Medicare's Comprehensive Primary Care Initiative - A Two Year Report

After all the buzz (for example) around the coming launch of CMS' Comprehensive Primary Care "Plus" program,  the New England Journal of Medicine (or NEJM) just published a "special article" on the original Comprehensive Primary Care (CPC) initiative.

This is important if you think CMS' approach to supporting primary care is the fix for what ails the U.S. health care system.

Population Health Blog readers may recall that two years ago, CMS launched CPC. This is a still ongoing four-year multi-payer study to determine whether primary care that is "turbocharged" with medical home-style capabilities (see here, here and here - see page 8) would increase quality and lower health care costs. 

The term "multi-payer" is important, because CMS recognized that clinics struggled with providing medical home care to some, but not all, patients on the basis of their insurance.  Better to have one standard of care to all patients.

The NEJM article is an analysis of CPC's results after two years. 

To summarize how CPC was set up, 502 clinics (from 978 applicants) across 8 states participated along with a total of 39 other insurers.  In addition to the usual fee schedules, the Medicare and the other insurers paid a per patient severity-based "care management fee" that, on average, ranged from $8 to $40 per beneficiary per month (PBPM). Practices were also promised an additional bonus if, after two years, they reduced health care costs (i.e., shared savings) and improved various quality measures and performed well in surveys about the patients' experience of care.

These CPC practices' outcomes were compared to a propensity matched group of non-participating practices with a similar electronic health record (EHR) infrastructure that cared for a set of patients with similar levels of disease and baseline costs. 30% of these practices had applied but were not accepted in the initiative. The total number of comparison practices was 908.

Results?  Not good.

Aft the end of two years, there was no statistically (p > .05) significant difference in the growth of health care costs between the CPC and control sites.  This was true whether just claims costs were examined (a negligible difference of $11 per patient per month favoring the CPC sites), or whether claims costs plus the additional fees were examined (a difference of $7 favoring the comparison sites).

When patient costs were examined by the burden of disease, there was no indication that more costly patients achieved any savings. 

CPC sites had a statistically significant reduction in outpatient office visits, but not in hospitalizations.

While the difference in claims expense failed to be statistically significant, the total additional fees collected by the participating sites amounted to a financially significant $389,000. This represented a 15% increase in their income. 

Was quality of care improved?

Patients with diabetes and a high burden of illness were more 3% more (p<.05) likely to receive the recommended follow-up measures to manage their disease. Otherwise, "the initiative did not have significant effects on the processes used as measures of the quality of care for the full sample."

Patient experience of care?

While surveys showed small increases in patient support, "there were no significant effects on other composite measures: ability of patients to obtain timely appointments, care, and information; how well providers communicate with patients; provider’s knowledge of care patient received from other providers; and overall rating of providers by patients."

Yikes. Ouch. Egads.

The authors correctly point out that CPC is a four year program and that it still may be too early to see the impact of the medical home turbocharging.  That was pointed out in the negative one year evaluation.  Maybe something will turn up at three or four years.

In addition, CMS has a lot of other value-based initiatives underway, which may have biased the results.  There may be a "ceiling effect" among the participating sites as well as the control sites, which were already working to reduce (for example) rehospitalizations or pursue the fee schedule modifiers.

It's also important to note that the impact on the other insurers' costs and patient quality was not reported.  It's possible that they saw a benefit.

The PHB's take?

1.  Many care management programs achieve claims reduction with savings (for example) within one to two years.  If CPC hasn't succeeded by now, it probably won't.  And if the just-announced CPC Plus is modelled after this, it's hard to see how that program will turn out any differently.

2. It is possible that, within all the statistical noise, there were some primary care sites with particularly robust approaches to care that did bend the cost curve.  CMS should seek these sites out and find out more about their secret sauce.  More on that in a future post.

2.  If CPC's approach to care is ultimately shown to not bend the curve, what's the problem? 

The PHB continues to believe that one size doesn't fit all and not all patients benefit from care management. Many patients, even those with chronic conditions are quite stable and need minimum attention; some patients are so sick that no intervention will keep them out of emergency rooms and hospitals. As pointed out here, as more and more patients are enrolled in care management, the return on investment can paradoxically go down. Better to focus on patients who are not only at risk, but have "impactable" condition profiles.

In addition, CPC is based on a 5 year-old model of care. Things have changed since then: modern population health brings many more resources to the table.  That not only includes in-depth analytics support (for example, to define those patients who are at greatest risk) but mHealth. For example, there is one innovative company (the PHB's Shameless Commerce Dept. over on the right side of your screen) that provides recently discharged patients with an app-enabled handheld configured to provide close follow-up.  And so on.

3. It may be that care management works best in a managed care setting.  CPC is a study of classic fee-fore-service Medicare beneficiaries with access to any participating Medicare provider. In Medicare managed care, the insurers and their providers have an even larger incentive to maximize quality and lower cost.  If that's the case, CMS - despite their commitment to innovation - may want to get out of the care management business, because they just don't know how to do it.

Are Primary Care Physicians (PCPs) Important to ACO Success? Payment Arrangements Say Otherwise

Long ago, the Population Health Blog learned that when it comes to health insurance, capitation or bundled payments brakes, while fee-for service payments are gas. Too many physician office visits?  Use "capitation" brakes. Want to increase physician visits?  Apply a payment for each encounter with some FFS gas. 

Health care organizations can pass this arrangement onto their physicians. They can pay them with a salary (a form of capitation), or a variable "productivity" compensation (seeing more patients is compensated with a form of FFS) or with a combination of both.
 
Simple, right?  To figure out this ying-yang of utilization management, just follow the money.

That's why the PHB was interested in this just-published Annals of Family Medicine paper on how primary care physicians are being paid by Accountable Care Organizations (ACOs). If you believe more primary care visits translate to savings in other parts of the ACO, then you'd want to apply gas. If you believe primary care visits are a cost that doesn't necessarily save money, you'd want to apply the brakes.

The authors used data from the 2012-2013 "National Survey of Physician Organizations" to compare primary care physician (PCP) compensation in ACOs with non-ACOs. 1,398 organizations were in the original database; after excluding solo practitioners and specialist physician organizations, 632 were left. 

Three groups were compared:

1) Medicare ACOs (21.1%) with exposure to some financial risk related to total health care utilization;

2) Non-ACOs (2.8%) with contracted financial risk for primary care costs (2.8%);

3) No ACO and no risk (76.1%).

Results?  PCPs in.....
Medicare ACOs got 49% of their income from a flat salary and 46% tied to productivity. 3.4% was tied to quality;
Non-ACOs at primary care risk got 66% of their compensation from salary, 32% tied to productivity and .8% from quality;

No ACO arrangements with no risk had compensation that was similar to the Medicare ACOs.

The PHB's take-aways?

Based on the non-ACOs, health care organizations are prepared to use salary to influence physician behavior.  If you believe PCP visits are a cost and you are at financial risk for utilization, apply more brakes than gas.  The model is still out there.

