Professional Physician Organizations: A Continuing Necessary Ingredient for Ongoing Health Reform

This JAMA article on "Professional Organizations' Role in Supporting Physicians to Improve Value in Health Care" reminds readers that "organized medicine" continues to have an important role in national health reform.  The Population Health Blog agrees and adds that these doctor professional organizations have not only been underestimated recently, but will continue to be a force to be reckoned with - both a national and state level.

The article points out that groups like the American Medical Association (AMA) along with the various sister specialty physician organizations, along with health systems, practice associations and various non-governmental entities, are critical to the success of the Affordable Care Act.  These doc groups been long-time advocates for health reform, are still trusted by a significant number of providers, collectively represent a majority of docs and bring insights to a complicated health system.

And what are they doing to help with reform?  According to the authors, they've been serving as "conveners," helping to marshal resources, are creating standards and helping regulators.  While the JAMA article naturally mentions a number of national initiatives (such as Choosing Wisely), the PHB points out the same kind of important activity is occurring at the state level.  A good example can be found here.

Before some PHB readers tut-tut the faux importance of the AMA and its many national and local affiliates by having you believe that docs have transitioned their loyalty from their profession to their employers, the PHB would point to three sentinel events that say otherwise:

1. Even the White House believed that organized medicine was important enough that it sought to circumvent the influence of the AMA by fostering its own professional doctor group called "Doctors for America."  While it hasn't worked so well, imitation is the sincerest form of flattery.

2. The Patient Centered Primary Care Collaborative's Board of Directors has a significant number of members with deep roots in organized medicine.  It's testimony to a vital constituency on which the success of the Patient Centered Medical Home depends.

3. While tort reform has been outside the scope of this blog, an important ballot initiative dealing with California's benchmark Medical Injury Compensation Reform Act (MICRA) will be put before the state's voters this fall.  The lead organization of an impressive coalition of labor, business and consumer groups that has been created to defeat the proposition and preserve MICRA is, you guessed it, a state medical association.

The lesson for population health providers?  Reach out to and work with the physician groups at all levels of reforming the system.

State Medical Societies: Obamacare's Early Warning System

A canary for the health care reform mine

The Disease Management Care Blog has a theory.

Whatever you think of health care reform, there is a possibility that its implementation could be troubled for years to come.  Too few healthy young people could sign up, provoking an upward insurance cost spiral.  Bureaucratic meddling could further increase administrative burdens. Washington DC's political and fiscal woes could erode fee schedules.  Large regional delivery systems, saddled by inefficient capital, workforce salary inflation and overly optimistic risk contracting could become stressed.  The medical-industrial complex's bubble won't necessarily burst, but increased demand and less money could mean a painful contraction.

What will be the first signal that that's happening?

It won't be the pronouncements from the intelligentsia running HHS. It won't be a late Friday press release from the White House. It won't be a breaking news report from the clueless reporters in any of the major media outlets.  And, unfortunately, it won't be in a prescient posting by the DMCB.

It'll be an uptick in physician membership in 50 state medical societies, followed by phone calls their affiliated professional liability insurance brokers.

The DMCB is talking about the state organizations that largely make up the base of the American Medical Association (AMA).  After seeing many of these organizations up close, the DMCB can assure readers that that is where the resemblance ends. Being much closer to the ground level of clinical practice, these entities are acutely aware of the decline in private practice. Many have watched their membership - and their income - go down as the result of docs joining salaried settings where membership dues are a cost and meetings are time away from patient care. As a result of their hunger for business, the state societies have responded in part by making their suite of member services more turn-key and easy to use than ever before.  They have to do that to hold onto their current membership.   

Fast forward the possible bleak future described above. The most expensive part of a hospital system's work force will no longer look quite so affordable.  Some physicians will have their contracts euphemistically non-renewed, while others will be beat up by less "fixed" and more "performance-based" variable salary arrangements.  Since its reasonable to assume that the health reform's malaise will be nationwide, it's unlikely that these disgruntled docs will be able to simply pull up stakes and get hired in some other comfortably suburban setting in the next county or next state.

They'll think about private practice.

They'll wonder if they can start their own businesses, negotiate their own insurance contracts and do so with less overhead and without being told what to do by clueless administrators.  They'll be wondering about finding a practice manager who knows about coding and billing. They'll think about about cutting out the insurer middleman with a cash-only option. They'll think about dropping of out Medicare. And they'll realize that they will probably need to buy "malpractice" insurance and want a quote.

