics. However, if these folks are assuming that

sending 70% of medical problems to specialists is appropriate then

that's pretty sad.

Maybe I'm just overreading this and they're just designing for the

dysfunctional system we now have. In a system with primary care

physicians working in overloaded, rushed clinics, it may make sense to

replace them with midlevels and a program that triages most problems to

a specialist.

-- PATIENTS,please remember email may not be entirely secure and that Email is part of the medical record and is placed into the chart ( be careful what you say!)Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD ph fax

impcenter.org

[Guest guest]

Folks,

As we all know yes many Primary offices are overwhelmed as they follow the only viable (????) model possible when you need to care half an army of staff to do all the garbage paperwork and therefore run the hamster wheel.... Speed up the wheel and make the hamster run faster... As Medical Economics and so many others have blantantly said many times before... "Declining cash flow, add a patient or two a day".... "Holy Meat Market Batman, what's a doctor to do???"

Until someone gets these nasty insurance companies out from between us and our patients, stop having HS grads using check lists to over manage an MD's choices, Insane insurance laws that make an honest clerical error fraud while stealing from doc's is supported and condoned and even protected, payment stinks, school debt is high, so is the cost of anything we need to buy that has medical grade associated with it (Freon for Electronics, $10 bucks a can, Same Stuff for Derm Procedures, $275, Now That's a Rip Off and Insane!). Unless we care to finally have a national conversation about what is a primary care doctor honestly worth and then compensating you guys appropriately, there will continue to be a very large and probably growing shortage in this field, and a larger percentage of those that do go into primary care will be from overseas too.

Again, Health insurance does NOT equal health care... or quality there of...

To: Sent: Mon, March 29, 2010 3:00:15 PMSubject: Re: triage designers assume most problems should go directly to specialists

I don't know where the stats come from in Jay's blog post but I agree with you that overworked PCPs may indeed refer a high rate of people off to specialists.

The point I'm making is that we know that effective primary care is the foundation of high performing health systems. Reading between the lines, Jay is positing a future world with a massive shortage of PCP and proposes an online triage mechanism that can join patients with the appropriate specialist.

I've seen some "direct access to specialist" systems in play and have to note that this tends to drive outcomes down and costs up, so I don't have confidence in that intervention. Jay's pretty imaginative, so he's probably coming at this in a new and different way, but I'm skeptical at this point.

If effective primary care solves the problem then solutions should be aimed at supporting effective primary care and not bypassing it.

If primary care supply is an issue then we should work on enhancing primary care supply.

The root causes of these problems are well described in the literature.

G

I didn;t understand this Was the statement about wastin g time in primary care offcies written by Jay P a primary care doc? I didnt undertsand the site... but he does say "overworked primary c are.." well overworked primary care does indeed have no time t do its workThe residents refer out constantly I don;t Order an MRI for everything becasue they are afraid and have no time Notme IT is IMPS and folks like us who do not refer hardly at all- we are not overworked We close our panels.The standard american doctor office visit is HI how are you type a little check the chart for bs an insulin an dI NRs and and labs and VS and say see you in 6mo.Docs do not talk becasue it would take time That's thermI guess that is what he is decribeding and that is what specialists see.And what

America sees.All t he more reason to form up your own little clot of docs in an ACO and change your piece of the world I don;t think I refer out 10%.

On Mon, Mar 29, 2010 at 9:44 AM, L. Gordon <gmoore@idealhealthn etwork.com> wrote:

Well, if the point is to drive the system into the ground, this would be a good intervention. Specialists are an integral part of any health system. Their role is crucial and valuable when there is an effective primary care foundation. We're in the mess we're in because we lack an effective primary care foundation.

Gordon

Am I bothered by this due to my biases as a primary care physician or have we forgotten that primary care can be comprehensive? :"Our first product we’re making answers the following questions when you’re in a medical bind and may need professional attention:

When should I take care of this?

Who should I see? (specialist, generalist, retail clinic, etc.)

How much should I expect to spend?Since overworked primary care physicians refer about 70% of their visits to specialists, if we point you to a specialist instead of a primary care doctor, we’ll automatically be “correct†(in terms of the consumers experience) 70% of the time. Why should people, when spending their own hard earned money, waste money on a primary care doctor visit just to get a referral that will happen anyway 70% of the time?"From: How would you fix the access problem?I love teaching patients how to care for themselves and avoid overutilization with self triage. We used to do a lot of this in overloaded military clinics. However, if these folks are assuming that sending 70% of medical problems to specialists is appropriate then that's pretty sad.

Maybe I'm just overreading this and they're just designing for the dysfunctional system we now have. In a system with primary care physicians working in overloaded, rushed clinics, it may make sense to replace them with midlevels and a program that triages most problems to a specialist.

-- PATIENTS,please remember email may not be entirely secure and that Email is part of the medical record and is placed into the chart ( be careful what you say!)Email is best used for appointment making and brief questionsEmail replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD ph fax impcenter.org

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