But......

The leaders running Medicare ACOs don't know what the right balance of FFS and capitation for PCPs, and are mirroring a status quo that is indistinguishable from business as usual.  Despite the fanfare about the critical role of primary care in health reform, the Medicare ACOs have decided otherwise. If they ultimately succeed or fail, it won't be because of any special innovation involving their PCPs' compensation.

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"Down Jobbing" to Primary Care Technicians?

Heard of "down-jobbing?"

Your PCT will see you now.....

The Disease Management Care Blog first became aware of the term years ago when it was pointed out that primary care docs can take on some specialty care responsibilities, while nurses can take on primary care roles, while office assistants can take on nursing roles. A parallel phenomenon is the movement of surgeries and other medical procedures from the inpatient to the outpatient surgi-center to the physician's office.

Naturally, the ultimate down-jobbing target is the patient. Examples include the reasonable innovation of self-service kiosks as well as emergency or wacky "self surgery."

Which naturally prompts the DMCB to offer it's own definition of down-jobbing: the historical movement of medical treatment from higher to lower levels or locations of health care services.

Of course, the major driver of down-jobbing is economics. DMCB readers are well aware of our national obsession with transitioning from "fee-for-service" (FFS) to more "value-based" reimbursement arrangements. These include pay-for-performance as well as shared-risk, global or other capitated approaches.

Since traditional FFS is notoriously linked to medical necessity as well as provider credentialing (examples are not hard to find), physicians have had little incentive to go along with down-jobbing. As FFS allegedly goes the way of the dinosaurs (a perspective likewise not hard to find), health care providers in these new value-based payment systems are looking for cost-effective ways to service their patients within a fixed budget or fixed payment system. One way to do that is to down-job.

So it was only a matter of time until someone thought of the option of "primary care technicians" ("PCTs") as a value-based and down-jobbed solution to the nation's physician shortage. As Kellermann et al point out in the November 2013 issue of Health Affairs, the pipeline for primary care docs, physician assistants, nurse practitioners is not only expensive, it's unlikely to meet future demand.  They argue that PCTs can be to primary care providers like emergency medical technicians (EMTs) are to emergency care rooms.  Like EMTs, PCT training to handle preventive care, treatment of minor illnesses and monitoring chronic conditions needn't be extensive. That's especially true if PCTs are armed with a health IT safety net that provides tablet-based decision-support algorithms that are ultimately tethered to (or teamed with?) a primary care physician.

So there you go: a few questions, a cursory exam and a recommended treatment plan for millions of healthcare hungry Americans is well within reach.  All it takes is some additional down-jobbing.

The DMCB thinks that, on paper, it's not a bad idea and no accident that it would appear in the academic health policy literature.  Whether this could gain any traction in the real world of patients remains to be seen.  Perhaps the next step is a randomized controlled clinical trial comparing the outcomes of patients seeing newly minted PCTs to those receiving usual care.

The DMCB has two additional concerns:

1. The promise of the expansion of access to health insurance under the current iteration of health reform was that patients would be able to access the current health care system, including doctors and hospitals.  Even if this system of primary care meet outcome expectations, this will hardly burnish American's ambivalent views of Obamacare.

2. Liability concerns are significant. Allegations of malpractice are inevitable with PCTs and their supervising docs will naturally worry about being ensnared in even more lawsuits by a very nimble plaintiffs' bar.

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Just Because You Build It They Won't Come: What ACOs, PCMHs and Population Health Advocates Need to Know About Poverty and Emergency Room Use

Thinking about an ER visit.....

As part of a research requirement that it had to fulfill prior to medical school graduation, the young Disease Management Care Blog conducted a patient satisfaction survey. To its surprise, the DMCB discovered patients cared less about high touch primary care and more about access to high tech specialists.

It naturally ignored the income implications and became a general internist.

Fast forward to its job as a Medical Director in a not-for-profit physician-led managed care insurance plan.  No matter how much we "polished" the primary care network, emergency room utilization remained persistently high.

The CEO naturally ignored the DMCB's conclusion that there was little that could be done and assigned another medical director to the task.

Fast forward to Uncle Sam's Healthcare Fantasy Land, where ACOs and medical homes caring for patients with universal insurance will, thanks to the enlightened efficiencies of primary care, save gazillions of dollars by steering patients away from emergency rooms and hospitals.

All three scenarios came together when the DMCB read some research by group of Philadelphia docs who wanted to better understand why patients with low socioeconomic status kept ending up in emergency rooms and hospitals.

Best of all, to do this, they used a novel methodology: they found some patients and.... asked!

Their report appears in the latest issue of Health Affairs.

64 hospitalized patients with low socioeconomic status were approached to participate in a "qualitative" research interview (here's one example of how it's done). The patients were selected because they had been hospitalized via the ER multiple times, were between the ages of 18-64 years, were uninsured or on Medicaid, lived in a poor ZIP-code region of the city. 24 said no, leaving 40 subjects who agreed to have their interviews recorded. A rigorous analysis followed, with two "coders" who listened to the recordings and independently developed themes or ideas. They then circled back to the patients for confirmation.

Two themes emerged:

1) Convenience/Access: Even if they have access to primary care, the emergency room and inpatient setting remains the more convenient option.  That's because walk-in is available 24/7 and all testing as well as specialty care is available during a one-time visit.  Zero dollar primary care co-pays don't make up for the hassle, time and expense of calling ahead for appointments, arranging transportation (even if vouchers through Medicaid are available) or being referred for separate testing as well as specialty consultation.

2) Technology: Based on personal experience with their primary care docs, the emergency rooms and hospitals were perceived to have more technically proficient providers who were better able to achieve the correct diagnosis and render the correct treatment in a timely fashion.

A subset of patients seemed to come from chaotic life circumstances. Those patients found hospitals offered what the researchers described as "respite" and social "support."

The presence of Medicaid insurance had little to do with the attitudes described above.

The DMCB's take:

While subjective qualitative research is viewed with disdain by researchers, policymakers and journal editors, occasionally, good studies like this comes along.  This article sheds important light on a potential Achilles heel of accountable care organizations (ACOs) as well as the patient centered medical home (PCMH).

That Achilles heel? Just because you build it, these 40 patients - and millions who live in poverty like them - won't come.

What's more, they are making rational decisions.

The authors point out that system solutions include co-locating multiple services (primary care, labs, x-rays and specialists), improving the quality of primary care and, when possible, mitigating any social challenges. The DMCB agrees, but is unaware of any ACOs or medical home initiatives that, outside of the usual process measures, specifically address these patients' special concerns.

The DMCB's suggestions:

Advocates for ACOs and the PCMH need to get real, lower expectations and recognize that a key solution to the problem of health care overutilization by persons in poverty is to stop politicians and health care leaders from medicalizing poverty. 

That being said, one possible solution for ACOs and PCMHs serving fragile patients with poverty is high intensity biopsychosocial intervention.  It sounds expensive but full time community-based care management with low case loads and lots of physician support may help ameliorate some of the dysfunction.  It's probably less expensive than all those hospitalizations.

