At the suggestion of Arnold Nemore, a health care consultant who specializes in helping health care organizations develop and improve their systems of care, Family Practice Management convened a roundtable of four members of our Board of Editors and a cardiologist to discuss the always-changing, often-controversial issue of specialty care management. Nemore moderated the discussion, which focused on economics, communication, decision making and management of hospitalized patients.
Douglas B. Bogart, MD, a cardiologist, practices with Northland Cardiology in North Kansas City, Mo.
Don Cauthen, MD, is chairman of the Department of Family and Community Medicine for Scott and White Clinic, a multispecialty group based in Temple, Texas.
Marc Rivo, MD, MPH, is medical director of AvMed Health Plan in Miami, Fla., and medical editor of FPM.
Susan Schooley, MD, is chairman of the Department of Family Practice at the Henry Ford Health System in Detroit.
William D. Soper, MD, MBA, is founder and senior partner of The Liberty Clinic, a primary care group based in Liberty, Mo.
Arnold Nemore is an independent consultant who specializes in capitation, disease management and Medicare risk arrangements.
Nemore: Successful cardiology management has a lot to do with building relationships between family physicians and cardiologists. As the financial mechanisms in health care have changed, groups of physicians have grown much more willing to sit down and examine the ways they interact, and we’ve produced some dramatic improvements in efficiency and quality as a result of these discussions. So I’d like to begin by discussing how the environment you practice in affects the relationships between physicians in your two specialties.
Rivo: Family physicians clearly are responsible for preventing, identifying and treating heart-related problems. Clinical guidelines help us to decide when a patient should be referred to another physician, but how we manage that referral once it’s made can have a major impact on the quality of care the patient receives.
Schooley: Referral management varies tremendously depending on practice setting and, in particular, on reimbursement structure. You can’t eliminate the economic issues from the process of making referrals, and sometimes those realities and the need to function intercollegially around clinical matters are misaligned.
Rivo: In a situation where a family doctor is capitated and a cardiologist is under discounted fee for service, there is an incentive for the cardiologist to continue to see the patient. If the cardiologist is capitated, there is an incentive for the cardiologist to return the patient quickly. In Florida, where many cardiologists still get discounted fee for service, some family physicians expressed to me their concern about losing their patients upon referral.
Schooley: I work in an integrated delivery system where my cardiologist and I both get a salary and share risk, which makes it much easier for our relationship and negotiations to be driven by the clinical matter.
Bogart: The primary care physicians that refer to our cardiology practice contract with so many health plans that we have no idea of the individual reimbursement arrangements. Our interactions with family doctors are influenced in large part by our prior experiences with them. The one thing you’re not taking into account that does affect us significantly is patient expectations. Patients who have had a complicated illness and have been through that with me want to come back and see me. Many times I’ll tell a patient to come back in a year. But three months later, he’s back in my office. Then the patient’s doctor thinks I’m trying to see the patient every three months. And it’s bad for our office because it ties up a follow-up slot.
Soper: I know that’s true. I’ll ask the patient why he saw the cardiologist and he’ll say that he just thought he should go. When I ask him what was wrong, he’ll say, “My sister said I ought to see a cardiologist and make sure that I’m OK because of my heart bypass six years ago.” It’s a mind-set, and it can be hard to discourage some people.
Nemore: But it can be changed if the cardiologist says to the patient, “Dr. Soper, your primary care doctor, is really good at handling these types of problems, and if you need to see me again, he will be sure that you get here.”
Soper: I think that only works if the cardiologist also talks to the sister. There are huge family pressures on these patients. I do think it helps to establish a plan with the patient. If you explain, “You need to be seen by someone every three months. In three months, we’ll have you see the cardiologist and three months after that you’ll see me,” then the patient has something to put on a calendar and feel secure about. A lot of times when patients end up in their cardiologist’s office unnecessarily, it’s because of kind of a free-floating anxiety.
Nemore: If the patient knows you’re communicating with the cardiologist about each visit, that also helps to ease the patient’s mind.
Cauthen: I agree that the economic issues are often secondary. In our multispecialty clinic, we have to consider lots of other factors, for example, whether the cardiologist we’re referring to is more inclined to be invasive or conservative. And some cardiologists are more communicative than others. They call you to discuss important findings.
Rivo: I appreciate a cardiologist who tries to clarify up front my reason for referring the patient, whether it’s a diagnostic issue, a treatment issue, help choosing a medication, or deciding on a management approach or a one-time intervention. I’m also looking for a teacher who can feed back some useful information. If I feel we have a partnership, that really opens the communication doors — and improves the care. Doug, I would think there is a set of communication skills you value in a family doctor too.
