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National Public Radio ran an article Tuesday about a family’s struggle with a lack of affordable health care. The protagonist, Amber Cooper, was employed as an accountant in a firm and a change in insurance left her with significant ($20,000 annually) out-of-pocket expense in order for her to continue her life sustaining treatment plan. The story was one of how the family made do with that much less over several years and is now doing better thanks to another change in coverage that her employer made. Paul Fronstein, of the Employer Benefits Research Council outlines the reasoning of the company as follows:

“Employers are trying to manage those costs. They’re trying to keep those cost increases as close to inflation as possible. And they’re doing everything they can to get their workers so that they think twice about the health care that they are using,”

Ms Cooper had the misfortune of having a liver transplant when she was 10 years old. Her medical expenses are anti-rejection drugs (the lack of which will lead to acute rejection, prolonged hospitalization, and potentially a second transplant) and lab work to monitor the levels of those drugs (the lack of which would, well, see above).

So, what should Ms Cooper think twice about? Perhaps she was engaged in risky behavior prior to her transplant such as drinking or promiscuous sexual behavior and should have thought twice about that, though that is doubtful. Perhaps at the age of 10 she should have anticipated this as a potential problem and chosen an early death as preferable to a life of serfdom to the medical-industrial complex, though I suspect the decisions were those of her parents and not hers. Perhaps she should have chosen less expensive care, searching for the Dr Nick of post-transplant care, though this would likely have the same effect as not taking drugs at all (see above). What she chose to do was to pay what she could, seek out charity for some care, and defer other needed care to be able to continue to afford food and shelter for her family. All necessary but risky decisions.

Ultimately, Ms Cooper’s company selected another insurance and she is back on her medication and being monitored appropriately. This speaks to the need to provide a seamless, affordable package of benefits regardless of who is paying the bills, including individuals.

What the reporter describes mirrors what I see as a primary care physician. Patients have reduced access to less expensive, primary and ambulatory specialty care as a result of increasing deductibles, co-pays, and arbitrary denials of coverage. Those that are unfortunate enough not to lose their job and move onto Medicaid become sicker and sicker, leading to heroic hospital based rescue care (subsidized in part by the community or the federal government). Each hospitalization leaves these patient  just a little weaker and that much closer to being on disability instead of holding down a job. Unless repealed, replaced or nullified, access and quality of primary and ambulatory specialty care will improve as a result of the ACA. Some of the  improvements in care delivery are happening now and some (near universal access and standardized benefits) will take effect in 2014. It will make my job, keeping people healthy and out of the hospital, that much easier.

As I mentioned here, not all is bleak in the world of care delivery. Forbes recently ran two articles on how things are changing rapidly. The first, found here, is about how Aetna is  reformulating itself as a consequence of the Affordable Care Act and other pressures/ From the article:

Aetna recognizes the transition from the “do more, bill more” generation to the value/outcome-based generation is going to happen regardless of whether the Supreme Court overturns the health reform. The employers picking up the largest portion of the healthcare tab are fed up with the “get less for more” story they are told every year. In fact, IBM itself is a leader amongst large employers that pushed for facets of the health reform that included an emphasis on primary care.

From afar Aetna , it appears there are at least four key insights driving Aetna’s behavior:

  1. Traditional health insurance business profits have been capped so they are pursuing complementary businesses that are unregulated.
  2. Simply going through traditional channels of employers and providers won’t allow them to reach all of their target market. They have to create new pathways to the ultimate consumer. For a bunch of reasons, healthcare is becoming a more consumer-driven market so they must build or acquire that skillset.
  3. The devastating Medical Loss Ratio (MLR) requirements mentioned in the Health Insurance’s Bunker Buster article demand that 80-85% of premium dollars go to patient care (vs. administrative overhead). I believe the aggressive acquisition spree will be for services that can be classified as patient care and thus help them with their MLR requirements.
  4. An onslaught of new requirements are being placed on healthcare providers. Smaller providers are especially ill-equipped to handle these on their own. Thus, Aetna wants to provide backoffice services for these organizations.

