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I have a neighbor who is riding his bike from Mobile Alabama to Springfield Missouri to call attention to the need for better mental illness care. They happen to have a son who suffers from mental illness and thus (as many of us do) got involved because of their own son and then become involved with an organization that has a much larger purpose. Not only is D. G. riding his bike across country but his wife, Connie, is an officer in the local chapter of NAMI. Part of D.G.’s reason for taking this on, he says, is that

Even if we don’t raise money, if I can change the attitude of just one person relative to mental illness, it’s worth it. We talk about every other disease but we won’t talk about mental illness. There’s just such a terrible stigma associated with it.

Mental illness has been stigmatized since Biblical times. with Descartes being the most recent scapegoat. Part of the stigma was, I suspect, due to the nature of the affliction. Unlike pneumonia with its fever and coughing, those afflicted with mental illness have no outward manifestation, so the common belief seems to be that if they would only try hard enough, they could control their behaviors. In modern times we have devised treatments but the situation has not improved as much as we would hope. Some people don’t respond to the medications. Others may respond partially but feel so fuzzy headed that they want to stop the medication. Others respond so well that they feel normal, so figure they are cured and quit taking the medication for that reason. All in all, not a good illness to have and very difficult to treat, but an illness just like many other chronic illnesses. Because of the need to keep people taking medicine that makes them feel bad even when they are feeling better, mental health professionals developed “Assertive Community Treatment” options that include (from Wikipedia)

  • a clear focus on those participants (clients) who require the most help from the service delivery system;
  • an explicit mission to promote the participants’ independence, rehabilitation, and recovery, and in so doing to prevent homelessness and unnecessary hospitalization;
  • an emphasis on home visits and other in vivo (out-of-the-office) interventions, eliminating the need to transfer learned behaviors from an artificial rehabilitation or treatment setting to the “real world”;
  • a participant-to-staff ratio that is low enough to allow the ACT “core services team” to perform virtually all of the necessary rehabilitation, treatment, and community support tasks themselves in a coordinated and efficient manner—unlike traditional case managers, who broker or “farm out” most of the work to other professionals;
  • a “total team approach” in which all of the staff work with all of the participants, under the supervision of a qualified mental health professional who serves as the team’s leader;
  • an interdisciplinary assessment and service planning process that typically involves a psychiatrist and one or more nurses, occupational therapists, social workers, substance abuse specialists, vocational rehabilitation specialists, and certified peer specialists (individuals who have had personal, successful experience with the recovery process);
  • a willingness on the part of the team to take ultimate professional responsibility for the participants’ well-being in all areas of community functioning, including most especially the “nitty-gritty” aspects of everyday life;
  • a conscious effort to help people avoid crisis situations in the first place or, if that proves impossible, to intervene at any time of the day or night to keep crises from turning into unnecessary hospitalizations; and
  • a promise to work with people on a time-unlimited basis, as long as they demonstrate a continuing need for this highly intensive and integrated form of professional help.

The goal is to maintain the client’s ability to function in society, despite a high cost and potential loss of freedom. If done right, it is expensive. Unfortunately, it is often easier to allow people with mental illness to wander about with no access to care and walk on the other side of the street as we seem to do commonly here in Alabama.

As we fight to destigmatize mental illness and offer appropriate treatment to those who have it, society seems to be moving to stigmatize other folks with certain types of chronic illness. The most recent example is that of diabetes mellitus. I went to a presentation about health coaching at the National Rural Health Association meeting. This presentation discussed a model of care that, although less intensive, offers many elements of Assertive Community Treatment. The goal of the therapy is to move folks with diabetes to a disease-free  state by working with them to encourage lifestyle changes, medication compliance, and disease self-management. It is surprising how rapidly the conversation turns to “disincentives” such as more money in insurance premiums, encouraging “self control” through shame and stigmatization, and “if only they would stay out of McDonald’s.”

As we come to understand how much of our healthcare costs can be reduced through positive lifestyle modifications, I hope that we can celebrate the triumph of modern medicine over the frailty of the human condition. Instead we seem to be moving to punishing those who are less than perfect. A trend I will continue to fight.