Finally, this may be an opportunity for nimble population health management service providers.  If any are already out there serving this population, the DMCB would like to know about it.

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Three Models of Primary Care Teaming (TL, CC and ET): An Unexplored Feature of the Medical Home

What defines optimal outpatient primary care "teaming?"

The Disease Management Care Blog just assumed that if it took equal scoops of adaptable physicians, dedicated nurses and supportive culture and baked with a dollop of accountability, "teaming" would just.... happen.

It turns out that what may come out of that clinical practice oven is a lot more complicated than that. 

Which is why medical home advocates should pay attention to this article by George Washington University's Debra Goetz Goldberg and colleagues.  Interested in finding out more about primary care "teaming," they interviewed, reviewed and observed three different Virginia clinics that had embarked on transformative quality improvement programs.

Each clinic came up with a different version of "teaming":

1."Top of License" - nurses interviewed the patients, presented the problems to the docs and then documented the care plan.  They were also responsible for the patient education.  Thanks to using this model, the physicians almost doubled the number of patients they were seeing per day.

2. "Care Coordinator" - nurses focused on helping patients undergoing care "transitions" (typically out of the hospital) and provided self-management and health education to high-risk, high complexity patients.  Interestingly, unsatisfactory reimbursement levels forced the practice to cut back, but they still doubled mammography and blood pressure control rates among persons with diabetes mellitus.

3. "Enhanced Traditional" - the physicians still performed the bulk of the patient care but the researchers observed that the other clinic personnel benefited from increased trust, communication and hand-offs that translated into patient centered care, shared responsibility and heightened volunteerism.  The practice was unable to measure any outcomes.

"Very interesting!" says the DMCB. Authoritative web-sites like this or this and peer-reviewed articles like this refer to "teaming," but fail to precisely define it.  Assuming the three categories described by Goetz-Goldberg (in shorthand, "TL," "CC" and "ET") hold up in future studies, the DMCB looks forward to learning which approach results in the greatest quality or cost-savings.

Coda: As a reader bonus, the authors offer up a definition of "team-based care" that seems to span all three models and can be used for the DMCB readers' quoting pleasure:

"A group of diverse clinicians who participate in and communicate with each other regularly about the care of a defined group or panel of patients."

The Philosopher King Approach to Health Care Payment Reform: Commissions, Councils, Task Forces, Panels and Lawyers

Paying for it is a whole new kettle....

Now that the U.S. Supremes have confirmed the Affordable Care Act as the law of the land, the Next Big Step - as the Disease Management Care Blog predicted - is the move from insurance reform to payment reform. While it's politically easy to broaden entitlements to cover everyone, figuring out how to pay for it is a whole new kettle of financing fish.

In response, a who's who of Obamacaregineers are stepping up with their Phase II recommendations for payment reform.  While you ponder whether the DMCB summary below is enough or whether you need to follow the link for more detail, ask yourself what's missing......

1. Let public and private payers combine forces to "negotiate" payment rates that aim for global spending targets at a regional level.  Embedded costs for research, training and uncompensated care would be carved out and preserved separately.

 2. Use bundled payment methods for episodes of care that span rehab and post-discharge care, starting out with cardiology and orthopedics. Aim to make this payment approach the rule for 75% of Medicare's budget within 10 years.

3. Commoditize medical devices, lab tests and radiology services by forcing suppliers to competitively bid for Medicare's business.

4. Encourage tiered insurance products, where consumers can pick progressively lower premiums in exchange for higher out of pocket costs.

5. Leverage state exchanges to ratchet down costs on pain of being "delisted" by forcing them to compete on cost and quality.

6. Simplify administrative costs by establishing a single format for all paper and electronic forms. The latter is the default unless the consumer opts for paper.

7. Make the pricing for medical services public and outlaw gag clauses.

8. Allow non-physicians to take advantage of scope-of-practice  laws to practice medicine autonomously.

9. Close the provider self-referral loopholes that allow docs to provide "in house ancillary services," unless its under a global cap.

10 Start all the above with the Federal Employees Health Benefits Program (FEHBP).

11. Use the "safe harbor" of practice guidelines to protect docs against allegations of medical malpractice.

What's missing is the usual emphasis on primary care and, in particular, the patient centered medical home.  While it could be argued that global targets and bundled payment methodologies will drive the inclusion of higher value/lower cost non-specialists, the DMCB is shocked, shocked that the experts and editors missed usual nod to primary care.

The DMCB will also point out that the proposal is rich in expert councils (to set spending targets), programs (as in Medicare Acute Care Episode to define the bundling), panels (for the competitive bidding and guidelines) task forces (for the administrative simplification), commissioners (to assure transparency) and, last but not least lawyers (expanding Stark to ban self-referral).  Plato, the champion of Philosopher Kings, would be proud. 

In the meantime, Ayn Rand is rolling in her grave.

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Putting the Doctor-Patient Relationship Into Perspective

Years ago, the Disease Management Care Blog had a pediatrician colleague who was widely admired for his diagnostic acumen, attention to treatment detail and personalized attention. As further testimony to his reputation, every physician wanted him to be their childrens' doctor. The DMCB was one of those lucky docs. The luck ran out, however, when the DMCB's spouse quickly realized that she couldn't get any appointments and even if she did, the physician's clinic routinely ran two hours late.

Persons who read this New England Journal Perspective testimonial on the joy and frustrations of a primary care career should keep that physician in mind.   That reality contrasts with Dr. Finegold's fantasy world of dedicated physicians with limitless time where 1) the personal physician individually guides complex patients through a complex health care system and 2) the doctor patient relationship is fountainhead of professional satisfaction and patient well being. That's why insurers should pay anything and policymakers should do everything they can to support this vision.

The DMCB sadly disagrees.

Primary care physicians are a precious resource. They're not only expensive, they are becoming more rare over time. As a result, use of their time and effort has to be restricted to circumstances when there is no one else who can deal with the paper work, make medication adjustments, work to increase treatment compliance, maximize the insurance benefit, deal with the social issues and provide psychological support. The DMCB thinks there are non-physician professionals who are better at these activities and do can do it far more cheaply. The solution is not more primary care physicians but more primary care physician support.

The DMCB physician colleagues may argue that the doctor-patient relationship is truly Holy Ground. Unfortunately, it is becoming increasingly apparent that there at too many patients and too few physicians to allow Dr. Finegold's indulgence of being so immersed in their patients' lives. The degree of personalized involvement described in this article may be a luxury - like open access to brand drugs, the latest technologies, the priciest specialists or a few extra days in the hospital - that society can no longer afford.

Why Traditional Physicians Will Trump Walmart's Primary Care Service Offering

A big box with plenty of
room for primary care?