The second item of interest, also in Forbes, is the use of the Direct Primary Care Medical Home (DPC) provision of the ACA by primary care docs. While the details are a little complicated (and found in the article) the results are not:

Because DPC models are a more pure form of primary care not having to worry about how to weave in cumbersome insurance-driven processes, they have shown an even more dramatic impact than the aforementioned PCMH. While garnering customer satisfaction scores higher than Google or Apple, achieving more 5 star ratings on CitySearch than any other business DPC practices such as Qliance, Iora Health and WhiteGlove Health have reduced expensive downstream costs (surgical, emergency department and specialist visits) by 40-80%. I predict some of the PCMH models being piloted will shift to DPC as payment reform continues.

In the words of Forbes, good primary care (mostly Family Medicine) is sexy:

Utilizing a collaborative care model, the patient becomes a valued member of the care team — more than just a vessel for billing codes. Patients win. Physicians Win. Employers Win. Even forward-thinking insurance companies win. In fact, most major health insurance companies have major efforts to make primary care the foundation of their plans and it’s not a moment too early.

PCPCC has a new executive director. Marcia Neilsen, has begun to move the organization from one of advocacy for policy change into one of implementation. Her credentials are as follows:

Nielsen holds a Ph.D. in health policy management from Johns Hopkins School of Public Health and a master’s degree in public health from George Washington University. Her interest in public health began with work as a Peace Corps volunteer in Thailand and matured through a position as a Senate staffer for Bob Kerrey during the health care reform debate of the 1990s. She also served as assistant director of legislation for the AFL-CIO. She was appointed by then-Kansas Governor Kathleen Sebelius as the first board chair of the Kansas Health Policy Authority, later becoming the executive director, responsible for developing a policy agenda and overseeing administration of the medical portion of state health programs including Kansas Medicaid, the State Children’s Health Insurance Program and the State Employee Health Program.

We were lucky enough to have her speak last week at the ADFM conference. Her insights into the world of care transformation were both exciting and overwhelming. Exciting because she sees the benefits of our organization:

“Primary care transformation is the foundation for larger transformation we need to see across the entire health care delivery system, and population health is at the heart of such change. This is something departments of family medicine recognized long before Affordable Care Act. They helped lay the foundation, and they are essential to the success of health care reform efforts,” she said.

Overwhelming because now we have to put our money where our mouth is.

My friend Paul Grundy has begun a blog on the IBM website, found here. In his first installment, he details the events of why, in part,  I am more optimistic about the future of American healthcare for having worked with him. In the first part of his entry, he identifies why IBM has more than an intellectual interest in health care:

With this information, [Watson, the IBM supercomputer] can suggest options targeted to a patient’s circumstances. This is an example of technology that can help physicians and nurses identify the most effective courses of treatment for their patients. And fast: in less than 3 seconds Watson can sift through the equivalent of about 200 million pages, evaluate the information, and provide precise responses. With medical information doubling every 5 years, advanced health analytic systems technologies can help improve patient care through the delivery of up- to-date, evidence-based health care.

The point he makes following this, though, is not that the computer will lead to a reduction in health costs by decreasing the need for human interaction. This data needs to be converted to actionable information. That is where IBM, the company that purchases health care, has taken the lead:

So, how to make sure this actionable information flows and is held accountable at the level of a healing relationship?With this question in mind, in 2006, IBM – as a buyer of care- hosted a meeting for 47 of the Fortune 100 buyers, TRICARE, the federal Office of Personnel Management (OPM), buyers and the whole house of primary care. They agreed to guidelines now known as the Joint Principles of the Patient Centered Medical Home (PCMH).

This is how the Patient Centered Primary Care Collaborative got its start.From this group came many of the elements of care transformation included in the Affordable Care Act.

As you can see, Paul and IBM have influenced healthcare for the better and will continue to do so. If you have an interest in policy, specifically where its going as opposed to where it has been, I would advise you to pay attention to his thoughts.

