Busy week of “Out Reforming Healthcare”

In our (soon-to-be-paperless-but-not-soon-enough) office, we have boxes where messages from patients, abnormal labs, and such are placed by the staff for action by the provider. Because it is not possible for everyone to know where everyone else is at any given time, we have taken to placing paper over the cubby-holes notifying the staff that we will be out until a certain day. If one is going someplace fun, a picture or something else fun is placed on the message as well. As Chairman, my cubby is covered more that most and this past week I used my “Out Reforming Healthcare” message for 3 of the 5 days.

On Tuesday I traveled to Birmingham to meet with the folks from the Patient Centered Primary Care Collaborative and hear Paul Grundy speak to primary care physician leadership as well as Alabama business leadership. His message is always strong and consistent and it is getting more focused.  As a physician who is involved in direct patient care as well as population based care for IBM employees, he is encouraging all employers to stop paying for garbage (his words). From a recent interview:

“40% of the care that’s delivered, according to some folks, is unnecessary and I see it every single day.  I know parts of the country where it costs $17,000 for the last six months of life and others where it’s $127,000 and by the way the patients in the $17,000 category, this particular case in Iowa live longer and are happier with the care than the ones that are in a scenario that is over $150,000.”

He sees transformational change coming and being lead by an empowered primary care workforce. Denmark is being looked at as a model with the number of hospitals reduced by 80%, for example.

On Wednesday I traveled to Montgomery to preside over the Alabama Rural Health Association board of directors meeting. As I have detailed previously, Alabama has an impending crisis regarding the healthcare workforce in rural Alabama. Although this meeting will not make a difference as a stand-alone activity, it is refreshing to get people in a room who are able to agree on a problem, potential solutions, and set in place a strategic planning activity focused in addressing the shortage. In that meeting we committed to focusing resources on FaceBook to recruit young folks interested in rural Alabama (search on FaceBook to find the page yourself), creating a strategic plan to better direct our resources, and finalizing issue briefs on the manpower crisis in rural Alabama health care prior to January 2010. We also committed to doing rather than talking.

Lastly, we went to New Orleans on Thursday to recruit Tulane students into our Family Medicine Residency program. The refreshing thing about this trip (aside from the soft shell crab) was that we spent a lovely evening with students who clearly entered medicine for the “right reasons” and they were committed to Family Medicine. We had a very pleasant visit and hopefully will see them in Mobile during the interview process.

In summary, like Paul Grundy I believe transformational change is coming. I believe it can happen in rural Alabama. The attitude of the students on Thursday confirmed my optimism. It was, however, a long week…

Putting their money where their mouth is…

I have been following the Patient Centered Medical Home movement for some time. The promise of “Advanced Primary Care” is that patients (clients/consumers/customers) will, by virtue of access to such care, be healthier. Although this sounds “pie in the sky”, there is good evidence that utilization of health care resources is moved from the Emergency Department to the primary care office (where chronic illness care and preventive services are also delivered), hospitalizations for primary care sensitive conditions (such as asthma) are reduced, and patients are more satisfied with their care. Additionally, the total costs of health care are reduced in systems which have instituted such a delivery system.

Earlier this week, IBM took the next step. They announced that they would fund 100% of primary care visits (no co-pay) to encourage utilization of primary care by the employees and their families. In a statement the company said “”This new approach advances IBM’s advocacy of wellness, preventative and
primary care — the cornerstone of keeping people healthy and productive,”
said Randy MacDonald, IBM senior vice president, Human Resources.  “As a
result of our focus on wellness and primary care, IBM employees have become
healthier and our costs are rising more slowly.”

In Mobile, Alabama, the University of South Alabama Medical Center had 380 admissions  (32% of all admissions) for “ambulatory sensitive conditions” in 2007. 1/4 of these spent time in the ICU.  This is despite the presence of 3 community health centers (25% charge for primary care if you are uninsured), the resources of the University, and the resources of the community. Maybe we need to take a lesson from IBM.

But what about gatekeeping?

I’m in correspondence regarding the concept of Advanced Primary Care with soeone from a rather large corporation who feel that the senior executives are having trouble distinguishing or telling the difference between a medical home and a the old HMO concept of primary doc being the gatekeeper in terms of who picks the specialists and asked id I can you help explain the difference.