Bogart: Yes, some doctors send all the background information on the patient to be evaluated, which facilitates our jobs as consultants. Some doctors don’t communicate as well and their patients come to the office with very little information. The patient may know he’s had three angioplasties, but he can’t remember what vessel or what hospital or which doctor did which procedure. A new patient visit in our practice is a 45-minute slot. If we have to spend 45 minutes trying to find out about a patient’s previous catheterization, we’ve got patients six deep in our waiting room the rest of the day, or we have to delay seeing the patient. Having the echo results, information about the last catheterization or the report on the bypass hastens our ability to evaluate the patient. I agree that our responsibility is to get information about that evaluation back to the primary doctor, but it’s a two-way street. We can waste a lot of time trying to gather information that the primary doctor could fax us in two minutes.
Soper: Is faxing the best way for us to send that information or should patients carry their records? In some situations, if the patient has never been seen in the cardiologist’s office, I suspect nobody knows what to do with the fax when it comes through.
Bogart: If patients hand-carry their records, that’s great. You can look at a record before you go into the exam room and you’re six steps ahead. But the sooner we get it the better.
Nemore: Telephone consultation can also be useful. One of the groups I consult with has discovered that for treatment issues, a five-minute telephone consultation between a cardiologist and a primary care physician can obviate the need for two-thirds of the referrals that would otherwise have occurred. Or, based on what the primary care physician says, the cardiologist may realize he needs to order a particular test prior to seeing the patient.
Rivo: Ideally, for each case, the family doctor and the cardiologist need to have a conversation to determine how the case will be managed and what their relationship will be. That discussion should take place in two parts — before the referral so that expectations are clear and after the evaluation. It helps things to go more smoothly, and it gives a consistent message to the patient.
Cauthen: But I don’t want to bother the cardiologist unnecessarily, and I’m busy too. What if I call and your secretary tells me you’re with a patient?
Bogart: We never say that. When a doctor calls, our staff is instructed to bring the phone to us. If I’m doing an angioplasty, I take the call. I may tell the doctor I’ll have to call him back as soon as I’m finished, but then I follow through. I don’t like it if I call a primary care doctor and am told he’s with a patient. If I’m calling, I’m trying to transmit some information that I think is important, and I expect to be treated the same way that I would treat another physician.
Cauthen: What do you do when a doctor doesn’t send you enough information?
Bogart: If I know he or she has it, I just call right then. If it’s a recurring problem, I talk to the other doctor and explain how important it is for us to have that information. But it’s not necessarily the family doctor’s fault. In some cases, the patient has been to multiple cardiologists and there are little bits of information here, there and everywhere. The family doctor is trying hard to get the information together, but he or she may be the third family doctor the patient has seen in two years.
Schooley: It is difficult. But practicing in the hospital has made me a lot more sensitive to what a poor job family physicians sometimes do of collecting that database. I’m often handed the responsibility of managing a patient that another family physician may have been seeing for years, but even in that case, the physician doesn’t have the information. He or she may know that this patient had bypass surgery or angioplasty or whatever, but the physician hasn’t bothered to collect the information so that the database is one place. When I meet a new patient, part of my initial assessment is to size up where the patient’s history is. One of the most common orders I write at the bottom of a first visit note is to send for x, y and z.
Bogart: The level of detail provided by the primary care physician may not always be sufficient. For example, we may need to know a specific valve area that isn’t readily available in their records. Just sending us a copy of the referral letter from the prior cardiologist is very helpful.
Soper: Another common problem family physicians have is getting information from the cardiologist after the referral. If we get any information back at all, it can take a month or two.
Rivo: In a health care system with individual physician practices, such as ours, that is a problem. In an integrated delivery system where cardiologists and family doctors are working from the same chart, the communication is significantly better.
Nemore: I can tell you from evaluating referrals for organizations throughout the country that consultants do not do a good job of filling out those reports. And it is the unusual primary care physician who fills out a referral form with enough information to be useful to the consultant.
Schooley: It’s time pressure that makes us lousy at written communication. I keep a little pad of stickies at my workstation and stick them on things in the chart I want copied. It’s actually quicker to have someone copy this material than for me to write it down.
Cauthen: When I get information back from the cardiologist about an angiogram, for example, it’s too much. I need a digestion; I don’t need the details. But I guess cardiologists need the details, and we should do that better.
Soper: Like you, I would prefer a half-dozen bulleted points to a page-and-a-half letter.
Schooley: A beautifully worded letter on bond paper saying, “Thank you for sending me your delightful patient, Mrs. Jones” is very nice. But I don’t need it. A copy of the note is adequate. And the niceties are probably very costly and time-consuming.
Cauthen: I still think the relationship is important. Having a clerk automatically photocopy something doesn’t do much to nurture the relationship. An occasional phone call goes a long way. Or a copy of the note with a handwritten message scribbled on it is more personal.
Nemore: I don’t think the style of communication can be standardized. The key is to find out what the other physician wants and provide it. It’s necessary to be flexible enough to give each physician what he or she needs.
Shared decision making
Schooley: I’d like to talk about communicating about clinical decisions that aren’t clear-cut. Although I obviously know less about cardiology than a cardiologist, I am sensitive to issues of cost-effectiveness. Some of my most awkward moments with cardiologists occur when I start asking questions, for example, about the epidemiological likelihood that a patient with atypical chest pain is going to need catheterization despite having a negative stress test. I think sometimes I’m perceived as stepping on turf that I don’t belong in when I start challenging the assumptions or questioning the logic of those types of decisions. But that’s part of my responsibility as a primary care physician.