Blue Cross of Louisiana is following Dr Berwick’s advice to act locally. For years in Louisiana care was delivered by specialists in the usual disjointed, uncoordinated fashion driven by dominant hospitals and medical schools. On December 2 a summit was held at the Pennington Research Center in Baton Rouge to initiate a sea change in the way care is delivered. They announced the rapid deployment of a primary care based patient centered medical home delivery model. In their press release, they cite the following data as contributing to this change:

According to the review, in South Carolina, patients in the patient-centered medical home started by Blue Cross and Blue Shield had medical and pharmacy costs that were 6.5% lower than the control group. Patients in a similar Blue Cross program in North Dakota saw hospital admissions drop by 6% and emergency room visits fall by 24%. During that same period, in the control group, hospital admissions were up by 45% and emergency room visits rose by 3%.

They go on to say

“The healthcare industry is facing unprecedented change. Blue Cross and Blue Shield of Louisiana has answered the call for new and innovative delivery models by embracing the concept of the patient-centered medical home,” said Mike Reitz, Blue Cross President and CEO.

“Accountable, collaborative, coordinated care delivered through the patient-centered medical home will transform healthcare delivery,” said Dr Kenneth Phenow, Blue Cross Chief Medical Officer. “As an industry, we have evolved as far as we can using costly, fragmented, fee-for-service payment. As we transform, pay-for-value models like those embodied by the PCMH approach will help us achieve better health and better care at a better cost.”

Mike Reitz reiterates his support for the concept as well as the importance of primary care on a video captured by Bayou Buzz found here.

This was e-mailed to me by Paul Grundy under the headline “PCMH as seen explained in the deep red states by an enlightened plan.” Anyone from Alabama listening?

I was asked recently to comment on how I felt increasing the emphasis on primary care would benefit the “system.” This is an important question because, as I have pointed out here and here, academic health centers and primary care education have no love between them. My answer was as follows:

Good primary care will not contribute a whole lot to the bottom line … As our primary payor is Medicaid and if the Alabama results are anything like the North Carolina, the Adult inpatient spending is down almost 10%with the bulk being in preventable adult admissions. In other words, the job of the primary care doctor is to keep folks out of the hospital and so by the very nature we in FM will be at odds with many of our colleagues. In short, better care will reduce folks in the hospital.

I then pointed out what I thought was an obvious strategy when faced with evidence that a tidal wave is fast approaching:

Our department [can] jump in front or not but I suspect it will happen either with or without us.

Why is the tidal wave coming? The payment system is unsustainable and is changing FAST. I believe (and everyone at CMS that I have spoken with concurs) that Fee-For-Service medicine is in deep trouble. HealthSprings Medicare Advantage plan is distributing a good bit of physician payment in the way of “shared savings”  (and recently was purchased by Cigna for almost $4 billion). Commonwealth is about to publish a report on outcomes on PCMH projects across the nation. They have found consistently improved care delivery and CMS is listening. Payment reform can be accomplished without a change in the Affordable Care Act and in the case of BC/BS by fiat. My money is on substantial payment change in Alabama Medicaid, Medicare, and BC/BS of Alabama soon.

Perhaps they’ll need primary care after all to help create a focus on quality instead of having the slickest procedures?  While my money is on primary care, don’t know that I’d bet on Academic Health Center transformation just yet.

I received the following question from a student today that I found very thoughtful but reflective of poor communication on the part of medical policy makers:

“I saw a clip of Bachmann denouncing the vaccine as forcing these ‘innocent
girls’ into getting a ‘government injection,’ implying that if you give it
to them you’re admitting and condoning that they’ll someday have
sex (which is bound to happen according to your stats today). She also
claimed you can become mentally retarded from the vaccine because of a
mother who told her it happened to her daughter. These ill-informed,
oblivious, and over- traditional views are not going to help public
knowledge or health reform. What do you think? How can health reform move forward with statements like this pulling us backward?