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Those of you that read this blog on a regular basis are no doubt aware that I feel very strongly about the need for the American health care delivery system to perform better. This is based on many years of working with a group of patients who would be in much better health had they had sufficient access to high quality health care. In addition, I have been training physicians for many years, helping them to develop the skills to deliver high-end family medicine interventions to a group of patients in need only to have them take jobs in lucrative areas of health care that lead to high patient satisfaction but do not improve health outcomes. Lastly, I work in a medical school setting where we deliver very expensive care very inefficiently. As a potential consumer of health care, I have to wonder why others can’t see what I am certain of: change is needed and fast.

In the 1990s, it was apparent that the health care system in America was causing a problem. As I have written previously, the high cost of health insurance led to lower real wages (all increases went to health insurance premiums), 15% of Americans were denied all but emergency access to health care, and care providers who were so inclined were able to game the system and make lots of money. Good managed care was able to co-opt the system and this resulted in better access, reduced costs, and better quality to a certain extent. We believed that the value of excellent managed care was self-evident so were surprised when the entrenched establishment was able to take several glaring examples of bad managed care and tar the entire care delivery process with them.

Those interested in care reform then took the intellectual high road. Crossing the Quality Chasm, published in 2001 by the Institute of Medicine, had as its opening paragraph:

The American health care delivery system is in need of fundamental change. Many patients, doctors, nurses, and health care leaders are concerned that the care delivered is not, essentially, the care we should receive (Donelan et al., 1999; Reed and St. Peter, 1997; Shindul-Rothschild et al., 1996; Taylor, 2001). The frustration levels of both patients and clinicians have probably never been higher. Yet the problems remain. Health care today harms too frequently and routinely fails to deliver its potential benefits.

Aside from a few headlines regarding deaths caused by medical errors, those in health care continued to deliver expensive procedures regardless of potential benefit to the patient. Kaiser Family Foundation began documenting disparities in 1994 and became one of the best sources of data documenting health disparities, but the disparities continued unabated through the 2000s.

President Obama took public interest in changing our broken health care system, combined with support for change from major corporations as a mandate. He took the evidence from the IOM report, the data from Kaiser, the support from industry and used it to convince Congress of the need for change. The passage of the Affordable Care Act is the consequence of these forces coming together. While not perfect, the bill offers a significant increase in access to health care with the potential to improve care and reduce costs. Unfortunately the hard work has not yet been completed. Building a framework for change into a law is one task. Convincing people that the framework is necessary and sufficient is another. The vast majority of people are fed up with the “system” but happy with their doctor(s). They are unhappy with the cost of other people’s care but unconcerned with the cost of their care. Why would they want to move out of their “comfort zone?”

In his important work Leading Change: Why Transformational Efforts Fail, John Kotter identifies the 10 reasons that large-scale change fails to occur at the corporate level. Error #1 is not establishing a great enough sense of urgency. In the 1990s, the HMO system was dismantled in many areas very quickly because of patient demand. A sense of urgency prevailed. Those who want to see “Obamacare” fail are doing their best to establish a sense of urgency for “repeal and replace.” Their case is  not being made with data and policy suggestions but through hyperbole and outright deception.

Mike Huckabee, currently “not running” for the Republican nomination for the presidency, has come out against the “comparative effectiveness research” aspect of the ACA. Although

even Republicans [likely] recognized that we shouldn’t be spending so much money on drugs, devices, and procedures that don’t actually make people better than existing treatments.

But Republicans and their allies in the conservative movement no longer say such things. Instead, they say that government will use CER to deny people beneficial treatments–that it is, as Huckabee puts it, “the poisonous tree of which death panels will grow.”

What could be more urgent than stopping that?

Or what about the claim that if the federal government can mandate health coverage they can force broccoli ingestion as well. That should put fear into many Americans regarding the overreaching federal government as well as mandatory broccoli burgers. STOP THE BROCCOLI!