There are many good companies that offer support services to physician-owned practices. They'll get phone calls too, but not like the state organizations. They'll be the first to know.

They'll be the canary in the mine.

And in case you think the DMCB is being a pessimistic weenie, consider this anecdote: decades ago, physician staff unhappiness with one health system's managed care contracting led a renegade group of docs to call a state medical society for help.  The society obliged and participated in a series of after-hours presentations on physician practice that was attended by almost a third of the staff physicians. The young physician DMCB was in the back of that room.

If the DMCB was in the Obama White House, it would advise that it assign one of its health policy interns to regularly call the execs of a number of state medical societies.  If they describe sharp upticks in membership, that'll be cause for concern.

Image from Wikipedia

The Death of Private Practice?

Private practice faces the future?

Quick: if you were asked how many practicing physicians have bailed out of private practice and have become employees of large corporations, regional hospitals, accountable care organizations or multi-site clinic groups, would you say.... a majority?  A huge majority?

You'd be wrong.  Most mainstream media reports on the decline of private practice either project the rise of large medical groups or have (shockingly) engaged in anecdotes. In other words, a killer version of the flu is not going to kill millions anytime soon, global warming is not going to result in the sea flooding of central Pennsylvania (at least not tomorrow) and private practice is not dead.

So says this report by the American Medical Association. Using the Physician Practice Benchmark Survey on a representative sample of physicians doing hands-on care more than 20 hours a week, 53.2% of respondents were full or part owners of their practices, while 41.8% described themselves as employed.  Compared to a similar survey in 2007/2008, the number of owners declined by 8%

Surgical specialists (a high of 71.9%) were more likely than adult primary care (50% to 56%) to be owners.  Approximately 60% of physicians work in groups of ten or less and about 18% of physicians are in solo practice. 

Only 23% of physicians were in practices that were partially or wholly owned by hospitals.

While this information isn't all that surprising to DMCB readers, it does point to a slow gradual decline in small physician-owned groups.  That decline, however:

1. does not point to a nation-wide collapse of private practices, which still remain the largest piece of the physician-cased care system, and

2. does not line up a bunch of points that inexorably lead to zero.  In other words, it's just as possible that the slow decline could accelerate or remain the same or level off.

3. does point how important it will be for policymakers, regulators and politicians to consider the well being of small physician groups when they concoct their proclamations on such things as electronic records (very capital intensive), payment reforms (can hurt small business cash flows) or fraud and abuse (audits can bully small practices).

4. is potentially questionable because, once again, the DMCB has to contend with a report that hasn't gone through independent third party review.  It hopes that some or all of the data is eventually reported in a reputable journal.

Coda:

Just in case you're like most smart DMCB readers and want to know the methodologic details: This survey sample came from the 155,000 users of "Epocrates" who use the app to access information about medications; according to the AMA, this pool of physicians appeared to be quite similar to the more than 600,000 physicians who are in the AMA Masterfile. 14,750 Epocrates physicians were asked to participate in the survey and the response rate was 28%.  The responses were "statistically weighted" to match the Masterfile.

Image from Wikipedia

The American Medical Association Recognizes Shared Decision Making

Readers of the Disease Management Care Blog may be surprised to learn that the American Medical Association "recognizes" shared decision making.  A document recommending precisely that is available for your reading pleasure here.

It's a good review of the topic and makes for interesting reading. While the DMCB knew that the term "shared decision making" was specifically mentioned in the Affordable Care Act, it didn't know that there was an group called the International Patient Decision Aids Standards (IPDAS) Collaboration that is developing and piloting standards.  It also didn't know that there is an academic entity in Canada called the Ottawa Health Research Institute (OHRI) that is devoted to research on the topic.  The one area in which the Americans seem to still be leading, however, is commercializing the concept.

The AMA also recognizes that shared decision making can make the physician-patient relationship stronger, opposes any effort to link it to insurance coverage and supports more pilot programs.

This makes the DMCB happy to be an AMA member.

