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After thinking about birthing care, pre-natal care, and pre-conception care last Sunday, I took the liberty of putting some thoughts together for the local paper. With the help of my wife and editor Danielle Juzan we were able to distill over 1200 rambling words into under 500 carefully selected words. The emphasis was changed to reflect less the lunacy of the current system and more of the promise of the future should system change be allowed to occur and these were published on Friday. In my now much more succinct voice:

Technology at delivery and pre-natal care are important, but we must work harder to facilitate preconception care. If chronic diseases such as diabetes, heart disease and high blood pressure are treated prior to conception, the rates of miscarriage and fetal death go down.

Fetal and/or maternal deaths caused by diseases such as rubella (German measles), hepatitis B, chicken pox, influenza and tetanus can be prevented through vaccination.

Other dangers to the fetus caused by diseases such as HIV/AIDS, syphilis, chlamydia, and other sexually transmitted diseases are mitigated by early detection and treatment.

Unplanned pregnancies can be reduced with access to adequate contraception. Preterm delivery can be reduced through pregnancy spacing.

I mention this because educating people regarding the failings of the current healthcare delivery system in the US and the promise that the Affordable Care Act holds regarding system change is very important. Don Berwick, the head of CMS, has outlined the Triple Aim of the care delivery system.  Dr Berwick describes it as his main focus and

As described in the Health Affairs article and by Berwick in his speech , the Triple Aim consists of (not surprisingly) three overarching goals:

  • Better care for individuals, described by the six dimensions of health care performance listed in the Institute of Medicine’s 2001 report “Crossing the Quality Chasm”: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.
  • Better health for populations, though attacking “the upstream causes of so much of our ill health,” such poor nutrition, physical inactivity, and substance abuse.
  • Reducing per-capita costs.

Pre-conception care is a perfect example of where the Triple Aim is important. Well planned care will lead to improved patient outcomes, better health for the population, and reduced costs.

For us to hit this Triple Aim, it will take more than doctors working harder. The Patient Centered Primary Care Collaborative held another meeting this past week to educate stakeholders.  Entitled Exhibiting the Evidence, it offered a mix of policy makers discussing the future of care delivery and ground troops discussing successes and failures. I strongly recommend going through the presentations, available here. In it you will find Paul Grundy’s report that the change to a primary care focus at IBM has led to a 30% reduction in hospital utilization and a 10% reduction in total costs (after 1 year). You will find reports regarding decision support and health information technology (tools necessary to produced patient centered care). You will find information regarding the accreditation process and the creation of Accountable Care Organizations. You will find several success stories.

Karen Boudreau from IHI pointed out at the PCPCC meeting that if we are not careful we are seemingly still poised to spend more and accomplish less within our healthcare system. She points out a better plan is to reform the system (the Triple Aim). This is what Dr Berwick is working towards at CMS. She also points out the trail blazers such as Group Health and Community Care of North Carolina have already established methods to effect system change. Those of us not in Washington or north Carolina need to push our local and state policy makers to get on the bandwagon.

Write a letter to the editor of your local paper pointing out that we do not have the best health care system in the world BUT COULD. Maybe you’ll make a difference.


The faculty at the college of medicine were asked along by the College of Medicine “blogger” to share what we thought were the top three advances in medicine. I named two drugs (H2 blockers like Tagamet because they practically eliminated a type of surgery and statin drugs like Zocor because they have altered the course of heart disease dramatically) and one process (outcomes measurement because it forces physicians to consider how they are in aggregate and look at an individual patient’s improvement or lack thereof). I was not asked what has changed Family Medicine training for the worse but I am certain in my top three would be the “Teaching Rules”.

I have discussed peripherally how we pay for physicians-in-training here and a little more detail about the agency that pays for them here and here, but I’ve not yet attempted to describe the disconnect between the payment process and the training process that currently exists. Partly that is because the story starts in 1965. It seems that from its inception, Medicare was expected to pay for some training but did not want to pay for all training. From testimony before the Practicing Physicians Advisory Council by the AAMC:

There is a 35 year history of Medicare requirements that a teaching physician is obligated to comply with when he or she submits a bill for a service in which a resident is involved. At issue over the years has been the extent to which a teaching physician must be present during a service in which a resident is involved, and the documentation that must be provided to support the level of a bill submitted to Medicare. Starting in 1967, The Centers for Medicare and Medicaid Services (CMS) and its predecessor organizations have issued a number of regulations, intermediary letters, memoranda and other documents that attempted to clarify the requirements. These efforts were not successful, and, in 1995, HCFA issued a new rule that superceded the old pronouncements. It became effective as of July 1, 1996.

Over the years, the Academic Health Centers had rationalized accepting payment for care provided by residents.  T he discussion around the development of this rule made it clear that Medicare felt that they were paying for the care delivered by the learner already and so the additional payment for care delivery seemed to be “double-dipping.” The 1996 “clarification” created a set of regulations which were well-intentioned but had several consequences, intended and unintended. First, it resulted in an immediate loss of revenue for the care of those patients who were insured through Medicare which was anticipated. Secondly, every other insurance followed Medicare’s lead (even though they do not pay us through any other method for training residents) resulting in additional loss of revenue which was unintended.