Those of who want to see most (if not all) Americans with access to high quality health as well as leave something in the national treasury for our children need to yell from the rooftops that the ststus quo is unacceptable and the ACA, while not perfect, is the best start on improvement we’ve had in 20 years. My friend Paul Grundy is doing his part. Don Berwick will likely lose a job as a result as well. Let’s all be real clear: #37 is UNACCEPTABLE.

At the Rural Policy Institute I heard many people’s views on the Affordable Care Act (or PPACA as it is known by folks that don’t use “ObamaCare” in polite company). As a prelude to our Hill visits we heard from representatives of HRSA, the VA, the National Health Information Technology office, and the USDA. We heard about the problems with PPACA from Senators Pat Roberts (R-Kansas), Senator Mike Johanns (R-Nebraska), Senator Mike Enzi (R-Wyoming). We also heard about the huge opportunities of the Affordable Care Act from Senator Daniel Inouye (D-Hawaii) and  Senator Bernie Sanders (I-Vermont). I had to leave before Senator Ben Nelson (D-Nebraska) spoke so I don’t know if he spoke of the Affordable Care Act or PPACA.

The highlight for me was getting to hear Don Berwick. Dr Berwick spoke of his new vision for CMS

CMS can and should be a major force and a trustworthy partner for the continual improvement of health and health care in this country. We all agree that we want the highest quality health care system possible, a system that coordinates and integrates care, eliminates waste, and encourages prevention of illness. With over 100 million beneficiaries depending on us each day, CMS has an important role to play in improving our nation’s health care delivery system. We are striving to meet this challenge, while attending diligently to the crucial, day-to-day work of our operations and preserving and enhancing the integrity of our payments, our programs, and the Trust Funds.

He again stated his vision to bring the Triple Aim to CMS. He said this would be accomplished through boundarilessness, speed and agility, unconditional teamwork, value innovation, and customer focus. He then went into specific work that CMS was focusing its energy on. This work can be categorized as involving excellence in operations, improved care for patients, integrated care for populations, and improved health for populations and communities.

Like Senator Sanders I think the Affordable Care Act offers incredible opportunities for care transformation, even more so after hearing Dr Berwick.

Addendum: Dr Berwick’s talk can be found here at 1:13:00

Y’know, a town with money is like a mule with a spinning wheel. No one knows how he got it and danged if he knows how to use it!

Lyle Lanley

As you may recall, there was an oil incident in the gulf. As a consequence, Mobile Alabama is expecting a rather large windfall. Apparently, the fines associated with the oil spill could range from 4 to 16 billion dollars and are supposed to stay in the Gulf Coast region. Consequently, each of the affected states (though some feel more affected than others) will get some of this money to mitigate the damages.

Alabama put together a Coastal Recovery Commission, which was created by the Governor and populated by his office, various local politicians, and representatives of coastal concerns. This commission was charged with creating a roadmap leading to the transformation of the gulf region into one of increased resiliency. In their words:

We must position ourselves to respond not only to future oil spills but also to other forces beyond our control, including everything from hurricanes to sudden shifts in the economic environment. We must assure a future for our coast that strengthens its appeal to visitors and investors from around the world and protects its environmental assets for generations to come.

To do this they determined that a roadmap approach would be most effective.

Then, we will propose bold but attainable goals, based on the most authoritative research and reality-tested best practices. Our roadmap should guide Alabama, regional, and national leaders in implementing policies that protect, preserve and enhance the assets that make Alabama’s Gulf Coast so important, not only to Alabamians, but to the Gulf region and the nation as a whole.

The commission published the “Roadmap to Resiliance” here. The commission identified problems not only with the physical enviroment but the human environment (health care, education, economic development, and insurance). Problems identified may be directly related to the spill but more often than not were related to our physical location (hurricane alley) as well as the long term problems associated with limited educational resources and an economy that suffers from too little diversity.