Several years ago, while the Disease Management Care Blog was supervising a medical resident clinic  (an example of how they work can be found here), an elderly patient came in for an appointment.  According to the resident, Mr. Jones (not his real name) would unexpectedly lose consciousness while walking. He also complained of feeling shaky and unsteady on his feet.  Prior to entering the clinic room to see Mr. Jones, the DMCB already suspected the patient had Shy-Drager Syndrome.  One look at the his staring and unblinking face confirmed it, all in the space of about five seconds.

Which is why the physician DMCB confidently thinks its profession ultimately has little to fear from Walmart's apparent interest in establishing a national network of primary care clinics in its big box stores. 

Careful scrutiny of the Walmart Request For Information (RFI) reveals that potential partner companies are welcome to showcase their health care "solutions," "applications" and "offerings" that are "convenient, accessible, affordable, consistent, scalable and integrated."  Walmart wants these companies to leverage its retail and multi-channel clout to to reduce costs and increase access while maintaining or improving outcomes in clinical care, diagnostic services, prevention and wellness. Care services can include a host of general medical services, management of chronic as well as acute conditions, laboratory testing and "other."  Ownership, financial arrangements, data sharing, integration, technology, logistics, back office functions and the level of customization are negotiable.  To be taken seriously by Walmart, candidate companies need to have a track record of success at a national level, a credible leadership team, a business plan, timeline, access to secondary partners as necessary and familiarity with quality assurance.  There is an notable absence of any reference to the "medical home."

While the similarity of "Big Box medicine" to retail clinics could be criticized at many levels, the DMCB has heard two two major concerns from its colleagues about Walmart:

1) Walmart and the like will further "Balkanize" the system, leading to more, not less, fragmentation and

2) it will commoditize health care, leading to narrow and regimented treatment protocols that don't take the "big picture" into account.

The DMCB disagrees with the first assertion because Walmart's RFI seems to envision a highly integrated system backed up by informatics, connectivity and quality metrics that - on paper - should lead to more coordination not less.  That's good.

Yet, the DMCB thinks that there may be something to the second  assertion. It is Walmart's style to relentlessly attack costs at every part of its service cycle and the company probably believes the strategy can be applied to health care.  If that's Walmart's intention, it'll almost certainly choose a vendor that industrializes guidelines like this in a one size-fits all "protocolized" fashion all the time every time.

That's not necessarily bad, but that means there'll be little room for the kind of smart heuristics that helped the DMCB get to a quick diagnosis.  The DMCB doesn't deny being "smart," but the the point is that the best primary care intelligently combines guidelines and heuristics.  The DMCB's physician colleagues have that special skill.  Thanks to competition from Walmart (and retail clinics), they'll hone that expertise and respond with a higher, more efficient and better quality standard of care for many patients for a long time to come.

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No Correlation Between Physician Supply and Patient Perception of Quality and Access (including primary care)

The Disease Management Care Blog suspects that a large fraction of its many regular readers work in or with medical settings. On the other side of that door, in the floor above or below you, in the building across the street or at the other end of that phone call, there are patients and doctors doing... well, the doctor-patient... thing. Since the patients and doctors use this "thing" a lot , patients would suffer if it wasn't there, right? If the hospital, or clinic, or system or or network closed its doors, disappeared or was swallowed up by the earth, dissatisfaction, illness, death and other consternation would follow, right?

Well, maybe not. At least, if you asked the patients. That's exactly what David Nyweide (of CMS), Denise Anthony, Chiang-Hua Chang and David Goodman (all of Dartmouth) did. 4,000 randomly selected, nationally representative, elderly and independently living Medicare beneficiaries were surveyed with 12 questions about access to and satisfaction with health care. Those data were correlated with the physician supply in their Medicare-defined "hospital service area" (the DMCB learned there are 3,067 of them). The physician supply in each service area was based on the data from the AMA Physician Masterfile.

2,515 completed the survey with a respectable response rate of 65%. After adjusting for age, gender, race, health status and local income (based on outside data sorted by zip code), there was no association between the local density of physicians and patient perceptions of access, being able to get a test, being able to see a specialist, being satisfied with their care, feeling that they had enough time to talk to the doctor or having a primary care provider. There was also no association between the local supply of primary care and local perceptions of care. There was only a weak association between the local supply of primary care physicians and having one.

The study is limited by being "observational" and only reporting associations. In order to better understand if more primary care causes a change in Medicare beneficiary perceptions, a prospective trail would be required. The study is also silent on the local quality of primary care, access to other health professionals, the limitations of sorting physician supply based on service area (versus more granular counties or zip codes) and the lack of input from managed care Medicare. Last but not least, there may be an association between the local supply of primary care and "hard" measures of health care quality, versus this study that used consumer perceptions.

Despite the limitations, the study should give pause to policymakers, regulators and politicians who think that increasing the physician supply or increasing the primary care physician supply is going to make a difference in voter-beneficiary-patient attitudes about local access or quality of care. It turns out that physician demand vs. supply may be more elastic than anyone considered. This should make persons wonder if pumping more physicians into a community is the "solution" we think it is.

And the DMCB asks why stop there? The NCQA and NQF should take note. Local hospitals argue that they and their physicians' social mission warrants not-for-profit status and being exempt from local taxes. Perhaps one gauge of how well that mission is being fulfilled should be perceptions of access and quality versus a national norm or a historical baseline. Since "Accountable Care Organizations" will be responsible for cost as well as quality, perhaps consumer perceptions like this should be part of the yet-to-be-defined measurement mix. Last but not least, perhaps all those suspect "Top One Hundred" surveys should consider using a variation of this.

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The Yellow Cake of Passing a Health Reform Bill

Knowing that the facts on the ground didn’t support its ideology, the Administration resorted to a sordid mix of selective disclosures, dissembling, outright spin and occasional bullying. Career analysts were ignored. What was left of the truth was stretched. The lazy media were rolled. A preconceived plot, engineered to support a dangerous dogma and short-term political gain, swamped a craven political opposition. The entire stinky premise was accepted hook line and sinker by a gullible public. When things didn’t quite work out as planned, it's only then that critics emerged to use hindsight to connect the dots. Administration excuses notwithstanding, there were serious allegations that the American people had been lied to.

The invasion of Iraq, you ask?

Off topic, says the Disease Management Care Blog. Yet, the DMCB wonders if a similar scenario could be unfolding for Mr. Obama and his fellow Democrats over the health reform legislation. Unbiased and informed observers have long been legitimately skeptical of the intellectual underpinnings of the Affordable Care Act. They doubted that it would simultaneously bend the cost curve, increase quality, expand coverage and rationalize health care. After-the-fact contrary information (for example, here, here and here) has begun to pop up faster than MSNBC's evening broadcasting of unflattering pictures of Tea Party candidates. As for the bullying, you be the judge.

And now, the Dartmouth Atlas - the Bible of the Beltway, those Groupies of GeoMapping, the Mavens of Medicare, the Prophets of Physician Behavior, the Oracles of Obamacare, the Viziers of Variation and those Diviners for the Democrats - has come out with another inconvenient healthcare truth: that the local availability of primary care may have little relationship with local health care quality.

