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med27I write this blog for 3 audiences. Many of these posts are written for the lay audience. Someone will ask me while mowing the grass about ebola or chikungunya fever and I will provide my (not so) learned opinion in blog form. My friends then access my deep thoughts through Facebook so that at the next cocktail party the conversation goes like this:

Friend: I read your post about chikungunya fever

Me: Chick-a-what?

It seems I have a short memory.

Another audience I write for is folks who make policy. I have a small following of people who actually have some influence. When I write about access to care for Medicaid-gap Alabamians (my favorite subject), insurance monopolies, or the fact that a certain legislator is both against Medicaid expansion and for trying to insert a phrase into a law that takes money away from Medicaid and puts it into a client’s pocket that is the audience that I’m writing for. So, after writing a blog like that, a conversation might go:

Person in position of authority: Who is this Perkins character?

Person who actually knows me: Some commie, I suppose.

Lastly, I write for students of family medicine. In my day job, I run a department of family medicine. This means that I am involved with teaching medical students (most of whom will not go into family medicine) and resident physicians (almost all of whom will go into family medicine), seeing underserved patients (who likely do not know they are seeing a family physician), and supervising faculty physicians (ALL of whom know what they do and let me know about it ALL the time). This blog post is for this audience (but all of you others feel free to read as well).

This past week, the president of the American Academy of Family Medicine, Dr Robert Wergin, announced that Family Medicine 2.0 has arrived. Why the reset? As Don Berwick and T.R. Reid point out at the accompanying press conference, we in family medicine have been working on changing the way we do business since 2000. Meanwhile, the rest of the the medical-industrial complex, not so much. In the words of Dr Berwick, the time to change healthcare is NOW.

What we as a specialty have committed to  is this:

  • Give patients the care they need when they are most vulnerable
  • Care for patients regardless of age and health conditions, and work to sustain an enduring and trusting relationship with them
  • Be each patient’s first contact for health concerns. Address all their health concerns, and resolve most of them
  • Help patients with preventing, understanding, and managing illness
  • Navigate the health system with patients, including coordinating with specialists and staying connected with patients before, during, and after time spent in a hospital
  • Set health goals that adapt to each patient’s needs as defined by them
  • With the care team, use data and best science to prioritize and coordinate services most likely to benefit patients’ health
  • Use technology to maintain and enhance access, continuity, and relationships, and to optimize patients’ care and outcomes
So, medical students, you are on notice that you need to leave our rotation knowing that this is who we are. Residents and prospective residents, you will be held to this standard. Patients, this is our promise to you. Faculty, we have some work to do.

Don Berwick left CMS last week. When he was appointed, he was vilified  because he used the word “rationing” in polite company. So vilified, in fact, that he was never able to gain the needed 60 votes in the Senate or confirmation and was appointed via the recess route. As a consequence, his appointment expired after a calendar year and it was for this reason that he stepped down.

Dr Berwick was never known for his shy, retiring demeanor and now that he is no longer in government service he is once again “telling it like it is.” He was awarded the Picker award at the Institute or Healthcare Improvement annual meeting and in his address he seemingly called out his opponents:

The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry ‘foul’ about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people — elders, the poor, the disabled –who are least able to bear them,” he said, according to a copy of his remarks.

Dr Berwick points out that the country is at a crossroads. If we attempt to reduce our country’s health care responsibilities through indiscriminate cutting, his concern (as is mine) is that the cutting will begin at the “voiceless and the poor” but won’t stop there. Soon, as a consequence of lower benefits, less access, increased payment burden for necessary services, and delays in care delivery, our country’s health care quality will further decay and the cost will remain high. Dr Berwick identifies six domains that our health care system has failed us:

  • Overtreatment – the waste that comes from subjecting people to care that cannot possibly help them – care rooted in outmoded habits, supply-driven behaviors, and ignoring science.
  • Failures of Coordination- the waste that comes when people – especially people with chronic illness – fall through the slats. They get lost, forgotten, confused. The result: complications, decays in functional status, hospital readmissions, and dependency.
  • Failures of Reliability – the waste that comes with poor execution of what we know to do. The result: safety hazards and worse outcomes.
  • Administrative Complexity – the waste that comes when we create our own rules that force people to do things that make no sense – that converts valuable nursing time into meaningless charting rituals or limited physician time into nonsensical and complex billing procedures.
  • Pricing Failures – the waste that comes as prices migrate far from the actual costs of production plus fair profits.
  • Fraud and Abuse – the waste that comes as thieves steal what is not theirs, and also from the blunt procedures of inspection and regulation that infect everyone because of the misbehaviors of a very few.