 

It strikes me that the difference is both one of attitude and a new emphasis on evidence based care. From the standpoint of the HMO, the insurance company dictated the “panel” based on who would accept their fee schedule and paid PCPs not to refer. The “advanced primary care model”, depending on how it’s set up, allows the patient to go see anyone (no reward for denying service) with several caveats. 1) The specialist must provide outcomes to the primary care office. Meaning, if you are seeing the specialist for a blocked carotid artery, the Primary Care doc should have a list of who does good work, bad work, or “kills people” work and you get to pick. 2) The patient must be willing to work within the “advanced primary care model” to accomplish outcomes. It turns out that it isn’t about one doctor but it’s that the patient is seeing several doctors who’s area of expertise overlap. All of the data needs to go to the “advanced primary care” practice, who will share that info with all of the other doctors. Most people think that happens, anyway. If one doc is unwilling to share then that doc is not referred to but would you really want to see that person anyway? 3) Typically, a lot can be done in the primary care office. Some plans pay a differential to the specialist if they accept someone on referral vs seeing people off of the street. In that way I can catch the person who needs their lipids checked while taking their skin tag off and give them a flu shot. If they want to see the dermatologist, they can, but at a higher out-of-pocket cost

It’s not an HMO

As the drumbeat of health care reform becomes ever louder, so does the hysteria surrounding system change. Having come of age clinically during the heyday of “managed care”, I find the criticism that “advanced primary care” is just another name for an HMO particularly disingenuous.

In order that some of you might spread the word that this is care far removed from “HumanaCare”, I have taken the Principles from the Patient Centered Primary Care website and noted which were not included in traditional managed care:

Principles of “Advanced Primary Care”  Bold italics  indicates not a part of HMO model

Personal physician—each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

Physician directed medical practice— the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

Whole person orientation—the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

Quality and safety are hallmarks of the medical home:

• Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family.
• Evidence-based medicine and clinical decision support tools guide decision making.
• Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.
• Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met.
• Information technology is utilized appropriately to support optimal patient care, performance measurement  patient education, and enhanced communication
• Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.
• Patients and families participate in quality improvement activities at the practice level.

Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.

Payment appropriately recognizes the added value provided to patients who have a Patient-Centered Medical Home. The payment structure should be based on the following framework:

• It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit.
• It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.
• It should support adoption and use of health information technology for quality improvement.
• It should support provision of enhanced communication access such as secure e-mail and telephone consultation.
• It should recognize the value of physician work associated with remote monitoring of clinical data using technology.
• It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).
• It should recognize case mix differences in the patient population being treated within the practice.
• It should allow physicians to share in savings from reduced hospitalizations associated with physician guided care management in the office setting.
• It should allow for additional payments for achieving measurable and continuous quality improvements.

HR 3400

Dr Jeff Terry has written another letter to the editor of the Mobile paper regarding the lack of attention that alternatives to the Democrats proposed health care reform (such as HR 3400) have received. Aside from the obvious (the Republicans had 6 years to do something and what they managed to accomplish was to give a $2,000,000 gift to Pharma) there’s the question of whether the alternative proposal has any merit.

As mentioned before, Kaiser Family Foundation has put together a nifty comparison of all of the Health Reform proposals. Dr Terry asks what the Democrats want to accomplish. I would say that President Obama lays it out quite specifically:

The President has indicated that comprehensive health reform should:

• Reduce long-term growth of health care costs for businesses and government.

• Protect families from bankruptcy or debt because of health care costs.

• Guarantee choice of doctors and health plans.

• Invest in prevention and wellness.

• Improve patient safety and quality care.

• Assure affordable, quality health coverage for all Americans.

• Maintain coverage when you change or lose your job.

• End barriers to coverage for people with pre-existing medical conditions.

• The plan must put the country on a clear path to cover all Americans.

HR 3400 Overview

Allow people who purchase coverage in the individual market to deduct the cost of premiums from their income taxes. Provide refundable tax credits to individuals and families with incomes below 300% FPL to purchase insurance in the individual market. Establish Association Health Plans and Individual Membership Associations through which employers and individuals can purchase coverage. Implement state high risk pools or reinsurance programs to provide coverage for people with pre-existing health conditions. Require states to provide coverage to 90% of children with family incomes below 200% FPL as a condition for expanding child eligibility to 300% FPL, and require states to provide vouchers to children eligible for Medicaid and CHIP, to be used to purchase private insurance.

Or, Kaiser has a tool that will generate a side-by-side comparison. By doing that, you can see that HR 3400 has no requirement for individuals to have coverage. Permit employers to automatically enroll individuals in the lowest cost group health plan as long as they can opt out of coverage (which will lead to high deductibles for low wage employess and lessen coverage). Barriers to pre-existing illnesses and injury are not reduced. Medicare fraud is the only example of wasteful healthcare spending covered and it prohibits comparative effectiveness research from being used to deny coverage of a health care service under a Federal health care program and require the Federal Coordinating Council for Comparative Effectiveness Research to present research findings to relevant specialty organizations before publicly releasing them (this will almost certainly increase costs).

Dr Terry feels that Representative Price has a proposal ”which offers real reform measures that put patients back in control of their health care and their lives”. I would argue that what it offers is more subsidies for the wealthy, less accountability for physicians, and less coverage for Americans. I hope Dr Terry will take a look at the Kaiser website.