Using their considerable expertise in navigating Medicare’s fee for service (FFS) data sets, the folks at the Dartmouth Atlas (DA) examined enrollment (including race) and medical claims data to look at the the relationship between primary care office availability and visits versus quality of care for diabetes and the incidence of limb amputations. The DA researchers geographically split the country up according to over 3400 “hospital service areas” (HSAs) (defined by how patients travel for inpatient care) from 2003 to 2007. Based on the utterances from the Administration, you'd think that HSAs with a lot of primary care providers would have many primary care office visits which in turn would lead to better health care. Right?

What was found was that about 78% of Medicare beneficiaries in the various HSAs typically see a PCP at least once a year with a range that extends from 60% (the Bronx HSA) to 90% (in a South Carolina HSA). Blacks were less likely to have a visit than whites (70% vs. 78%). There was, however, very little relationship between the HSA area supply of primary care physicians and the likelihood of a beneficiary having at least one visit (though the relationship was slightly stronger when analyzed by family physicians vs. other types of primary care). What’s more, there was also little correlation between having one primary care encounter and subsequently having a high number of primary care claims.

At a greater level of detail, however, there was only a modest correlation between having had at least one primary care visit and mammogram and A1c diabetes testing. This didn’t hold up at all for other types of diabetes testing (for example, eye examinations), getting a leg amputation (something that could be prevented if diabetes or atherosclerosis was aggressively treated) or being hospitalized for a bucket of “ambulatory care sensitive conditions.”

Expansion of primary care has been a linchpin of health reform, leading to programs like this. While there are other studies (like this) that show there may be an association between primary care and quality, this negative report from the highly regarded DA isn't helping the Obama Administration regain any momentum in the political rearguard defense of health reform. The DMCB, based on plenty of studies, has always doubted the primary care yellowcake of the Administration's case for the ACA - not because there may or may not be an association, but because it's never been clear that the importation of primary care into areas of high utilization would do any good. The DA study makes things even worse.

Mr. Obama summed things up best at his Sept 10 news conference:

"Bending the cost curve on health care is hard to do."

No kidding. While that may either be a) a new administration insight or b) an excuse for not finding any weapons of mass cost containment, the DMCB worries that the recognition of just how hard it is was known prior to March 23. If that's the case, why wasn't that shared during its pre-passage war planning? Was it because they had already decided to pass a bill no matter what and at any price, using any means necessary? Has this become the standard approach of the political class of both parties?

The Risk of a Physician Boycott of Medicare, Congress' Duty, Enterprise Risk Management & What MedPAC Should Do

The Disease Management Care Blog thinks of Medicare as a large health insurance company overseen by a Board of Directors that just also happens to be called "Congress." As a Board, Congress' job is to provide oversight, including approving the benefit, premium levels and the provider fee schedules. Like other Boards, it's also supposed to be ultimately responsible for the appointment of executive leadership. Last but not least, it should engage in "enterprise risk management" (ERM). More on this later.

Medicare's "Board" has struggled with the cumulative costs of repeatedly delaying the Sustainable Growth Rate (SGR) reductions for the Part B fee schedule. A perfect storm of election year politics, deficit spending concerns and partisan brinkmanship has led to another "temporary fix" of the scheduled 21% cut. The day of reckoning has been pushed back to November 30, 2010. While grumpy organized physician organizations are publicly concerned about the SGR's impact on patient "access" and "choice," the real threat is that many physicians who currently accept Medicare will "go Texan" and boycott the Medicare if the SGR goes through.

Should Medicare's "Board" be concerned?

As the American College of Physician's* (ACP) Advocate Blog's Bob Doherty points out, physicians have been repeatedly warning for years that Medicare's payment rates are unsatisfactory. In the meantime, the Medicare Payment Advisory Commission (MedPAC), which uses surveys of Medicare beneficiaries to gauge whether physicians really really mean it, remains unmoved. According to MedPAC's data, the vast majority of Medicare beneficiaries still have adequate access and most docs still accept Medicare. Liberal pundits, such as Maggie Mahar, think that threat of a physician boycott is an "overblown" paper tiger unsupported by facts on the ground involving real docs, like hospitalists, cardiologists and geriatricians.

Yet, the ACP's Bob Doherty wonders if things could be different this time. His anecdotal conversations with docs makes him think that substantial - if unquantifiable - numbers of physicians are really thinking about dropping out of Medicare.

Which brings the DMCB back to the topic of "ERM." This is defined as the systematic and objective quantification of all significant risks to a business. ERM typically includes identifying what risks exist, their individual likelihood, their potential magnitude, strategies for their mitigation and assessing progress in keeping them at bay.

Congress' Medicare ERM issues are multiple and include the growing number of baby boomer beneficiaries, their considerable appetite for pricey technology, looming government debt and the involvement of sophisticated organized crime networks in Medicare fraud. But one important risk that continues to languish is the SGR and the potential for a physician backlash.

The DMCB thinks Medicare's Board, i.e., Congress should perform its fiduciary duty and use ERM to carefully examine the issues raised by Mr. Doherty.

What is the risk of a physician boycott?

While the prospect of a wholesale nationwide exodus of physicians from Medicare participation is still small, it is not zero and, given Mr. Doherty's credible suspicions, the risk is growing. The risk is probably greater among the smaller physician owned practices with access to alternate sources of patient care income. It's likely to first show up in refusals to accept new Medicare patients. It'll occur regionally (Texas may be a good example) and vary by practice specialty. The risk is highest among the "cognitive" physicians who a) can't make up for lost revenue with additional patient volume, and b) are dealing with payment rates that have been widely regarded as inadequate.

What is the potential magnitude?

There are two dimensions: operational and political.

It's operationally moderate because of two factors:

1) the relationship between the threat of an SGR reduction and a physician boycott is not linear. While current physician Medicare non-participation rates are low, reaction to inadequate payment rates could quickly cascade under a classic self-reinforcing phenomenon. This is discussed by the DMCB in greater detail here,

and

2) the interplay between spotty regional access issues and other parts of the health care system - even if access is maintained - could lead to further stressors. While low numbers of Medicare beneficiaries per primary site may not be able to receive primary care, the phenomenon at a regional level across multiple sites could easily lead to delays in care, emergency room crowding and spikes in avoidable hospitalizations.

It's politically high because even spotty regional access problems could be spotlighted by the news media and used by opponents of health care reform to further gum up the President's agenda.

How can it be mitigated?

It's going to take either a) finding new money or b) moving money from other sources. That's the topic for another DMCB post but two additional points should be made:

1) thinking that "savings" from efficiencies, prevention, wellness or the electronic medical record, medical home and accountable care organizations demos and pilots will solve the SGR is fanciful thinking. Don't even bring it up, because the doctor-audience won't believe you. They're too smart.

2) Just the threat - real or not - of an SGR reduction is undoubtedly causing physicians to plan for the possibility of a boycott. Accordingly, "the SGR" needs to be removed from the public spotlight and replaced by a credible signal that Congress and the Administration are taking Medicare payment rates seriously.