How Can the AMA Wield Such Power in Health Reform? The DMCB Explains

There they go again. Tossing a monkey into the wrench of Senator Reid's fragile health reform compromise, the American Medical Association has come out against the Medicare buy-in plan for persons age 55 to 64 years. While physicians, hospitals and insurers dislike the economics, the AMA has stressed that it's Medicare budgetary woes that are the real problem. Things are on hold until the Congressional Budget Office 'scores' this latest scheme.

Let the games continue.

But who IS this AMA and how can an organization with a membership that is only a fraction of all U.S physicians wield such clout? There are other physician groups out there, there is no shortage of docs that vociferously oppose the AMA's positions and some of them have the President's ear. Yet, when the AMA rises in oppotion to the motion, Presidents, Legislators and the media still pause and listen.

The Disease Management Care Blog explains.

1) Despite having a membership that comprises only minority of physicians, it is still the nation's largest physician organization.

2) While there are sufficient numbers of docs to fill a Rose Garden for the cameras or create impressive web sites, the AMA argues that it also represents the silent majority of politically inactive and non-dues paying physicians who don't belong to any advocacy group. They may have a point.

3) While many physicians are members of 'other' professional specialty-based organizations, a huge number of those organizations participate in the AMA. The AMA has been referred to as the House of Medicine for a good reason.

4) Despite attempts of some hostile media to convince folks otherwise, the 'AMA' has a recognizable advocacy 'brand.' It makes no difference if, as many allege, that the association is slowly losing it's grip on the physicians' conscience, the public believes it still has it. The President's political calculus recognizes that. By the way, so does the AMA - and they just might.

5) You may call it lobbying, but the AMA has an impressive policy infrastructure that has been long relied on Inside The Beltway for its expertise. Their insider access is not a function of money or lobbyists but history, relationships and insights.

6) JAMA, a premier peer review journal that is must reading for any physician. 'Nuff said.

The DMCB is a proud member of the AMA. While it may not agree with all of the House of Medicine's positions, it thinks it has a greater voice by being a dues paying participant. It immodestly believes the AMA is better off for it.

Medicare Fee Schedule Cuts, Private Fee For Service, the AMA and Hand Gestures

The Disease Management Care Blog thought Karen Ignagni had cornered the hand gesture market. Ms. Ignagni’s classic two-handed chops, sweeps and grabs in her speeches not only help emphasize her points, but remind the DMCB of a martial artist's kata. Observe Ms. Ignagni’s interview here (once the initial question is over) and this classic kung-fu exercise and see if you can tell the difference.

Well stand back, because Nancy Nielsen, MD, President of the AMA has her own repertoire of jabs, pokes and pushes that accentuate her organization's considerable annoyance at the U.S. Senate’s recent failure to cancel a scheduled 10.6% fee schedule cut by transferring the necessary funding from the private fee for service (PFFS) Medicare plans. Dr. Nielsen and Ms. Ignagni obviously stand on opposite sides on this issue, and the DMCB recommends someone get these two experts together not only for what would be a hugely educational discussion but for an equally entertaining hand gesture smack-down.

Want to learn more about this Republican-Democrat health care kerfuffle? In the opinion of the DMCB, the best summary can be found here at the Health Affairs blog site.

But the DMCB wanted to learn more about hand gestures. This is an excellent article from Scientific American that explains speech and hand gestures are hard wired together in humans. For example, babies who have not yet learned to speak use gestures, while persons with damage to the brain’s ‘speech centers’ lose their ability to interpret gestures. In addition, humans (and primates) are vicariously endowed with ‘mirror neurons’ that are not only activated when we perform a movement but when we observe another person performing the same movement. Numerous studies that have shown speech plus gestures results in far better communication than speech alone.

In fact, this hand-speech connection may be so hardwired, that having your mouth say one thing and your hands do another can be a telling clue to an audience that something is amiss. Unsurprisingly, the best medium for observing this mismatch can be found in politics. Not getting this right can make all the difference in a contender’s career, which is why considerable time and effort may be needed to tie a speech and the movements ‘naturally’ together.

In the meantime, the DMCB has trouble understanding what the Medicare physician fee schedule has to with Medicare PFFS. It has to admit, however, that tying them together and forcing the PFFS supporters to vote ‘against physicians’ was a stroke of partisan genius. Too bad it’s also another example of the manipulative gamesmanship that can get in the way of real health care reform. To the folks in Congress, here’s a gesture from the DMCB to all of you.