The miracle of childbirth

One of the things that I have been able to do as an academic “Family Doc” is to continue to participate in the deliver of babies. The word obstetrics is from the Latin obstare which means “to stand by”. That is what I did last night, stand by for a complicated laboring patient who ended up having a sunrise (5:30 am) delivery. By my calculations I have either delivered or supervised the delivery by Family Medicine residents of over 1000 babies. I am struck by how deliveries at “teaching hospitals” have changed since I was a student at Charity Hospital in New Orleans. Medicaid required states to pay for prenatal care beginning in the mid 1990’s. Given a “public option”, many people are happy to use SOBRA Medicaid to pay for their pregnancy care (although in fairness, they don’t have any out-of-pocket expense) and many companies are content to have at least some of their maternity care covered via”the public option” when their employees can’t afford the high deductible insurance.

The stigma attached to being on “public assistance” for maternity care is gone. Many hospitals in Mobile are more than happy to take maternity Medicaid. We have had to compete for these patients and so we deliver babies at a very a nice facility (USA Children’s and Women’s Hospital) with birthing rooms, televisions, and lots of stuff that looks nice and makes patients want to come back. This is in contrast to my memories of Charity, with its open bay wards, communal laboring patients, and lack of involvement (in my memory) of the teaching faculty in the daily management of the patients.

Neonatal mortality has been reduced in the United States from 4/100 births in 1940 to 0.6/100 today. This correlates with the inclusion of maternity care in insurance policies and the growth of Medicaid as a viable payor for maternity care providers. Unfortunately, even for pregnancy care, access is not universal.  There are still great disparities in outcomes that are associated with the race of the mother in this country, almost certainly due to differences in access to healthcare. Mortality and morbidity correlates with state of origin. In Alabama  the current rate is 1.1/100 births, probably reflective of access and underlying conditions. 

Although changes in infant mortality can be attributed to other things as well as access to the health care system, it is clear that improvements in maternity care correlate with the reduction of the use of cash for childbirth and the development of this  public/private partnership, however dysfunctional it may be. When I was in medical school in 1985, prenatal care and a comfortable well attended delivery were clearly luxuries.I have attended this healthcare system during the transformation.  What we need to be discussing is which components of the care work and how to deliver them more efficiently. Instead, we have Senator Kyl who wishes not to pay for anyone else’s childbirth, no matter what.   Why are we as a country even having this discussion?

Evidence for what I am talking about

While flipping through the channels last night, I ran across the movie “Knocked up“. Although unable to watch for more than a couple of minutes (it seems to be a very high concept movie about a guy, a girl, a one night stand, and a lot of pot) there was a scene which illustrates the “Less is More” concept. The Katherine Heigle character, after spending what must have been $1,000 of home pregnancy tests, collects her “baby daddy” and goes to the doctor for a offical diagnosis. The doctor had 3 choices. 1) Believe the patient and proceed as if the patient was pregnant. I’m not saying that people would lie about such a thing, but I wouldn’t feel comfortable proceeding in this manner. 2)Gather objective evidence (a pregnancy test in the office) and proceed on the information obtained from that test and an assessment of risk factors, obtaining an early ultrasound if the patient had risk factor for an ectopic (tubal) pregnancy. 3) Do an ultrasound on every pregnant person, perhaps  in fear of missing an ectopic (tubal) pregnancy (2 out of every 100 pregnancies, almost all of which have symptoms before problems occur). Katherine got an ultrasound and saw a cute baby with a heart beat (how cute!)

The doctor fees for these visits are as follows. Lets say that the office visit for an OB intake is reimbursed by the insurance at $200. The pregnancy test might be reimbursed at $10 and cost the office $4 to administer, a profit of $6 to the practice. If you practice based on option 3 some would say that it is cheaper because the ultrasound is “free”. However, the office does have to pay for the machine and the time of the sonographer. If the physician charge the insurance separately for the ultrasound because the patient has “pain”, you can charge an extra $200 per pregnancy. This goes to pay for the machine and gives the patient “peace of mind” in addition to increasing the physician’s bottom line.  What’s a doctor to do?

More isn’t better

Americans like to believe they have the best health care system in the world. They certainly seem to believe that access to specialist physicians and high end technology is important in maintaining the “quality” of the health care delivery system. Little by little, the word is getting out that more is not necessarily better and almost certainly is often worse. The most egregious example of this is Michael Jackson’s death which was ruled a homicide, allegedly perpetrated by his personal cardiologist. Turns out that having a cardiologist attending you 24/7/365 may not be a good thing. On a more mundane note, NPR decided to look into this and has posted an in-depth look at health care variation that is very well done. The key points of this report are that 1) Americans are the same no matter where you go (despite the belief of some folks that we’re made differently), 2) doctors influence patient choices when determining among choices of equally appropriate healthcare, and 3) money and payment structure influences doctors. This is not rocket science but the fact that it took Alix Spiegel 20 minutes to explain may mean it is more difficult for the average person to grasp than I might believe (and then again, I suspect the NPR demographic may not be average anyway). NPR quotes the Dartmouth Atlas data that suggests almost 1/3 of all healthcare costs are for procedures that are not helpful and may be harmful.