“On the other hand, do you think something like Perry’s executive order in
Texas for the vaccine is a bit extreme? I’m all for getting this vaccine out
to as many girls as possible, but I’m not so sure if a mandate is the best
way to go about it, because I feel like people should have the choice not to
get it. Then again, doesn’t the government mandate immunizations like polio,
tetanus, etc, so how is this different? The key thing that makes this
different is it’s an STD, but I could see that government interference with a
vaccine for an STD could easily go sour (interesting that Perry’s order was

My short answer is “Why is this different from Hepatitis B?” No one asks why they are getting Hep B (well, less than .01% of the folks). The main difference is that we ONLY know that HPV vaccine is effective for about 10 years pre-exposure and up to a certain age, whereas Hep B is partially effective post exposure (birth canal) and we now know has a much longer known immunity so we moved it to birth to prevent “chronic hepatitis B.” No one questions why we are giving a shot for a disease known to be caught through blood and body fluid exposure to innocent babies. This may happen with the HPV vaccine (to prevent congenital warts, perhaps?) but it’ll be a while. The big question is did Texas pay full price or get a significant discount for buying in bulk?

In the interest of disclosure I did receive training regarding the Gardasil in the late 2000’s and was on their speakers’ panel for a year. I chose to do this because IT IS A SHOT THAT PREVENTS CANCER (see Snopes to debunk the stupid e-mail). How often do I get to say I prevented cancer? For now,  every time a 9-12 year old comes to the office. Under the Affordable Care Act, for  no co-pay so as not to discourage people from having their children’s cancer prevented. Under Governor Perry, would have been the same. Under President Perry, apparently not so much….

The state of Alabama has a generous retirement system for teachers and other public employees. After working for 25 years (regardless of age), you can retire. This has been a boon for teachers (by far the largest employee group in the state). The legislature was successful this past session  in putting into place an increase in the employee match over the strong objections of the teachers. The problem was not the cost of the pension itself, which has been relatively secure as a result of investments on the behalf of the System. What will bankrupt us is the cost of health insurance. If a teacher retires at 47 (possible under the current system), he or she will be retired for 15 years longer than his or her working life. The health insurance product that is offered (PEEHIP) is a PPO. This means that the beneficiary pays a fixed amount and if he or she goes to a preferred provider there is little or no “skin in the game” for either one. As health care costs have risen, the premium paid by the retiree (about $4,000 annually for family coverage if not Medicare eligible) is only 30% of the total premium ($12,000 annually) with the rest paid by the state. Back when high health care costs were economic multipliers that were  GOOD, a report identified that

…healthcare payments surpassed $1.4 billion and over $1.3 billion went to Alabama providers and facilities.

Now that health care costs (for PUBLIC EMPLOYEES) are bad

Alabama’s PEEHIP program needs an immediate comprehensive strategy for cost containment and pre-funding of PEEHIP benefits for future retirees. Of the three options available—raising taxes, reducing government spending, and reforming PEEHIP—only the latter two have the potential to both save the state money and keep the state’s economy from further harm.

I would argue that health care costs are what they are, they are very expensive for certain people in Alabama, and they are possibly most expensive for retired teachers. There are many things that we can do to reduce the cost of health care, but the first rule of change is that people have to want change for it to happen. In an editorial on the Kaiser Family Foundation website, Drew Altman talks about the realm of the possible. The regulations surrounding the Affordable Care Act are being written and put forward for public comment at a fairly rapid pace. As he points out

The regulations give states substantial flexibility in structuring exchanges, should they choose to set them up. (If a state doesn’t establish an exchange, then the Federal Government will operate one in the state.) In crafting the draft regulations, federal policymakers had to weigh how prescriptive to be. For example, they had to decide whether to prohibit insurance company representatives from serving on the boards of exchanges, or require exchanges to aggressively negotiate with insurers. In general, they erred on the side of less, rather than more, requirements.

My dream is that Alabama Medicaid, Alabama Blue Cross (the folks that manage PEEHIP) and our Republican physician governor will get in a room and petition CMS to allow a grand experiment on how we can do better. We should be able to provide adequate care for our poor, cost effective care for our retirees, and allow choices such that if you want to pay for excessive care, you can (at the risk of hastening your own death). If only Richard Nixon had gotten this law passed the first time around.