The response of Academic Medicine could have been to provide free care and charge learners tuition to make up the difference. Instead we decided to work within the new rules to maximize revenue generated as a consequence of patient care. For most hospital based specialties this meant the Teaching Physician needed to be present for certain aspects of care (such as a surgery performed by a resident, for example). The rules posed a particular challenge in Family Medicine, where most training took place in the office and involved thinking more often than the performance of a procedure. The thought process is more difficult to supervise than the removal of a gall bladder. Initially it looked like the rules would lead to the death of primary care training. The rules eventually  included an exception for primary care training to mitigate some of the potential difficulties. Unfortunately, as the rules were interpreted and reinterpreted, it seems that lost in the process was the intent of preserving primary care training.

As I said before, Family Medicine training tends to be different. Here at South Alabama we want our learners, by the time they finish their residency, to know how to take responsibility for patients over time. This includes caring for their acute illness, chronic illness, and facilitating their use of preventive services regardless of their insurance. The only way I know of to do this is to begin with heavy supervision and offer learners the opportunity to gradually practice independently over the course of the training program. We wish for our learners, when they graduate, to care for underserved populations so we would like to offer them the opportunity to provide care for patients with Medicare and other insurances while in training.

When the new rules were enacted we could (and did) request a “primary care exception” to allow us to not have to directly supervise the care delivered by every resident who had Medicare insurance. To obtain this we had to have one faculty for every four residents (which we were already doing) and the residents couldn’t bill for “higher level” codes. Although this sounds fairly simple, the rules have been interpreted and  re-interpreted.  So if a resident sees a patient who is “not complicated” but becomes complicated, what should the teaching physician do? Regarding the 1-4 ration, what if there are 7 residents and 2 teaching physicians? Under such circumstances, must each faculty member supervise a designated 3 or 4 of the 7 residents, or can they essentially provide “cross-coverage” of the entire 7 residents between them? If one of the teaching physicians takes a phone call, is he capable of supervising or does he have to call in a back-up supervisor while he’s on the phone? Each of these circumstances is open to interpretation, and unfortunately the audit is typically 2-3 years behind so we are required to keep records and detailed notes on what happened.

Part of the problem is that the rules are interpreted by intermediaries and are different in different locations and at different times.  What I can do is not what my colleagues in the northeast are able to do so we can’t offer best practices to our colleagues. Another problem is that the interpretations of the rules  are colored by “consultants” who have no more knowledge than most about the interpretation of the rules but as a consequence of their status can cause great disruption.  Because of the teaching rules we focus on style over substance, documentation over instruction, and worry all too much about payment for a particular activity. Our Family Medicine Center went from being marginally profitable prior to the Teaching Rules to being $700,000 in the red.

Clearly there are competing demands on the system and even under the current oppressive set of rules it is cheaper to use residents than any other labor source for many types of care delivery in Academic Health Centers. In Family Medicine it is more expensive to provide such care in the context of training. I believe we continue to do so because we realize the importance of our training mission and understand that there are no alternative training methods. As a consequence we react to continual reinterpretation with coping (like the frog in the boiling water) rather than saying “to heck with it.” I hope that the value of high quality subsidized training for Family Physicians is understood by Dr Berwick and he will work with the leaders in Family Medicine training to make the rules less difficult to interpret and follow. On my wish list for the primary care exception as it relates to the Teaching Rules are the following:

  • Changing the direct  payment structure such that the money follows the trainee instead of going through the Academic Health Center. This would allow me to hire the appropriate team members to transform the Family Medicine Center into a true Patient Centered Medical Home
  • Changing the rules such that the resident can deliver care for his or her patient without having to with hold documentation so that he or she can remain in compliance with the teaching rules. This means eliminating the restrictions on the codes that can be billed in the residents name if the Primary Care exception is followed
  • Use the PQRI process as a method to document the reception of value for care rather than focus on how residents are supervised as a metric. If we are able to deliver good care, does the minutia of supervision matter?

Are there more? Maybe Dr Berwick is open to suggestions…

I have already expressed my excitement at having Don Berwick at CMS. I am pleased that President Obama found a way to make the appointment without allowing “death panels” to become a major media concern again. As expressed by Ezra Klein, “unless and until we find some way to ease the pressure Medicaid and Medicare are placing on the budget, we need not just good people running CMS, but great people.” Of the people I am aware of that might take this job, Don Berwick is one of the few with potential to be great.

Turns out that within the bill is the key to transforming American medicine, if only we use it for the powers of good. The Center for Medicare and Medicaid Innovation was established to” test innovative payment and service delivery models to reduce program expenditures under the applicable titles while preserving or enhancing the quality of care furnished to individuals under such titles. In selecting such models, the Secretary shall give preference to models that also improve the coordination, quality, and efficiency of health care services furnished to applicable individuals defined in paragraph (4)(A).” In English, to allow innovators to innovate, leading rapidly to better care. As someone who believes that there is a place for government in health care delivery, especially for those who rely on the government, either because of age or disparity, to provide access to quality healthcare. Don Berwick will be all over this. This program is seen as a potential game changer for the following reasons:

  • Because it is set up to run “pilots” instead of “demonstrations” the approval of Congress isn’t necessary for every project and rapid replication is possible for successful pilots
  • 18 possible programs were offered as a choice rather than Congress dictating care based on their collective (or individual) whim
  • Budget neutrality is not required, meaning that you don’t have to predict outcome (or be afraid to attempt it) prior to starting a program
  • Funding ($10,000,000,000) is adequate to try several things at once

Mnay of these ideas have been through small pilot efforts already so it may be that transformation will be on a fast track. The list of projects include: