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My wife (and editor) is a columnist for a hyper-local start-up trying to compete with our local newspaper. She wrote a column, published today, on the trials of one of our (now deceased) “urban chickens.” The story takes the reader from the designer chicken coop to the vet who specializes in urban chickens, through the diagnostic testing (mostly physical exam), and the outcome (the chicken had to be “euthanized”). We have had several conversations about this event in our household, mostly around how a vet can charge so much money to diagnose a bird that one can get pre-cut up at Food World for 69 cents a pound with a coupon. Mostly, I filed this under people with extra money do odd stuff for their animals and vets are willing to work with us to facilitate this behavior. I couldn’t help but reflect that in the old days, the county agent would have provided the diagnosis (“That’s bad”) and offered a free solution (wringin’ its neck). Or so I learned from watching reruns of Green Acres while I was growing up.

In catching up on a backlog of New England Journal articles, I came across an article that points out the cost-effectiveness of environmental prevention (either through creating opportunities such as walking and bike paths or prohibiting bad behaviors such as driving without seat belts) when compared to individual focused efforts such as screening for colon cancer. I also read the review of the Insitute of Medicine report on childhood obesity in a subsequent issue. Disturbing was the breakdown of attribution of cause by political ideology, with “conservatives” more likely to blame children for their own obesity. Another Bloomberg article points out that physicians are at times willing accomplices in subverting any requirement for personal responsibility. The writer documents physicians self-referring into a surgery center that gives them a tremendous profit in exchange for only referring folks with the “right” insurance and looking the other way as the insurance companies were milked (or bilked, depending on the outcome of the lawsuit) for excess payments.

In short, to improve the health of the country we are going to have to make societal changes that lead to prevention, convince 30% of the population that this is not socialism, and find ways to keep physicians and others from gaming any new system. Paul Grundy, my friend with the Patient Centered Primary Care Collaborative, would see the chicken story as a metaphor for a broken system but would understand the need for a county agent approach. He sent me an advanced copy of  their newest report (to be released September 6) entitled “Benefits of Implementing the PCMH: A review of cost and quality results, 2012.” The Patient Centered Medical Home is a way to organize care delivery that combines the best of high value physician interaction, rewards for population health, and identification and elimination of waste. The new assessment of this method of care delivery is:

The PCMH improves health outcomes, enhances the patient experience of care and reduces expensive, unnecessary hospital and ED care.

It is being implemented across the country with the following consequences:

  • As medical home implementation increases, the Triple Aim outcomes of better health, better care and lower costs are being achieved.
  • Medical home expansion has reached the tipping point with broad private and public sector support.
  • Investment in the medical home offers both short- and long-term savings for patients, employers, health plans and policymakers.

Note that the outcome for human patients (better health) is different than the outcome for chickens (stewpot). I hope for the sake of all of us that we achieve these outcomes (for people). Now if only we can bring a County Agent to Mobile who knows about chickens.

Last week I spoke of a goal for care delivery in Alabama that I believe is achievable.  This goal is not Alabama specific although given some of our health markers I suspect we have more “opportunities” than most. This goal was long on vision but short on specifics. Today I want to offer nine specific challenges to us all (targeted to consumers because we are all health care consumers) that I believe will help push the health care delivery system in Alabama towards that goal. If we as patients and/or a provider demand care in this manner, it will happen (maybe).

1) If quality care exists in your community, use it

This is the most important point of them all. We all know that people choose a physician based on affability, availability, and ability is assumed. Unfortunately in rural America ability is not assumed. The phenomena of bypass is a testament to this fact. Patients need to be educated regarding certification by accrediting bodies and the implication regarding “ability. This means the JC for hospitals and NCQA for ambulatory sites.  Physicians need to demand transparency. Post practice data and encourage others to make practice data available. Hospitals are now making hospital data available  Patients need to be educated to be vocal if demands are not met and most importantly, not to just vote with their feet

2) Demand improved  primary care (and be willing to pay for it)

Communities need to be taught how to recruit and retain a primary care physician. There is a lot of work that has been done on this. The academic work can be found here and a resource can be found here.

3) Seek out and use “Medical Homes” for health care

The American Academy of Family Physicians has been working for the past 5 years on creating a type of primary care practice for the future. They refer to their model as the Patient Centered Medical Home (PCMH) and more information can be found here. Family physicians have been called America’s best kept secret. The majority of them are changing over their practices to Patient Centered Medical Homes.  In a PCMH quality care is documented, measured and improved. The patient experience is enjoyable and patients are encouraged to communicate and self-manage problems. Technology is used to improve the care experience. The care experience is continuously improved. There will be a certification process that will probably be through NCQA.

4) Find physicians who have conquered the digital divide

Without electronic health records, it is almost impossible to accomplish chronic disease management. With an electronic health record, however, a VA in rural West Virginia showed a significantly improving 12 of 13 care processes and 3 of 6 clinical outcomes (HbA1c, LDL, cholesterol).  There are now Health Information Exchanges being developed that will facilitate E-prescribing, receipt of structured lab results, and sharing patient care summaries across unaffiliated organizations. In addition, congress has directed the development of Regional Extension Centers to help physicians “get connected.” Alabama’s Center is Al-Rec. These centers are charged with providing education and outreach to providers, assist with vendor selection and purchasing for electronic health records, and provide workflow design consultation. In addition, these centers are tasked with promoting interoperability.

5) Find a doctor comfortable with telehealth/telemedicine

Telemedicine is effective but expensive, We have very  good evidence for improved outcomes in toxicology (Poison Control) where Every $1 spent on manning phones saves more than $7 in avoided health care charges. We also have evidence for ophthalmology, orthopedics and fracture care,  telemetry, stroke treatment, and dermatology. Unfortunately, the expense is difficult for many practicing physicians to cope with but if patients were to demand remote access there are effective solutions.

6) Demand a focus on quality

Rural hospitals that use established guidelines, such as the American Heart Association’s  GWTG-CAD performance measurements,  mortality is same as in urban settings. The performance measures mentioned above include recommendations such as early aspirin use, smoking cessation counseling, and use of certain drugs at discharge that are very easy to follow. Better systems, not more expensive equipment, save lives and are easily achievable in rural America.

7) Demand provides in your community to collaborate, collaborate, collaborate

If there is a community health center (CHC), a rural health clinic, and a critical access (or small rural hospital) in your community, encourage collaboration. Only 19% of critical access hospitals  report  a collaborative relationship with CHCs. Barriers include a lack of knowledge about the other and competition for patients. In communities where this collaboration happens, there are improved primary and preventive health services, improved Inpatient care, better 24 hour emergency care and  better access to specialty care.

8 ) Encourage mental health and primary care to work together

Primary care is already used 50% of the time for those seeking care for mental illness. Persons with mental illness are more likely to make a visit to their primary care doctor to receive care than they are to go purposefully to a mental health professional.  Primary care doctors do have a lack of recognition of mental health issues based on billing data but this may be an artifact of the billing system. Although there is currently a lack of integration of general medical and mental health services, there is a groing trend for physicians in private practice as well as rural health clinics to offer mental health services on site. This needs to be encouraged.

9) Work to build a healthy community

Health care delivery can only go so far. A healthy community is needed to move a community to being full on chronically ill individuals to one full of individuals who are chronically well.

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.

An object with a large mass moving at high-speed (such as a Navy ship) requires a lot of effort to turn as shown here. Health care consumes almost 20% of the economy, has a lot of momentum, and changing the direction is going to take a lot of energy. The Affordable Care Act includes several provisions that will move healthcare, discussed here.  Many practices are experimenting with changes in care delivery and mechanisms of payment, documented by the Patient Centered Primary Care Collaborative here. The American Academy of Family Medicine has posted resources on practice change for established practices and residency training sites here. We are graduating 16000 physicians every year, though, that may not be exposed to any of this. The AAMC has identified 12 medical schools (out of approximately 120) who are trying to expose students to different types of care delivery, discussed here, but we are not trying to influence medical students in an organized fashion.  Because of the 8 to 12 years needed from admission to practice, turning this ship will require new educational materials, new faculty skilled in different types of care delivery, and new methods of educating physicians-to-be.

The American Academy of Family Physic ians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association have put together a list of educational skills that they feel should be adopted by medical schools and used to teach American physicians-to-be, found here. Th reason for this, as identified by Perry Pugno of the AAFP is

“Training for PCMH practice has been embraced by the graduate medical education community, but at the medical school level, the response has been less — hence, the development of these principles to guide development at the medical school level of training,” said Pugno.

The reason these were developed is to help turn the health care ship around

It’s important for medical schools to recognize the need to invest in the future to provide these educational opportunities, Pugno said.

“We know that the current model of health care isn’t financially sustainable,” said Pugno. “We need at least some medical schools and their academic medical centers to show leadership and make some difficult choices — and change how they do business. In the short term, it will cost, but the dividends will come in the future.”

Maybe not “All Engines Reverse” but perhaps moving off “All Ahead Full.”

Beginning to sound like a broken record, the newly elected Alabama Republican state representatives are once again demonstrating their “market” credibility. They are quoted in the paper today as  identifying the state funded teachers health insurance as the place to insert needed market reforms. The legislators and the governor are quoted as having this as a priority:

Starting health savings accounts for teachers and state agency employees. An employee and the state could put money into a person’s account, which would belong to the employee and could be used to pay medical costs. Together with the accounts, the state would offer high-deductible health insurance, which would save the state money.

  Such a plan, which Bentley championed on the campaign trail, could cut the number of insurance claims paid by the state because people, in theory, would be less likely to seek medical care that wasn’t absolutely necessary if they had to pay more of their own money for it, said William Ashmore, chief executive of the State Employees’ Insurance Board.

As I have discussed before, HSAs are good theory but haven’t been shown to improve health or reduce risk taking behavior.  This was looked at more in-depth here and here (subscription required) with the following observations from the literature.

  • Cost savings for a care event have never been documented. For the most part the health costs seem lower because healthier people tend to use HSAs and spend their health care dollars on things such as dental work, vision care such as lasik, braces, cosmetic procedures, and maternity care.
  • Chronic illness care costs more in these types of plans and the “catastrophic” coverage often doesn’t kick in leaving people to make “hard decisions” regarding life saving treatments
  • People using these types of plans tend to disregard preventive recommendations leading to fewer immunizations, PAP smears, and mammograms and more late stage and preventable illness
  • People tended to make poor decisions about seeking care for serious symptoms (such as chest pain)

So why does this idea not die? Possibly because it is consistent with the  constant message from groups like the Heritage Foundation denying the benefit of all government oversight and extolling market solutions (regardless of the supporting evidence). For the most part I think it has traction because it seems intuitive that if people have “skin in the game” when it comes to their health purchases they will make better decisions. We would all like to believe that humans will make rational decisions, in particular when in comes to health, as no one wants to lose one’s health. Unfortunately, as my friend Josh Freeman has pointed out, most people use very little health care so have little opportunity to make decisions and influence the market. When folks need it, however, they really need it:

Seniors, because they are also more likely to have multiple chronic health problems that require multiple hospitalizations, and because they are more likely to have cancer, which costs a lot to treat, are also disproportionately represented in the high cost group. However, they are still the minority of that group. These high-cost users are the “outliers”, and also include other people with cancer, people with trauma, as from auto accidents, requiring multiple surgeries, and premature and sick babies requiring incredibly expensive care in neonatal intensive care units.

What HSAs do is encourage those people who are low utilizers to spend more on things that provide a marginal benefit, thus raising healthcare costs. A better way would be to work within the confines of the Affordable Care Act to create efficiencies within our state (as is being done in other states). If we are lucky our legislators will come to this conclusion as well before the HSA lobbyists sell them a new policy for the teachers and folks like me are left to clean up the mess.

