Wednesday, May 20, 2009

Nyuk, nyuk, nyuk.

One reason the Disease Management Care Blog likes to go to national meetings like the World Health Care Congress is because of the lunches. Yes, the chicken may taste like decolorized rubberized by-product and the dessert's fat content will induce an unending afternoon torpor, but that's the price of doing business if you want to make or renew old acquaintances.

Case in point? The 'we're not worthy' DMCB got to chat (again) with a very well-known academic physician from an even more well-known teaching hospital. She's not only published reams of peer review studies on the quality of healthcare, but she still sees patients as a primary care doctor. Like most of the DMCB's agreeable physician colleagues, she is extremely bright, has the scars that give her every right to be deeply cynical and has a scintillating sense of humor. Think nyuk-nyuk-nyuk laughter over anecdotes about despotic insurers, clueless administrators and mercenary specialist physicians between bites of big bowl Cesar salad and sips of watery iced tea.

And she doubts that her home institution primary care site's recent NCQA recognition as a patient centered medical home (PCMH) will ever lead to any measurable increase in her personal compensation or the availability of additional care resources for her clinic's patients. The DMCB believes her.

While primary care clinics within large multi-specialty care systems typically have revenues from insurers and expenses for salaries and other direct costs, the budgetary fact is that all they money they make typically goes to the institution. There are many reasons for that kind of arrangement: the institution provides the overhead, the physicians are salaried with a small amount of variable compensation and the centralized allocation of resources by a Chief Financial Officer can be more efficient. What's more, many primary care sites in large multispecialty practices are functionally 'loss leaders' that are kept around not only because they are a 'feeder' source of remunerative referrals, but because they also contribute to the larger mission - despite what Senator Grassley says - of their not-for-profit organizations.

Ironic, isn't it? The DMCB has doubts that smaller physician owned practices will want or even be able to achieve recognition as NCQA medical home. Yet, they are the ones that supposedly stand to gain the most from additional revenue if healthcare payment reform includes a care management fee that supplements collapsing primary care income. They eat what they kill. In the meantime, physician practices that are in the large not-for-profit multispecialty clinic-hospital systems will see their PCMH revenue continue to disappear upstairs while they make due with the same number of office assistants and a cost-of-living adjusted salary. If this plays out nationwide, there are big implications for the ability of the PCMH to turn primary care around.

She and her colleagues deserve a lot of credit for succeeding as an NCQA medical home. My mug-faced congratulations were interrupted by her Blackberry buzzing. It was an email from her boss that inviting her to the Open House and Grand Opening of a new tertiary care cardiac electrophysiology center. Nyuk, nyuk nyuk.

Coda: Another speaker at the Chronic Care and Prevention Congress pointed out that that there was a simultaneous meeting going on in an equally windowless room somewhere in the basement of the White House. That's where decisions were being made about billions of dollars for health care by individuals who have no experience in real patient care by real physicians. If that windowless basement room exists, the DMCB hopes - but doubts - they are talking to some of the its physician colleagues.

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