Personally, I find that the most objectionable feature of the conservative attitude is its propensity to reject well-substantiated new knowledge because it dislikes some of the consequences which seem to follow from it – or, to put it bluntly, its obscurantism. I will not deny that scientists as much as others are given to fads and fashions and that we have much reason to be cautious in accepting the conclusions that they draw from their latest theories. But the reasons for our reluctance must themselves be rational and must be kept separate from our regret that the new theories upset our cherished beliefs.

Fredrick Hayek

To follow-up on my previous post, we seem to find ourselves in a position where the overwhelming evidence is that we do not live in the country with the best health care in the world, only the most expensive (with a thanks to Barbara Starfield, who passed away this week, for steadfastly pointing this out). The previous point I was trying to make was that there is a role for regulation in various aspects of our life and health care seems to be one of them. Poorly regulated health care delivery has led to excess capacity in the cities, diminished capacity in rural and underserved areas, and care that is excessive and expensive overall. It has also led to poor general health (see We’re #37 for an in-depth analysis). It was reading comments from another health care blog that reminded me of another potential cause of poor care delivery that regulation must change.

The Dartmouth Atlas Study has looked at variations in health care for over 20 years. The study began, very simply, because investigators began asking “Why are certain rates of surgery so much higher in one place than in another (geographically proximate) place even though human beings don’t vary that much?”  What they have found are some dirty little secrets about our care system:

Regarding the supply of care

Simply put, in regions where there are more hospital beds per capita, patients will be more likely to be admitted to the hospital. In regions where there are more intensive care unit beds, more patients will be cared for in the ICU. More specialists will result in more visits to specialists. And the more CT scanners are available, the more CT scans patients will receive.

In regions where there are relatively fewer medical resources, patients get less care; however, there is no evidence that these patients are worse off than their counterparts in high-resourced, high-spending regions. Patients do not experience improved survival or better quality of life if they live in regions with more care. In fact, the care they receive appears to be worse.

Regarding physicians role in the demand for care

We see dramatic variations in rates of surgical treatment for other conditions where multiple treatment options are possible, such as chronic angina (coronary bypass or angioplasty), low back pain (disc surgery or spinal fusion), arthritis of the knee or hip (joint replacement), and early stage cancer of the prostate (prostatectomy). Such extreme variation arises because patients commonly delegate decision-making to physicians, under the assumption that doctors can accurately understand patients’ values and recommend the correct treatment for them. Yet studies show that when patients are fully informed about their options, they often choose very differently from their physicians.

Regarding the type pf doctor we train

Increasing the number of physicians will make our health care system worse, not better. First, unfettered growth is likely to exacerbate regional inequities in supply and spending; our research has shown that physicians generally do not choose to practice where the need is greatest. Second, expansion of graduate medical education would most likely further undermine primary care and reinforce trends toward a fragmented, specialist-oriented health care system. Current reimbursement systems strongly favor procedure-oriented specialties, and training programs would almost certainly respond to these incentives. Third, workforce expansion will be expensive. If outcomes and patients’ perception of access improved as supply increased, then we could debate whether an expansion of training offers better value than investments in preventive care, disease management, or broader insurance coverage, which have known benefits. Instead, the costs of expansion will limit the resources available for necessary reform efforts without any evidence-based promise of a benefit.

In short, the evidence is clear. The bastardization of the market has brought us not only poorly organized and distributed care, but extreme excesses of useless care. I am willing to pay for my share of necessary medical care to ensure that if I incur an illness others will pay for me. I am also willing to support a public system that rewards physicians for delivering care of proven high quality. I am increasingly unwilling to support a system that rewards excesses in the manner that ours does. If we must maintain specialists pay at current levels, let’s stop training the excess and pay the current ones not to deliver excessive care like we did for tobacco growers not so long ago. At least then we will have healthier Americans.

From Kaiser Family Foundation, information found here