A note for clarification: Apparently, state employees already can opt into an HSA. Someone should probably brief the Governor-elect on the existing options.

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 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 have lived on the Gulf Coast for all but 5 of my 50 years. I grew up in Baton Rouge, Louisiana and now live in Mobile Alabama. I was educated in the public schools during the height of the de-segregation battles and my experiences were colored by those battles in a number of ways. I ran track in high school and was in the racial minority on that team (as well as among the slowest). I have worked at South Alabama to increase minority representation in the medical school as well as the residency class. Although aware of race, I try to not let racial awareness influence my decisions in any way (and hopefully am successful most of the time).

I began thinking about race because of the events of the past week. The first was my trip to Uriah. I was asked to go and represent the Alabama Rural Health Association and speak to a group of black ministers (their word, not mine) on “ObamaCare.” As we drove to the church (go north past Little River, go over the bridge into the next county (no sign, turns out to be Monroe), take a left after the first two towns (churches, really) onto the dirt road) I couldn’t help but reflect on how difficult it was to make ends meet in this part of America. Although only 1 hour away from my home, it seemed like another country.

The ministers were acutely interested in what I had to say. I pulled up information regarding the benefits soon to be made available as a result of the passage of the Affordable Care Act and expressed my concern that state leaders may not avail themselves of these opportunities unless prodded. The ministers are very concerned about their congregants as well as their own health (which it turns out could use some help as well). The most interesting question I got was whether the reaction to “ObamaCare” was as much a function of President Obama’s race as it was his policies. Given that every President since Harry Truman has tried and failed I am more impressed by his abilities than disappointed by the reaction of some.

My second observation is a consequence of my visit to the PCPCC Stakeholders meeting in DC. Aside from the obvious contrast in settings, I remain concerned as I attend these meetings and see large corporations (Whirlpool, Boeing), government agencies (the VA, Tricare, Medicare) and large provider groups report success as they transform the process of care and see little of it in Mobile. I had a very interesting conversation about this with Allan Goroll, MD regarding reform and the South. He pointed out that the Community Health Center Movement which is vital to providing care to 20 million (soon to be 40 million) Americans got its start in Mound Bayou Mississippi and suggested that given enough interest and willing workers more surprising things have happened.

Third was an article in the New England Journal of Medicine about health care reform and Medicaid. In this article, the author reports that Medicaid has undergone a fundamental change. He reports that historically the program was seen as a poorly designed safety net, only to be used by the very poor. The not so very poor either had to find reduced healthcare or go without. As written into the Patient Affordabilty Act, Medicaid will act as a true safety net, functioning as a provider for those between jobs which provide insurance as well as a provider for those who are unable to get insurance through their jobs. In this way, Americans will be provided a coverage umbrella which will facilitate delivery of preventive and chronic disease care throughout the life span eliminating a rush to care which now occurs at age 65 (when the time for the most effective prevention has passed).

In an article by Greta de Jong entitled Staying in Place: Black Migration, the Civil Rights Movement, and the War on Poverty in the Rural South (subscription required) the politics of the South in the 1960s are cast in a different light. The farm worker was not needed, so one interpretation of the racial politics of that time identifies the lack of attempt to develop the resources for the community was a hope that the poor, uneducated black worker would move away if starved and barred from services such as health care. The story seen in this light is one of workers fighting to access services guaranteed by a federal government while local politicians fought against these efforts.

I remain concerned that the southern states  may once again try to block the federal government as they try to deliver services to the citizens (in this case health care). The New England journal article identifies seamless health care as important to our wellbeing as a society, regardless of how access is acquired. My conversation with Dr Goroll reminded me that it was as a result of Southern community activists that we have a delivery infrastructure that can be used to deliver this care once implementation occurs. The black ministers reminded me of the importance of place, community, and being on the side of right. Let the games begin.