How do we avoid this undesirable fate? Dr Berwick refers to the Affordable Care Act as a “majestic law” and feels that if we work effectively we can save $1,000,000,000 in health care costs. He outlines 5 prinicples all of us in healthcare should follow:

  • Put the patient first. Every single deed – every single change – should protect, preserve, and enhance the well-being of the people who need us. That way – and only that way – we will know waste when we see it.
  • Among patients, put the poor and disadvantaged first – those in the beginning, the end, and the shadows of life. Let us meet the moral test.
  • Start at scale. There is no more time left for timidity. Pilots will not suffice.
  • Return the money. This is the hardest principle of them all. Success will not be in our hands unless and until the parties burdened by health care costs feel that burden to be lighter. It is crucial that the employers and wage-earners and unions and states and taxpayers – those who actually pay the health care bill – see that bill fall.
  • Act locally. The moment has arrived for every state, community, organization, and profession to act. We need mobilization – nothing less.

It is not going to be easy work. As Dr Berwick points out, the “pace of change is majestic.” We now have the framework for health care improvement. Leadership will now not come from the top but will come from those of us in the trenches. Let’s get to work!

We are slowly working on redesigning the way we deliver care in our Family Medicine Center. We have focused on care of folks with chronic illness for a while but recently (with the passage of the ACA and the coming of ACOs) we are working on hitting the sweet spot.  A couple of weeks ago Dr Berwick made it easier. He published an article in the New England Journal of Medicine that identified areas of care delivery that primary care physicians will be required to focus their quality energy on in the future if they expect payment and recognition in a post-ACA world. For those, like me, who believe the future is now below are the areas where documentation of level of care (followed by improvement) in the primary care setting will be expected:

Ability of the practice to provide an enjoyable patient and caregiver experience

• Getting timely care, appointments, and information

• How well your doctors communicate

• Helpful, courteous, respectful office staff

• Patients’ ratings of doctor

• Health promotion and education

• Shared decision making

• Health status or functional status

Ability of the practice to facilitate care coordination —transitions

• Risk-standardized, all-condition readmission

• 30-Day post-discharge physician visit

• Medication reconciliation

• Care transitions measure

• Management of ambulatory-sensitive conditions: diabetes; chronic obstructive pulmonary disease (COPD); congestive heart failure (CHF); dehydration; bacterial pneumonia; urinary tract infections (UTIs)

delivery of services related to preventive health and early disease detection

• Influenza immunization

• Pneumococcal vaccination

• Mammography screening

• Colorectal cancer screening

• Cholesterol management for patients with cardiovascular conditions

• Adult weight screening and follow-up

• Blood-pressure measurement

• Tobacco-use assessment and intervention

• Depression screening

Care for members of at-risk populations —diabetes

• Composite and individual measures (glycated hemoglobin, LDL cholesterol <100 mg/dl, blood pressure

<140/90 mm Hg, tobacco nonuse, aspirin use)

• Poor glycemic control (glycated hemoglobin >9%)

• Blood pressure control in diabetes

• Screening rates for microalbuminuria

• Dilated eye exam; foot exam

Care for members of at-risk populations — heart failure

• Left ventricular function assessment

• Left ventricular function testing

• Weight measurement

• Patient education

• Heart failure prescription rates for left ventricular systolic dysfunction (LVSD)

• Angiotensin-converting–enzyme inhibitor or angiotensin-receptor blocker (ACE/ARB) rates for LVSD

• Warfarin therapy for patients with atrial fibrillation

Care for members of at-risk populations — coronary artery disease

• Coronary artery disease (CAD) composite and individual measures (oral antiplatelet therapy for patients with CAD; drug therapy for lowering LDL cholesterol; beta-blocker for patients with CAD with prior myocardial infarction; LDL cholesterol <100 mg/dl; ACE/ARB therapy for patients with CAD and diabetes, LVSD, or all of the above)