How should progress be measured?

In addition to regularly reading the ACP and DMCB blogs (and being skeptical about the can-do-no-wrong loyalty of liberal media sycophants), MedPAC should reinvigorate its reports (like this one that said no problem) and reexamine access from the perspective of ERM with special attention to specialty, region, practice size, non-linearity and worse case scenarios.

The Federal government failed to adequately assess the environmental risks of deep water oil drilling and the systemic financial risks from the easy money and housing bubble. It's not unreasonable to ask if MedPAC is on the verge of committing the same mistake in a key part of healthcare policy.

(Addendum: Interested in this debate? There's more here)

*an organized physician group that represents internists, who focus on prevention, diagnosis, and treatment of adult diseases. The DMCB not only a proud member of the AMA, it is an internist and an ACP Fellow.

More on the (Non)Death of Small Independent Physician-Owned Primary Care Practices

Somewhere in the Obama Administration, there is an elitist central cabal that operates with the support of the highest organs of our central government. It conspires in windowless basement rooms to plot the gun control, mass vaccinations and the nationalization of key U.S. economic sectors like automobile and chardonnay manufacturing.

Healthcare, however, is its maximum target. Much like pieces on a chess board, and with the support of renegade organizations like the Commonwealth Fund, the New England Journal and UNICEF, it wants to arrange hospitals and providers into regional klepto/monopolies that coordinate care, deprive us of access to breathing as well as dialysis machines and suck up tax dollars faster than Ms. Pelosi can say "but we're saving money!"

Just kidding, but it does seem to the Disease Management Care Blog that a lot is riding on the concept of large, regional and risk-bearing "accountable care organizations" (ACOs) that can reconcile cost and quality. And don't think that there isn't a hospital CEO, academic medical center Board or a medical school Dean that isn't lusting over the prospect expanding and consolidating their local empires under the guise of Obamacare and enlightened not-for-profit community service. Ask these healthcare potentates, and they'll tell you that this is the wave of the future, where size, access to capital and rationalized central planning will finally break the back of health care inflation and those evil insurers. It's Wal-Mart, it's Amazon, it's the electronic record, it's inevitable, right?

It's easy to think that is the conspiratorial purpose of the Central Committee's minions when it comes to small independent PCP clinics. And thanks to the travails of managed care, Medicare's SGR, competition over Botox parties, poaching of patients by Convenience Clinics and dismay over Concierge Practices, what's left of primary care is ready to be swept up into ACOs, right?

Maybe not so fast, according to an article appearing in the July 3 issue of The Economist. Dubbed "The Click and the Dead," it describes the double whammy of transparent E-Commerce pricing and economies of scale that slaughtered smaller book stores and travel agencies. However, it turns out that the very smallest book and travel shops with low numbers of employees, lean overhead and special service niches thrived despite the fierce competition from the Internet and big business.

Which is why the DMCB thinks some primary care practices will consolidate and many will become aligned with bigger health care systems. However, a considerable percent that remain small, minimize costs and, most of all, provide high customer value (defined as a combination of service and quality) could continue to thrive.

The DMCB has opined before about reports of the death of small practices being an exaggeration. Maybe it's wishful thinking, but this article in The Economist is another reason to keep an open mind.

Picture from Wikipedia

The Busywork Burden of Primary Care Physicians: A Review and What Population-Based Care Management Organizations Already Know

Everyone knows primary care physicians are a legitmately grumpy and depressed lot, but does it really come down to being overworked and not being paid well compared to their specialist colleagues? To get some better insight about what's really going on, check out the April 29 New England Journal article by primary care internist Richard Baron titled "What's Keeping Us So Busy in Primary Care? A Snap Shot from One Practice." The entire manuscript is available on line gratis. There's also this report in The New York Times with some additional interview tidbits.

Using an electronic record's patient encounter database from a five person community-based Philadelphia practice called Greenhouse Internists, Dr. Baron looked at how a typical doc's day gets filled:

24 patient phone calls per physician per day, with 80% of them handled personally and mostly involving medical advice, dealing with insurance issues or talking to other docs about patients.

17 emails per physician per day, mostly dealing with test results or patient inquiries.

12 prescription refills per physician per day outside of a face-to-face patient encounter.

20 lab reports per physician per day. If any are abnormal, they'd need to be attended to, often the same day.

11 imaging reports per patient per day.

14 outside physician consultation letters or notes per physician per day. If there are recommendations, they'd also need to be attended to.

By the DMCB's count, that's 98 paperwork events per day. Even if each took one to two minutes to accomplish (and it doesn't) that's about three hours that are not involved in patient care. It's also important to note that Greenhouse Internists is not a struggling physician-owned practice saddled with poor management. They have Level 3 NCQA PCC-PCMH recognition and are the smart guys behind this insightful 2005 Annals article Electronic Health Records: Just around the Corner? Or over the Cliff?

This snapshot is quite credible and the DMCB suspects most community-based primary care physicians will readily identify with the numbers described above.

What does this tell us?

Quality, Not Quantity: The actual paperwork is not necessarily mentally or physically taxing and the DMCB suspects Greenhouse has money coming in. Rather, it's the mismatch between professional work expectations and the reality of modern practice management. The DMCB can't blame docs for seeking alternatives outside of primary care and doubts more money alone is the answer

Don't Drink the Kool-Aid: While astonishingly disconnected utopians continue to promise that the electronic record and the patient centered medical home (see here and here) will fix all that ails primary care, note that Greenhouse already have both and still have to funnel busy work to the docs. Despite The Time's interview with the author saluting both the EHR and the PCMH, the DMCB notes that the workload described above was happening despite the EHR and PCMH.

Now You Know Why: Care management organizations, quality assurance mavens, non-physician administrators, managed care executives, pharmacy benefit managers, policymakers, politicians, C-Suite types, advocacy groups, electronic record vendors, regulators, academics and anyone else with a good idea that will take just a little bit of a physician's time may now appreciate why docs can be so resistant to taking on another task - no matter how small it is. This is death by a thousand cuts.

Successful disease and care management organizations painfully learned about the importance of physician attitudes long ago. They already know that, to succeed in this environment, their programs need to not only deliver outcomes for their sponsors, but unburden physicians as much as possible with a flexible service mentality. What's more, they're already at work learning to align themselves with the PCMH and EHR to take up even more slack. Their perspective is one of "all hands on deck."

The DMCB has seen disease management nurses aid physicians by getting to patients figure out what to do for themselves, independently communicate and interpret important lab results and run interference with their sponsoring health insurance companies. When done right, physician satisfaction surveys (for example here, here, and here) run counter to the canard that all docs routinely dislike disease management.

Afterall, it's easy to see why they like anything that can help them with 3 plus hours-a-day of busywork.