The solutions take up 17 pages. Some are fairly vague but “feel good” such as “”Restore and enhance habitat for fisheries as needed.” Some are very concrete: “Require fire protection every 1,000 feet where public water is available.” Some are relatively inexpensive: “Combine county efforts for regional events.” Some would take all of the money for one project: “Build the I-10 Bridge and make it spectacular with reasons for travelers to stop at the Mobile end, not just pass on through – follow the example of the Sydney Opera House or the Bilboa, Spain, museum – a building that could house a Southern Cultural Center or the like.”

The aspect of this report that caught my eye was written up here in our local paper.

A gubernatorial commission making recommendations for oil spill recovery urges the creation of a Mobile-based Center for Coastal Health with a wide-ranging mission to address and research primary care, mental health, lifestyle issues and disaster response.The proposal for the independent center at the University of South Alabama is outlined in the 198-page report that the Alabama Coastal Recovery Commission gave to Gov. Bob Riley this month in Montgomery.

The commission report said that the center should focus on four areas: occupational health for coastal populations; primary care and mental health; disaster preparedness and management; and minority health care, including the mental health needs of immigrant and refugee populations.

Dr. Richard Powers, medical director for the Alabama Department of Mental Health, said the spill revealed that the coastal region is largely ill-equipped to “deal with its unique health needs” during times of crisis. Powers, a Riley appointee to the commission, said, “It would be nice to have a group of smart health care professionals wired to the national networks to be looking after our welfare, and not have to summon them up every time a disaster happens.”

Start-up of the center would likely cost $30 million to $50 million, according to Powers. He suggested that the funding should come from fines and grant payments made by BP PLC, majority owner of the ruptured well.

According to the commission report, the new center and its faculty would be supported by a foundation established for that purpose.

Now that’s a mule I can get behind.

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.

In September the local paper carried an article detailing a march to promote Certified Professional Midwives to attend births in the state of Alabama (being one of 11 states who specifically prohibit such). As a physician I can see both sides of this debate. On the one hand, we have overmedicalized the birth process. The United States has a rate of delivery via c-section of 31% and state of Alabama has a C-section rate of 35% (10% is the rate considered optimal and achievable). There is a lot of variation among hospitals with the highest rate for a Mobile hospital being 50% (and this is not the USA Children’s and Women’s Hospital that cares for complex patients). There is anecdotal evidence that at least some of these variation are a consequence of physician and patient convenience (the failed induction syndrome).

On the other hand, midwives were utilized when the birth rate was much higher as was the infant mortality rate, it being 44/1000 births in 1945 and 8/1000 in 2008. Medicalizing the birth process introduced many different interventions in a brief period of time (most were introduced between 1950 and 1975). It may be that the lowering of the maternal and infant mortality rates was completely unrelated to any of our interventions but that is doubtful. Concomitant with the fall in birth rates has been the expectation that every pregnancy will end in a perfect baby. Part of the medicalization is the pressure physicians may feel to intervene when faced with perceived risk to the unborn child.

I didn’t even feel compelled to respond when Dr Wiley, the president of the Alabama Academy of Pediatrics,  weighed in regarding the need to continue the medicalized status quo. His concern for the citizens of Alabama is touching, especially when he says

The next time someone suggests to you that home birth with a lay midwife is a good idea because birth is a natural process, remember this — death is also a natural process. If even one baby or mother is lost due to this legislation, isn’t that too many?

There have several doctors who have written in support of Dr Wiley, and again I was determined to sit on the sidelines on this one. Dr Mozley’s letter, published yesterday, has led me to break my silence. He is a retired obstetrician and reiterates the need for physicians to be in charge of the birth process in a hospital setting. He points out that

When I came to Alabama in 1984 as professor and chairman of the department of obstetrics at the University of Alabama School of Medicine, Tuscaloosa Branch, I found that there were 27 counties in Alabama where no physician would deliver a baby. To overcome this problem we established a one- year fellowship in obstetrics for board- certified family practice physicians. This fellowship has been well received throughout the U.S. and now is recognized by the American Board of Physician Specialists.