Care for members of at-risk populations —hypertension

• Blood-pressure control rates (<140/90 mm Hg)

• Hypertension plan of care

Care for members of at-risk populations— COPD

• Spirometry evaluation

• Smoking-cessation counseling

• Bronchodilator therapy based on FEV1

Care for members of at-risk populations — frail elderly

• Screening for fall risk

• Osteoporosis management in women who had a prior fracture

• Monthly INR for beneficiaries on warfarin

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

The rules for creating a Teaching Health Center (which I discussed before here and here) have been posted. If you are thinking about applying, note that the deadline for submission is December 30, 2010 at 8:00 pm ET.  Here is a link to the application page. Below are some excerpts from their announcement with my commentary. 

The government is willing to pay for direct expenses associated with sponsoring an approved graduate medical education training program and indirect expenses associated with the additional costs relating to teaching residents in such programs out of this money. This money will go directly to the THC instead of being filtered through a hospital. Although the program period is one year, it is HRSA’s intent to fund qualified THCs for the entire five year THCGME program period pending satisfactory performance of awardees and availability of federal funds (putting the THC at risk if congress changes its mind but also putting the THC on notice that they may not take advantage of this progrma to continue to create traditional residency training programs). Funding can only be used for the costs of new residents in a newly-established THC or an expanded number of residents in a pre-existing THC (this is not to pay for residency slots currently being paid for but to try and create new slots which is a problem because many current slots are underfunded). These payments will be as much as $150,000 per resident per year (which shows you how much it costs to train residents).

Payments must directly support the THC ambulatory training site (to try to keep hospitals from taking the money and re-purposing it). If a THC-affiliated teaching hospital receives GME funding from Medicare or other sources for the new THC residents, the THC cannot claim that portion of the time for HRSA GME payments (you can’t double dip).

 Corporate Eligibility

Eligible entities include community-based ambulatory patient care centers that operate a primary care residency program in high-need, underserved communities. (This will move training into the community where it belongs).  

 Training Program Eligibility

Only specific residency training programs program (family medicine, internal medicine, pediatrics, internal medicine-pediatrics, obstetrics and gynecology, psychiatry, general dentistry, pediatric dentistry, and geriatrics) are eligible (Hospitals can’t use it to create radiology residencies).

 Funding Limitations

Successful THCs have common elements, foremost of which is an institutional commitment to a dual mission of medical education and service to an underserved patient population, including underrepresented minority and other high risk populations.  In addition, there is significant patient- and community-based input into THC operation and management; and THCs have also demonstrated progress toward innovative models of patient care delivery such as the patient-centered medical home, implementation of electronic health records, population-based care management, and use of interdisciplinary team-based care (HRSA is not interested in funding the same old stuff)

Measureable outcomes

Measureable outcomes will include practice patterns of graduates such as whether they are providing primary care, and whether they are serving in safety net settings one and five years after completion.  It may also include outcomes such as creation of interprofessional teams that provide person-centered care, improvement in quality parameters, improvement in patient outcomes, and improvement in use of electronic medical technology. Not only does the successful applicant have to say they are going to do good things, they have to actually do them.

I look forward to seeing the applicants and how they propose to change our training…

The Wall Street Journal published a very good article several weeks ago about how payment is set for physicians provided clinical services. It does a good job of highlighting a little known aspect of care, the “fee schedule.” Historically, fees were set in a very disorganized fashion and the introduction of Medicare necessitated the creation of an infrastructure (one might even describe it as a bureaucracy) to establish a fair amount to pay physicians. Importantly, many other insurances use Medicare as a basis to set their rates. Over the years there has been much give and take regarding who can request payment for a certain procedure and what the payment should be. For as long as I have been a physician, my colleagues have complained about non-physicians determining who gets paid and how much. Turns out it’s been the physicians setting the rates all along. Reading this article will give those who want to allow physicians to police their own profession without non-physician oversight pause.

Much of the payment structure was established when physicians did a lot more in the hospital with only occasional tweaking over time. The payment was bundled, with each procedure having a pre-hospital component, a component in the hospital, and a post-procedure follow-up visit. This was supposed to even out (I suppose) unpredictable complications. In the interim, much of the care has moved away from the hospital but

For instance, one operation to treat male urinary incontinence wraps in payment for 118 minutes of hospital visit time after the day of surgery, though 2008 Medicare data show it is done around 80% of the time outpatient or in a doctor’s office. Stephanie Stinchcomb, manager of reimbursement for the American Urological Association, says the surgery used to be largely inpatient; its payment was last updated based on a RUC evaluation in 2003. It’s not clear if a new analysis will find doctors should now be paid less for it, she says.