Planet Doctor Rules Say Professor Reinhardt Is Only Partly Correct on a 'Just' Physician's Income

The Disease Management Care Blog spent over 25 earth-years on Planet Doctor. Located in Earth orbit on the other side of our sun, it is oxygen starved and the surface temperature can vary from absolute zero to blistering. Only when you know the serpentine thinking of its kooky inhabitants, can you survive. Armed with this expertise, the DMCB would like to share some truth about primary care physicians (PCP), courtesy of Planet Doctor logic.

PCP numbers in the North American continent are decreasing and, as a result, a cadre of Significant Earth Leader (SELs) is giving them considerable attention. These SELs have observed in their pronouncements to their underlings that, compared to other specialties, the PCPs’ average income is considerably lower. Using the linear input-output logic typical of this class of human species, the SELs have calculated that income -> incents medical students to -> select more remunerative specialties which will -> lead to a shortage of generalists. To correct this trend, the ELs have decided to increase the income of PCPs.

We of Planet Doctor ask you to consider the following ‘thought experiment,’ of Robert Frank. He stole his counterfeit invention from us when he visited us via spaceship decades ago. While the relative income and lifestyle of our denizens compared to your Earth is indeed higher, the relative status of PCPs, compared to specialists, is at the low end of our world's socioeconomic scale. It is hard for Earthlings to comprehend this, what with incomes > $100K, but it is true.

This is why Professor Reinhardt’s assessment of a just physician’s income focuses on the wrong earthbound standard. While PCPs certainly appreciate the status conferred on them by Earth society and their patients, the rules of Planet Doctor are what really count. For example, your RBRVS system was really invented here and beamed to your CMS headquarters by our satellite radar array. That and specialist physicians’ words and deeds reinforce the second class citizenship status of PCPs (see p. 5) on a daily basis. Even patients, even if they savvy about health care policy, still want to see a specialist instead of relying on the training and judgment of their PCP.

Silly Earthlings. You think money and percentiles are what is important to PCPs? Whether you consider it in relative or absolute terms vs. other professions or society at large, income and status are insufficient windows on the many dimensions of professional status and the impact on the number of PCPs. The truth is far more complicated. More money courtesy of SELs is not the fix and simplistic economic notions of status fall short of the real truth.

Death From a Thousand Cuts Outside of the Patient Centered Medical Home

The Disease Management Care Blog continues to invite and receive submissions from readers. This is one from a family physician buddy who is concerned that the patient centered medical home (PCMH) will not necessarily fix all that ails primary care. The examples below are the dysfunctions of a thousand cuts, best described as deprofessionalizing, demoralizing time consuming annoyances that are outside the PCMH. While each one may make individual sense based on the limited point of view of the specialist/insurer/administrative sponsor, they are collectively bleeding this corner of the profession dry. While money is mentioned, keep in mind that the PCPs gave up getting rich a long time ago. Rather, to quote one sage, the cash is simply a method of keeping score. Decide for yourself who is losing.

With the economy swirling down the commode and primary care at the bottom of the proverbial medical hill, the physicians that actually see patients full time are finding that clinical practice is becoming ever more difficult. The patient centered medical home (PCMH) is in danger of being overrun by hassles before the foundation even gets poured.

Some examples:

According to a local gastroenterologist, Medicare is now requiring that a complete history and physical (H&P) is completed and documented before a screening colonoscopy with anesthesia will be scheduled. Since doing an H&P is apparently outside the skill set of busy 'scopologists' or 'gas passers', completed that task is defaulting to being the responsibility of the primary care doc. Reimbursement? $0.

A large rural integrated delivery system that is currently all the rage in DC requires multiple pages of medical records with the ‘appropriate’ documentation (that demonstrates the need) to be faxed before specialist referrals will be covered. Reimbursement? $0.

Patients seeing diabetes specialists result in a payment of $200- $300 to that physician for their visits. Yet, these patients are typically seeing non-physician providers such as nurse specialists. Knowing that they are not seeing a 'real' doctor, many of the patients have come to the conclusion that the family doctor is closer, cheaper and just as good. Reimbursement for that just-as-good service? It’s not $200-$300. It’s $50. What’s more, the diabetes specialists have done little to help me improve my clinic’s HEDIS measures, torpedoing my chance of getting some pay for performance (P4P).

Centralized scheduling in large physician-hospital systems are making urgent appointments to specialists complicated, cumbersome and all but impossible. In several instances, my patients were unable to wait and had to urgently seek out care in the local emergency room. Since emergency room use is another HEDIS measure, this in turn has led to withholds of P4P, leading to negative reimbursement.

I tried to schedule an magnetic resonance imaging (MRI) scan for a possible extension of an old CVA. Personnel in the MRI facility argued that their 'protocol' for a 'CVA' was MRI plus an magnetic resonance angiogram of the head plus an MRI of the neck. I had to argue to get less!!

If this primary care home has any chance of being habitable, some basics need to change. The drainage pattern of the offending septic 'systems' of care is hurting community-based practice. We’re running out of boots at the bottom of the hill.

Coda: For additional examples of how the system is becoming hopelessly complicated, cumbersome and unfriendly for primary care, check out how the Feds are offering training on how to avoid being threatened by accusations of overbilling, how appointment times may be subject to regulation, and how patient billing warrants attention from the Federal Trade Commission. Egads!

Retail Clinics and Usual Primary Care: Both Respond to Rising Numbers of Unemployed the Same Way

If you, like the Disease Management Care Blog, take the time to read Managed Care Magazine, you already know a lot about Clayton Christensen's view that Retail Clinics are a disruptive innovation in healthcare. Maybe they are, but the DMCB was reminded today of just how similar that business is to 'usual' physician-based outpatient primary care.

Today there was a news release on how Walgreen's Take Care Clinics will be offering free acute care services to persons who can prove they are unemployed and show up between the hours of 11 AM and 3 PM. Remarkable you say? Give them a Gold Star for being socially conscious you say?

Not really. Before the news release described above, the DMCB recently broke bread with some community based primary care physicians and chatted about the bad economy and its impact on their practices. All three physicians described how many patients with 'good' insurance were a) losing their jobs, switching into COBRA and using their insurance to 'catch up' on all that previously foregone testing while it was still covered, b) going onto the Medicaid rolls or c) becoming uninsured. The DMCB asked if the docs were tempted to 'drop' the patients without good insurance from their practices. Their response was not surprising, when you think about it.

The answer was 'no.' All three physicians were seasoned businessmen who had been through previous economic downturns. They had seen this before. Today's patients with no or non-remunerative insurance were not only yesterday's richly insured but tomorrow's also. These providers know that when the economy eventually turns around, these patients are going to join the ranks of the employed/insured. By the way, continuing to care for these patients is the right thing to do, but from a business perspective, this is a loss-leader and an investment in the future. In contrast to Walgreens, there are no press releases.