The practice of obstetrics requires sophisticated machines and surgical skills and should not be delegated to any lay person who does not possess these abilities and support facilities.

Interestingly, there are now 35 counties in Alabama with no ability to provide a medically assisted delivery.  Using this logic, the fellowship has actually reduced access and we should eliminate it.

As a health care consumer, it is important for an expectant mother to explore all of her options and to make the best decision possible for herself and her unborn child. Although it’s not Alabama, English physicians have studied the homebirth process and determined that it offers safety and efficacy equal to a hospital delivery for selected patients. In addition, these women would not expose themselves or their unborn child to risks associated with the possibility of an unnecessary c-section. She should ask her physician what his or her rate is and look up the hospital.

Of the 63,500 births in Alabama in 2008, less than 300 of them were at home or in a hospital that does not ordinarily deliver obstetrical care. That suggests that midwife certification and licensure may not be needed to solve an access problem. It is unclear if it will lead to improved care though it almost certainly will lead to fewer c-sections. On the other hand, Dr Wiley and Dr Mozley have missed the point. It turns out that despite increasing intervention, maternal and infant mortality rates have been stable since 1980.  More important to further reduction is not increasing technology at delivery but facilitating the delivery of preconception care. Listed below are the conditions which, if attended to prior to conception, lead to improved outcomes:

Chronic diseases: Diabetes; heart disease; high blood pressure; thyroid disease; asthma; anemia; kidney disease; metabolic and hematological disorders; depression and other mental disorders; autoimmune disease; and physical disability (access)

Infectious diseases: Vaccine-preventable diseases (rubella, hepatitis B, varicella, influenza, and tetanus); HIV/AIDS; syphilis, chlamydia, and other sexually transmitted diseases; periodontal disease; toxoplasmosis, and cytomegalic inclusion virus

Reproductive concerns: Unplanned pregnancies; contraception; infertility; adverse past pregnancy outcomes (preterm delivery, birth defects, fetal/infant death, maternal complications)

Genetic/inherited conditions: Sickle cell anemia; thalassemia; Tay-Sachs disease; fragile X syndrome; Down syndrome; cystic fibrosis; muscular dystrophy; hearing and vision loss associated with genetic predisposition

Medications and medical treatment: Prescription medications contraindicated in pregnant women (FDA’s Category X Drugs, 117 products in 2001 PDR, antiepileptic drugs, oral anticoagulants for maternal clotting disorders, and Accutane); diagnostic radiation exposures

Personal behaviors and exposures: Smoking; alcohol consumption; illicit drug use; overweight/underweight; folic acid supplement use; domestic violence; eating disorders; exposure to infections; exposures to chemicals and other environmental toxins; consumption of over-the-counter medications; hyperthermia (e.g., from sauna use)

What these have in common is that they are amenable to primary care intervention. The Affordable Care Act will allow women who to have access either through Medicaid (those with an income below 133% of FPL) or through the health exchanges (the other women of childbearing age). I hope to see Drs Wiley, Mozley and the rest educating Alabamians about the important care  that they will soon be able to access thanks to President Obama.

Seaside, Florida is a neat place to visit. On the gulf coast in between Destin and Panama City, it was built 25 years ago to function as a livable community that happened to be on the beach.When the project was begun, in 1984, the area resembled every other Gulf Coast development:

From the development’s eastern boundary to Panama City, some thirty miles away, the seashore is as crass and chaotic as any in America. Lining the highway on the Gulf of Mexico are economy-grade motels, concrete-block convenience stores, mansard-roofed refreshment stands, shops selling airbrushed T-shirts, and a profusion of cramped housing developments, each built according to a different pat formula–Tudor townhouses, weathered-cedar-shake apartments, stucco-and-tile condominiums, gray clapboard row houses, rustic log cabins, and many others. The state highway department, with unintended irony, has put up signs designating this a “scenic route.”

The developer. Robert Davis,  wanted something special and he hired an architect/planner duo, Andres Duany and Elizabeth Plater-Zyberk, to make the 80 acre site something special. Like all good architects they started with the buildings.