It seems that the committee only moves in one direction

Out-of-whack Medicare doctor payments are supposed to be corrected in a required review every five years. MedPAC says in the three previous reviews, the RUC endorsed boosts for 1,050 services, and decreases for just 167. Many recommendations on which services to examine came from doctor societies. The upshot may be that payments don’t keep up with medical realities when procedures become easier or faster, MedPAC said.

And has ended up accomplishing one thing

A recent analysis for the Medicare Payment Advisory Commission, or MedPAC, a Congressional watchdog, calculated how much American doctors would make if all their work was paid at Medicare rates. It found that the primary-care category did the worst, at around $101 an hour. Surgeons did better, at $161. Specialists who did nonsurgical procedures, such as dermatologists, did the best, averaging $214, and $193 for radiologists.

These disparities have increased tremendously over the past decade. To be honest, I feel well compensated for what I do but I can guarantee you that students are well aware of the pay differential and it enters into specialty selection.

What should we do? One physician posted a comment

I don’t really understand this attack on medical specialists. I am one such physician and I can tell you that we serve a valuable role in the medical community. … Thus, I propose a different alternative. I believe the days of primary care physicians are coming to an end. Like the death of the dinosaurs. They will be replaced by lower cost medical providers like PAs and ARNPs most likely in the next quarter century. Perhaps PAs and ARNPs could serve as the hub/organizer to refer to the most appropriate specialist. This may save the system money. …. I am a big fan of primary care physicians but I still believe it is inevitable they will be extinct.

If you have read this blog, Josh Freeman’s blog, Paul Grundy’s work, or Barbara Starfield’s work you will know that this is not the case. This would, however, help certain physicians to maintain their income. As I have previously discussed, it will lead to more procedures on unsuspecting patients who are told that more is better. Let’s change the system instead, shall we?

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…

As you might be able to determine from reading my entries regarding the new health reform law,  I am excited about the possibilities and am looking forward to seeing how the regulations are written that implement the law. There are many agencies who will have a hand in regulation, but none more important than CMS. This agency sets the tempo and tone for the entire health care enterprise in this country. They dictate payment rules for Medicare. They dictate eligibility requirements for Medicaid. They set rules regarding the training of resident physicians. In short, although we may have believed we have a “market-based” health care system, in reality I worked in a system whose rules were dictated by some faceless bureaucrat that ran the Center for Medicare and Medicaid Services. This has been brought home to me at intervals when I am told that I have to turn my training program upside down to satisfy “CMS.”

This is why I am very excited about the news that Don Berwick will be named to head up CMS. I have been a huge fan of his organization, the Institute for Health Care Improvement, for the last 10 years. I first became aware of this organization when I decided that there must be a better way to see patients in a primary care setting than the way we were doing it. I began looking for others who believed in primary care and ran across IHI and their “Idealized design of Clinical Office Practice” project. Although we were unable to participate in these programs, I eagerly read about their efforts to incorporate:

  • Access: Care is available when patients want and need it. 
  • Interaction: Every patient is the only patient.
  • Reliability: “All and only” effective and helpful care is given.
  • Vitality: The practice is sustainable and continually innovating.

into clinical practice and we have been striving to make our changes in our clinical practice leading to enhanced care as a consequence. Much of the work of the Patient Centered Primary Care Collaborative is built on IDCOP principles.

Don Berwick’s organization has as its goals:

 No needless deaths
 No needless pain or suffering
 No helplessness in those served or serving
 No unwanted waiting
 No waste
 No one left out

and the strategy to accomplish this is to build will and optimism for change, drive broad scale adoption of sound changes, invent new solutions, build the future healthcare workforce, and to stay vital for the long haul by achieving excellence in loyalty, financial stability, and worklife for IHI.
Although I doubt he knows who I am, my interactions with Don have been rewarding and we practice better medicine because of my interactions with him and his organization. I look forward to watching him (should he be confirmed) change the culture at CMS. These are interesting times…