Nemore: The training of cardiologists has changed dramatically over the last 25 years. The interventionists are being absolutely honest when they say, “I can’t make a decision about this patient without a cardiac cath.” But that doesn’t mean another cardiologist, one with a more clinical orientation, couldn’t or wouldn’t make a decision. When we’ve changed patterns of care in cardiology practices so that a group of patients would be seen first by a clinical cardiologist, that is, one who is noninvasive, catheterization rates are 50 percent lower in these cases while still achieving high-quality outcomes. So the challenge is to truly understand what each cardiologist is capable of and choose the right one.
Cauthen: When you’re in the hospital, it’s easier to know the variation among the cardiologists. I think you can guide the process a little bit, for example, if you want somebody to have angiography but the cardiologist you’re dealing with is more conservative. It’s not a game, but the process is more dynamic than most people realize. You’ve just got to talk about it.
Soper: Doug, do you find yourself doing studies or not doing studies according to what you sense the referring doctor expects?
Bogart: Maybe I’m just insensitive and don’t pick up on it, but I think we usually agree about what needs to be done. And a lot of times neither of us knows the best course of action. Everything’s kind of equivocal. I frequently call the primary doctor and say, “This is your patient, and these are our options. We can catheterize him to know for sure or we can just follow him.” Sometimes the other physician will say she’s comfortable with following the patient or she might say she’s really worried about the patient, and then the decision is made.
Schooley: Setting up that discussion is important.
Rivo: I agree. I think it’s important to acknowledge that there are evidence-based best practices that ought to be followed. Then, where there is uncertainty, the family physician and the cardiologist together need to decide on a course of action. That doesn’t happen as often as it should.
Schooley: Systems aren’t really set up to support that kind of communication, so it’s up to us to foster it. That dialogue can be of great value to the cardiologist too. For example, I can think of a half-dozen patients who refused catheterization who really would have benefited from it. The family physician could have helped the cardiologist and the family to reach a better decision.
Referral management in the hospital
Bogart: From our standpoint, it’s far better to have the family doctor involved. The family doctor understands the history and can help us talk to the patient and the family. But the hard reality is that many family doctors want to be in their office. A lot of times we see patients in the emergency room that we think need to be admitted, and when we call the family doctor we’re told, “Well, it’s primarily a cardiac problem. Why don’t you just take care of it?” That works well in many situations, but if there are special social or family problems, we frequently need help.
Rivo: If the family physician does ask you to admit the patient, what information do you want?
Bogart: All the information you can give is helpful, for example, regarding social or family problems.
Rivo: Just for you to be able to say, “I talked to Dr. Rivo and he filled me in on your background and I know your son is flying in and ...”, gives you this seamless relationship that’s so much more comfortable and effective.
Soper: I had not really thought before about the bind it puts the consultant in when we just say, “No, go ahead and admit him; it’s your area.”
Bogart: It’s not a problem if the patient comes in having a big MI, I open the artery and everything goes perfectly. Then the patient thinks I’m great. But if the patient goes into renal failure and ends up on a ventilator and there are antecedent family problems, the situation may become very difficult. Another example involves the treatment plan for an acutely ill geriatric patient. In this situation, it may be difficult to establish the baseline mental status without the primary physician’s input. If the patient is quite elderly and seems demented, I’m not sure whether I should be doing anything. I need to know what the patient’s mental status is like most days. That information is vital, and I need the family physician to provide it.
Nemore: Another issue we find difficult is deciding when and how to make a cardiologist the primary physician for patients who are so ill that they are difficult to manage and are being repeatedly hospitalized. Usually there is a small number of these patients, but they have very high costs.
Cauthen: I think the problem is that the family physician is often more available than the cardiologist. When patients don’t have access to cardiologists, they go to the ER, and then we get involved just trying to keep them out of the ER.
Bogart: It’s a huge challenge and a large time commitment for us to manage these patients outside of the hospital. A significant part of our practice is devoted to interfacing with various home health systems to deliver high quality care to a group of very complicated patients. We receive multiple calls per day about these patients.
Nemore: We’ve found that if cardiologists work with these difficult cases, although the patients may not live longer, they may have a considerably improved quality of life. If the cardiology group has enough patients, they may have a full-time case management nurse to work closely with these patients. We’ve set up programs for cardiology groups where volunteers call CHF patients every day and have cut hospitalizations from three-and-one-half per patient per year to less than one-half per patient per year.
Rivo: There’s tremendous potential for improving the outpatient care of patients with heart disease if family physicians and cardiologists communicate better. In addition, many health care plans offer patient education, home health nursing services and 24-hour on-call lines, which help physicians improve the patients’ care. Family physicians need to find out how to take advantage of those services. When these systems of care or any type of referral work well, everybody wins. The patients win because they get good care, the family doctors and cardiologists win because they learn from each other and provide coordinated, more effective care.