Every house built in Seaside is different, but within the variety is a fundamental orderliness, established by the unifying wooden walls and metal roofs, the substantial porches, the proportions of the windows, and a number of other elements, among them the harmonious colors–a rainbow of pastels.

Important in the appeal of Seaside is the attention to not just the built environment but the common environment

Davis, rejecting the traffic-engineering standards of most municipalities, kept the streets narrow. The pavement is usually eighteen feet wide–“just enough for two cars to pass comfortably.”

Andres Duany was recently in Mobile at the invitation of the Downtown Mobile Alliance. I have read much about the New Urbanism movement which he founded and so was disappointed not to be able to go to his speech. I was delighted to find it posted on  the Alliance website. Duany doesn’t dwell on what he saw here. Instead he speaks to the value of a generalist as a planner. He points out that the zoning specialist focuses on zoning and the planning specialist focuses on planning. If the policy makers allow them to make the rules without input (he’s the expert)  then the city has no character and is built for ease of use of special constituents (such as “big box” stores) and not for the citizens resulting over time in “dead malls.”

What does this have to do with Training Family Doctors? A lot, it turns out. Andres Duany is a self described generalist. He commented that during his ride from the airport he was able to identify the exact corner where the death was occurring. Like a physician, he says, he can predict what will happen, what will happen, and perhaps what it will take to correct the problem. As a generalist, he points out that the work of planning the cities by the “specialists” has left whole areas decaying. While this was not by design there is certainly a cause and effect.

There is a very good article in a recent New England Journal of Medicine (subscription required) entitled “Lessons from the Mammogram Wars.” In it, the authors point out that as a consequence of a panel suggesting that less use of a service (in this case, mammograms) might actually result in not only less cost but in better patient care. They point out the controversy is cause in part because folks who benefit from the increased use of technology (in this case the mammographers) write rules regarding optimum use of the technology and then criticize those who would suggest differently.

The authors point out that part of the problem in medicine is our belief that specialists always act in the interest of the patient alone and another part of the problem is that people want to believe that technology doesn’t lie. Thus, if you the patient have an understanding of an intervention and how the experts determine it should be used then the patient can make an informed purchasing decision without further assistance (A).

Instead, we now know that all interventions have a potential risk and a potential benefit to the patient. In the words of the authors (and illustrated as B in the illustration):

To this end, for most interventions, rather than seeking a single, universal threshold for intervention we should be arguing over a minimum of two distinct thresholds: one above which benefit clearly outweighs the risk of harm, in which case clinicians should recommend a treatment; and one below which concern about harm clearly dominates, in which case clinicians should recommend against that treatment. Between these two thresholds lies a gray area of indeterminate net benefit, in which clinicians should defer to an individual patient’s preferences — including, for example, a woman’s emotional response to her risk of breast cancer — in choosing whether to intervene

To that, I would add the gray area at the end of life for many interventions as well. It is clear that the specialists are expert at designing effective systems for certain situations and when the patient fits into these situations this results in “the best health care in the world.” It has also resulted in expensive and ineffective health care. The addition of the generalist in the mix, both at a policy level as well as at the patient care level. will result in better, more personalized care. Your family physician may not be an expert on mammograms, but let’s allow them to be an expert on “you” and what your wants and desires are. I only hope we can create a a system in urban planning as well as in health care  that values and rewards generalist discussion over blind intervention.

The Archives of Internal Medicine published an article questioning the conventional wisdom regarding physician selection. In this article they tried to correlate a number of variable with a number of indicators of “quality care” (more on this, later). The authors did find that female sex, board certification (indicating completion of a residency and ability to pass an exam on set intervals), and graduation from a domestic medical school correlated with “significantly” better performance.  Medical malpractice history, interestingly, did not indicate poor medical practices.