Why is this important to Alabama? The talk of “Health Care Reform” has morphed into “Health Insurance Reform” and now has morphed again into “Covering the Uninsured with Private Health Insurance.” In 2008, Blue Cross of Alabama reported $4,000,000,000 in premium collection. Most of this business, as I understand it, was done with companies who use Blue Cross of Alabama to administer their plan. They have no risk (the companies put money into the plan and take money out) but they take a percentage of the money (8%) and get to hold the premium in the bank (drawing interest) until it is needed. It would seem that they do better as more money is spent on health care, necessary or not. I certainly hope that someone pressures them to look at the payment structure and outcomes, not just  Alabamians’ satisfaction with their product.

Despairing of rationality

Two observations on health care delivery. One from a trip to Montgomery and another from a trip to Mayo’s Barber Shop. The hair cut was yesterday. One of my fellow customers was speaking of the cancer treatment received by a family member. Although we have a comprehensive cancer center in Mobile (the Mitchel Cancer Institute) with world class physicians treating the disease in question, my barbershop buddy chose to go to a competing concern (The Cancer Treatment Centers of America). This was likely prompted by the advertisements on television (in 1996, they were sued for being overly aggressive and their commercials are still worrisome), the promise of “holistic” care, and the fact that Blue Cross of Alabama would pay for the care. Turns out, the differences between our local comprehensive cancer center and the CTCA include the aggresive approach of CTCA, the presence of shareholders and the profit motive. An article in Business Week follows a patient who maxes out her $1,000,000 policy limits but is very happy with her care. It seems that some of what they sell is “hope”. The second difference is that CTCA will likely not treat uninsured cancer sufferers from Mobile Alabama as is required of the local cancer center (as CTCA requires $125,000 up front and reserves of $250,000 prior to starting treatment). What for-profit healthcare concerns may be selling to their shareholders is the ability to generate a lot of charges posted to each patient’s insurance policy.

My trip to Montgomery was to attend a board meeting of the Alabama Academy of Family Physicians. I have known most of these “Family Docs” for over 10 years. They have fought for many of the programs that now exist to get folks who might consider practice in rural Alabama into medical school. The group has seemed beaten down the past couple of times we’ve met. Partly this is because Blue Cross of Alabama, our single payor, has raised the codes billed by Family Docs by 20% over the past 19 year whereas the codes billed by our “partialist” colleagues have been raised over 300%. Also, it is because they would NEVER consider limiting access by making someone take out a mortgage to see if their diabetes/hypertension/arthritis would benefit from the care of their hometown physician.

The system that has evolved over the past 60 years requires a lot of overpayment from some areas to allow care to be provided at some level to all who presented for care. For-profit organizations such as CTCA take money away from communities such as ours. If they had demonstrably better outcomes and if care were available without such cost shifting, it might be justifiable. Unfortunately, the outcomes aren’t easily researched (try googling “outcomes” and “cancer centers” and getting unbiased information) and paying for indigent care is still not easily done in places like Mobile. I’m still waiting to see Congress solve this one.

Cholesterol and me

From the cardiometabolic risk initiative

I gave a talk to the Alabama Primary Care Association on Lipid Management yesterday and was struck by several things. One was how lipids, along with everything else on the risk factor list (see figure) are affected by diet and exercise. Secondly, was how cardiovascular risk has been incorrectly sold to the American public and the health care enterprise. The National Heart Lung Blood Institute apparently decided that Americans were not going to be able to comprehend the concept of multi factorial risk. The simplistic version of “cholesterol” is 200 GOOD, 201 BAD. The more complex version takes into account smoking status, blood pressure, and sex. The cholesterol calculator then allows the “patient” to make a choice based on a risk determination. I find it to be a much better educational process for my patients and I hope I helped to increase the use of this tool. I was heartened that I was asked the question about “established standards” for review of care. We really are changing the way clinical care is delivered in the ambulatory setting.

  After spending time talking about pharmacologic interventions, I was not surprised to get the question regarding prophylactic use of “statins” in people who are low risk (< 10% mortality over 10 years). My answer surprised even me. As someone who doesn’t take pills, my response was that we as health care providers need to take advantage of the “teachable moment” not to encourage compliance with a potentially unnecessary medication but instead to encourage compliance and problem solve with patients about diet and physical activity. I answered that my response to my increased risk (due to impending “maturity”) was a daily run rather than a daily pill. Like to see Merk selling that, wouldn’t you?