Press releases aside, the same business logic applies to Walgreen's Take Care. Like the usual primary care providers the DMCB spoke to, Walgreen's is interested in serving today's uninsured, because tomorrow they'll be paying patients who will appreciate what Walgreen's has done for them. The positive word of mouth will help, there will be good press and lastly, while at Walgreens, these patients are likely to buy prescription and over-the-counter meds and while they're at it, print out some photos and pick up some diapers (and, by the way, hopefully NOT be tempted to buy any tobacco products). This is shrewd business sense in the field of primary care. It wasn't discovered by Walgreens.

The DMCB wonders if, with time, the stark differences between Retail Clinics (nurse practitioners using decision support with health information technology to treat common medical conditions) and usual primary care (which will use decision support with HIT to intelligently manage most medical conditions) will fade away. The response of both to the rising numbers of unemployed makes the DMCB wonder if there are more similarities than we've suspected.

"Disruptive?" Maybe not.

The Ironic Conundrum of the Preference Sensitive Measures, P4P and HEDIS Criteria

The Disease Management Care Blog received this posting from a primary care physician who prefers to remain anonymous. It speaks to the good intentions of applying HEDIS measures in the real world of primary care practice involving real physicians and real patients:

Most readers are familiar with the Oracles of Dartmouth and their numerous reports touting the opportunities from reducing variation around preference sensitive care. In the ideal world of measurement around the average, it all seems so logical and even warm and fuzzy. However, practitioners in the real primary care world are having a tough time fulfilling its promises in day to day practice. Is the problem the art and science of medicine, or is the problem with the logic underlying the measurement methods?

As a family doctor I am constantly being measured by HEDIS criteria and compared to my peers' average measures. This is how I am graded by most of the health insurers I contract with and my pay for performance (P4P) dollars are often based upon them. Yet, no matter how much my patients prefer – after careful, physician-delivered full disclosure of why this should be done - not to have a colonoscopy, not to schedule a diabetic eye examination or not to take a statin for coronary artery disease, it is the physician who is penalized for not obtaining one. When charts are reviewed, and documentation is read, informed choice is not a consideration for HEDIS.

In my opinion, HEDIS criteria are unreasonable, static, inflexible and fail to account for patient preferences. It measures physicians by the same unforgiving yardstick that expects all patients to be the same. It fails to account for the degree of patient preference care that’s been described in other care settings in the Dartmouth Atlas.

The only way to incorporate flexibility of choice in the P4P system is through the use of multiple individualized clinical pathways. Yet, each of the multiple clinical pathways are also inflexible and ill-suited to the special circumstances of each patient. Here’s the conundrum: If I am offering flexibility to my patients through multiple inflexible options, how can I properly inform them flexibly?

Good point. The physician points out that the current blunt force approach to HEDIS in managed care networks is based on a) comparing physicians to an ill-suited average measure that fails to capture the uniqueness of each practice setting that has a population of unique individuals, b) doesn't incorporate patient preferences and c) is demoralizing because it fails to give physicians credit for trying. The physician also doubts that health information technology and decision support will ever be up to the task of overcoming the special perspectives of any individual healthcare consumer. Last but not least, the DMCB is fascinated by this portrayal of the flip side of 'patient sensitive care' which, according to the Dartmouth Atlas, is prone to overutilization.

The DMCB doubts managed care medical directors will care much about this point of view, partially because they've been brainwashed by regular attendance at the Church of the Holy HEDIS and partially because their bonuses often depend on it.

When Primary Care Physicians Go Tone Deaf

By the way, not all physicians are necessarily sympathetic to the plight of primary care. It’s not just a matter of the members of the House of Medicine jostling over who gets a bigger share of the fixed economic pie, but, according to this newsletter, the PCPs losing their way.

With that in mind, it was with some interest that the Disease Management Care Blog – who is a “Fellow” of the American College of Physicians (ACP) - decided to investigate when it found out a letter had been sent to HHS Secretary-designee Daschle on its behalf.

The letter recommends that another ‘stimulus package’ be created that a) assists persons who are newly unemployed to access insurance coverage, b) expands Medicaid and SCHIP, c) increases Medicare payments for primary care physicians (PCPs) including a 10% payment bonus over 18 months and d) provides incentives (grants, interest free loans and tax incentives along with technical support) that increase PCP adoption of health information technology (HIT) as part of a broader effort to promote the Patient Centered Medical Home.

The DMCB understands why its ACP colleagues believe that a key ingredient for health reform is physician payment reform. It’s uncomfortable, however, with the mercenary tone of the letter. While primary care physician income has serious problems, the ACP letter above is muddling the patients’ well being with its physician-members’ economic interests. A cynic would argue that the otherwise laudable advocacy for the unemployed, expansion of government subsidized insurance, bonus payments and incentives are really attempts to preserve their members’ income levels.

The DMCB also thinks the request for a 10% bonus is bordering on nervy. Compared to the pain from the widespread mortgage foreclosures, lay-offs and vaporizing retirement funds, even the worst-off primary care physicians have little to complain about.

Is there no limit to the willingness of those in positions of privilege to seek government hand-outs, based on pleas that it’s really all about the little guy? Maybe the DMCB is being overly sensitive but a word count reveals the word ‘patient’ appears 8 times in the letter, while the word 'physician' appears 15 times and the word 'payment' appears 11 times. Conflict of interest anyone? Or is this just a case of tone deafness?

Maybe there is an element of truth to the notion about losing their way.

Innovation in Primary Care.... NOT

Much like the earnest gecko hunter of those Geico commercials, a reporter has been dispatched from the New England Journal to observe ‘innovative’ primary care physicians in their natural habitat. According to this intrepid correspondent, there are creative docs out there who are field testing ways to see fewer patients, work-smarter-not-harder and avoid burn-out.

And just what are these precocious practitioners of the Plains, these daunting docs of Dubuque, trying out? According to this safari jacketed writer, the ingredients for physician innovativeness consist of downjobbing routine stuff to the nurses, being savvy schedulers, using group visits, email and telephony. See, this may free up time for precious moments of physician-patient intimacy sprinkled with some real medical stuff, like worrying about potassium levels.

This is insight from the New England Journal? Maybe among Boston's Brahmins. The rest of us know the nurse-physician dyad has been the bedrock of well functioning outpatient clinics for decades. Not only have nurses plowed the road for the physicians in high performing clinics, they know better than anyone else that in primary care, quick one-on-one '12 minute' visits are ultimately more remunerative and that complex time consuming issues can be referred away.

Group visits, e-mail and telephony are not ‘all that’ either. The DMCB suspects these remain pretty much confined to very large physician practices, which seems to be the favored hiking range of the Journal’s academic writers anyway. As for the other 90% of primary care that has been missed by this reporting, these docs have probably calculated that adding to or substituting lots of patient visits with lots of phone calls and emails is a losing hand in a zero sum game. They also know that group visits are not a slam dunk either, especially in smaller practices with limited square feet.

Nonetheless, even this faux field report couldn’t help but spot the recruiting struggles of the large primary care practices. And it begs the question: if large group practices, nurse teaming, scheduling know-how, remote care communications and group visits are all that cool, then why are young physicians not flocking to innovation/large group practices so admired by the New England Journal?