When looking more closely at this data, it shows some of the weaknesses of using statistics on numbers to describe behavior. The authors looked at 10,000 physicians and over a million patient encounters. They apparently analysed  all of this information with a statistical package and then looked to see if any of the better performance was seemingly due to something other than chance. They found that all physicians did 62% of the activities that were expected. Female physicians for example were 1.6 percentage points higher than male physicians in regards to performance as a group (and the other differences were equally small). Because of sheer numbers this was seen to be “statistically significant” but given that based on this a random male doctor would be correct 61% of the time compared to the females 63% I think I would find a different way to pick a doctor.

This story was picked up in the lay press by the LA Times. In fairness to the writer, she did point out the weaknesses of the study, pointed out how limited information was for doctor selection, and pointed the reader to an AHRQ website with some pretty good advice:

Look for a doctor who:

      [x] Is rated to give quality care.

      [x] Has the training and background that meet your needs.

      [x] Takes steps to prevent illness-for example, talks to you about quitting smoking.

      [x] Has privileges at the hospital of your choice.

      [x] Is part of your health plan, unless you can you afford to pay extra.

      [x] Encourages you to ask questions.

      [x] Listens to you.

      [x] Explains things clearly.

      [x] Treats you with respect.

The site goes on to explain quality care and offers a checklist to use when interviewing a physician to see if they meet your criteria.

This came up because Blue Cross/Blue Shield of Alabama has decided they are going to try to reward us primary care physicians for delivering “quality care” by increasing the visit fee by 5%. To find out whether I would qualify I decided to look on their Find-A-Doctor website to see where I stand. I was somewhat hesitant because I am an educator in a teaching practice. As such, all of the patients seen  by learners while I am a teaching attending are counted against me in addition to those patients I am personally caring for. I would like to believe our learners are delivering excellent care but belief often is trumped by evidence.

Going beyond the user friendliness of the site (too many poorly categorized physicians with incorrect practice addresses) I am pleased to say that we are delivering good (and sometimes great) care. When measured on screening for certain types of cancer as well as diabetes care we were at or above the national and Alabama average. On the other hand, we do not perform as well as we could.

This measure is done on patients who have come to our office for care. They are not asked if they want for us to provide these services nor are we paid for providing such services. Although my staff, my residents, my colleagues, and myself are certainly motivated to deliver quality care, wouldn’t it be easier if we could dedicate staff to assure quality happened? Wouldn’t it be nice if we could enroll patients to incorporate their wishes and beliefs regarding their healthcare rather than assigning patients to me based on (perhaps) a single visit and assuming they want me to take responsibility for the care plan? Wouldn’t it be better if we were paid well for delivering care for acute illness and equally well for handling chronic illness and preventive services that don’t require a visit. Oh well, at least I’m liked (search for Perkins)  by all 7 of the people who bothered to filled out the survey.

Earlier this week I posted about Blue Cross of North Carolina and how instead of trying to incent physicians to provide better care they have elected to pay more for the same old care and hope doctors do better. I also mentioned Community Care of North Carolina and they have facilitated change in North Carolina which may make the North Carolina Blue Cross “experiment” appear to be more effective than it should be. It is worth looking more closely at Community Care, especially when compared to a more traditional Medicaid “managed care” model.

I’ll use Alabama’s plan as an example. Alabama has a traditional Medicaid Patient Management program started in 2004. Called Alabama Patient 1st, it offers every Medicaid recipient in Alabama an opportunity to designate a primary care physician. All of the doctors get paid “fee-for-service” (they get money for seeing patients in the office) but this designated physician gets a small amount of “capitation” (approximately $3 per month per enrollee) and in return is expected to provide some coordination function (the most apparent one is to provide referral requests for patients who need specialty care). In addition, the primary care provider has an opportunity to collect “shared savings.” The shared savings is calculated annually and is based on

  • Efficiency – the amount Medicaid spent on behalf of a PMP’s panel compared to expected
  • Performance – Utilization of generic drugs, non-emergency services, and office visits as compared to expected.

This is calculated on a point basis with each point being worth $0.2190 from the efficiency pool and $0.0660 from the performance pool.

I feel like I understand this pretty well and yet have trouble translating my practices action into dollars in our pocket.

North Carolina had a very similar  program to Alabama’s, called North Carolina Access. In 1999 North Carolina looked at their Access program and determined that although they had accomplished a key goal (an identified primary care provider for every Medicaid recipient) they were not achieving the desired results of better care for less money. They then began work on the North Carolina Care model, discussed in detail here. This program was based on 4 principles:

  • local control and physician leadership
  • primary focus on improving quality
  • the need for public/private partnerships
  • shared responsibility at a state and local level to develop management tolls needed to provide actionable information

Currently, the plan is throughout the state. A series of local networks take responsibility for the enrolled recipients as a group (population medicine). Each network has a physician leader who serves as a medical director and focuses activities as they relate to quality improvement, cost containment, and care management.

In addition to providing traditional physician services on a fee-for-services basis, physicians are expected to follow recommended guidelines, participate in patient education activities, provide information back to the network, and provide 24/7 coverage. They get $2.50 per patient for providing these services, another $2.50 to hire non-physician case managers, and additional money will follow for providing quality care.

Easy for the docs to understand and budget for.

In short, as the Patient Centered Primary Care Collaborative has pointed out, doctors need to be paid differently:

  • The most effective way to re-align payment incentives to support the PCMH would be to combine traditional fee-for-service for office visits with a three part model that includes:
  • A monthly care coordination payment (“bundled care coordination fee”) for the physician work that falls outside of a face-to-face visit and for the heath information technologies needed to achieve better outcomes. Bundling of services into a monthly fee removes volume- based incentives and promotes efficiency. The prospective nature of the payment recognizes the up-front costs to maintain the required level of care. Care coordination payments should be risk-adjusted to ensure that there are no inherent incentives to avoid the treatment of the more complex, costly patients.
    • A visit-based fee-for-service component that recognizes visit-based services that are currently paid under the present fee-for-service payment system and maintains an incentive for the physician to see the patient in an office-visit when appropriate.
    • A performance-based component that recognizes achievement of quality and efficiency goals.

Or, put another way, when we paid people like the HMOs did, the patient didn’t get enough care. When we pay them fee-for-service like we do now in Alabama the patient gets too much care. We need a more creative system of payment.

I was sent a bit of information regarding Blue Cross of North Carolina. It seems that they don’t want to pay a management fee for chronic illness care. Instead, they will increase reimbursement for office visits because

…patients who generate the most physician orders for medical services also generate the most office visits, so doctors are getting paid extra to see the patients most in need – rather than getting a capitated rate for both the healthy and sick, Komives says.  “When you’re actually spending time with the patient in the office, that’s the value,” she adds.

Is that really the value? Interestingly, Community Care of North Carolina (the Medicaid managed care product) has found differently. By paying for the following:

Local non-profit community networks that are comprised of physicians, hospitals, social service agencies, and county health departments provide and manage care.

•Within each network, each enrollee is linked to a primary care provider to serve as a medical home that provides acute and preventive care, manages chronic illnesses, coordinates specialty care, and provides 24/7 on-call assistance.

Case managers are integral members of each network who work in concert with physicians to identify and manage care for high-cost, high-risk patients.

•The networks work with primary care providers and case managers to implement a wide array of disease and care management initiatives that include providing targeted education and care coordination, implementing best practice guidelines, and monitoring results.

•The program has built-in data monitoring and reporting to facilitate continuous quality improvement on a physician, network, and program-wide basis. 

 They have found significant cost savings and

…asthma patients experienced improved care as evidenced by greater reductions in inpatient hospital admissions and emergency room visits. Diabetes patients had fewer hospitalizations and achieved high rates of performance measures, such as primary care visits, blood pressure readings, foot exams, and lipid and A1C tests.

Some say that what BC/BS of North Carolina is actually doing is benefiting from the changes initiated by North Carolina Medicaid. While thay may not have done the heavy lifting at least they seem willing to pay for improved care. I hope that patients and the doctors realize the value is in the care coordination which can occur when given extra time but doesn’t have to.

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