Monday, March 30, 2009

Will physicians embrace "the change we need?"

Health Affairs has published a scathing blog critique of the medical home by Dr. Caroline Poplin, a primary care internist. Her post, in my view, represents a deep misunderstanding of the model. In response, my colleague, Dr. Michael Barr, and I responded on the ACP's behalf.

I don't plan to repeat our response to Dr. Poplin here, although I invite you to read the exchange and post your own comments, here or on the Health Affairs blog.

Her commentary represents a broader problem, though. Most primary care physicians are keenly dissatisfied with the current system. Yet when a new idea is proposed to fix the status quo, like the medical home, it is greeted with skepticism, cynicism, and even downright hostility.

For example, primary care physicians intensely dislike the financial pressures to increase the numbers of patients they see per hour, yet this is largely the consequence of a fee-for-service payment system that rewards doctors for seeing patients face-to-face and ordering more procedures. But proposals to sever the link between payment and volume, as the Patient-Centered Medical Home would begin to do, are greeted with deep distrust.

Primary care physicians loath the constant barrage of "hassles" imposed on them. Pre-authorization, utilization review, documentation guidelines - the list goes on and on - are rightly viewed by physicians as intrusions that sap the energy and satisfaction from their professional lives. Yet much of the paperwork associated with practice is the result of fee-for-service. Why? Because any system that bases payment on volume invites "controls" to reduce the volume of "unnecessary" procedures, as determined by the payer. A different payment model that rewards physicians for efficient, effective and high quality outcomes, not volume, could reduce or even eliminate the need for such intrusive utilization controls.

I understand why physicians, and particularly primary care doctors, are skeptical. Primary care physicians have had a long history of being subjected to the latest reforms (think RBRVS, gatekeeper, capitation and pay-for-performance) that are supposed to make their lives better, only to find that they either fell short or made things even worse. One ACP member has described it to me as "death by a thousand cuts" from well-intentioned health reformers. I would be the last to suggest that ideas like the medical home should not be subjected to scrutiny and challenge - that is why, for instance, ACP supports pilot testing of the medical home before it is adopted more widely. What concerns me though is when healthy skepticism becomes outright cynicism.

The other challenge is trying to explain the latest new ideas to physicians. As Dr. Poplin's commentary demonstrated, even when ideas are developed by the primary care physician organizations themselves, they may be poorly understood by rank and file primary care physicians.

Going forward, it is self-evident that we need new payment and delivery models, not just for primary care physicians, but also for specialists. Such models should move away from pure fee-for-service reimbursement to basing compensation on accountability for the quality and effectiveness of care provided.

Today's question: Will physicians embrace the changes we need in how care is organized and paid, or allow their distrust and cynicism to rule the day?


james gaulte said...

"Largely the consequences of a fee-for-service payment system".
I disagree, the disintegration of primary care, is largely the consequence of price controls enacted by Medicare and reinforced by the hegemony of private insurers and laws that restrict the collective bargaining of associations or confederations of physicians.

PCP said...

Dr. Poplin makes some valid points that those of us in the trenches have long noted.

Her caution about this train moving so fast that she fears unintended consequences ala yesterdays reforms to help primary care are well founded. If we look at the RBRVU system and the constitution of the RUC committee it is clear atleast in retrospect that there was never any real chance to improve the lot of primary care. As such, these genuine concerns cannot be brushed aside as cynicism, they are grounded in reality.

Her concerns about the viability of this model for smaller practices too is a very valid one. The issues facing primary care are not ubiquitous. They vary by geography and many local factors influence it. Integrated health systems will obviously have a better chance at valuing primary care since they have better control over their specialty services. Such issues take on more nuance in more rural single hospital town settings. In this regard trusted professional organisations like the ACP have a very large and influential role, which will doubtless be expanded as this effort takes root. On this issue, the AMA to be blunt has lost all credibility with primary care physicians(perhaps that explains the source of some of the cynicism). The point Dr Poplin makes about the access issues for patients finding Primary care Physicians while simultaneously less than 2% of medical students planning Generalist IM careers is truly a testament to the gravity of the problem at hand. In part their career choices are driving health care costs, however we cannot legislate away their freedom of choice we can only incentivise/disincentivise it.

Her point about the underpayment of complex care and the "overpayment" of simple care is a very valid and real one, in an era where many seem reluctant to distinguish between the very real differences in training/skill/liability and other differentials between primary care Physicians and Mid-level providers. When I see a complex, multiple chronic illness patient in follow up from a Hospital admission and take the time to do a good job, everything/everyone except my practice bottom line benefits. In that 30 minutes or more I would have spent, I can easily see 4 patients with Strep throats. The payments however would reflect very differently, since (usually the Strep. Throats are younger and have commercial insurance and demand exceptional "customer service", the complex patients are older with medicare/medicaid and slow moving and patient. In any case the payments will be vastly superior for the 4 Strep Throats and inferior for the complex patient even with the duly adjusted service level codes).
Hence the nascency of the "minute clinic" concept. So in essence either treating Strep. throats is overvalued or the former is undervalued. I think we all realise which is the case. Mid level practitioners are adamant that they provide comparable care for 85-90% of cases, they speak nothing of why those other 10-15% are paid at or near the rates of their expertise. Surely there is a disconnect in this. Additionally, it does not appear that the American Public is ready to accept Primary care entirely detached from a Physician's watchful eye. However, this does not appear to translate into any tangible value to the career value of Primary care Physicians. One that would be crated, for example by a mandate that all mid level practitioners must practice under the supervision of a Physician in an advanced medical home. Perhaps politics gets in the way here. The ACPs recent policy paper on NPs in primary care does nothing to alleviate these concerns in younger doctors. If an NP is acceptable as substitute (even in a pilot) as a practitioner overseeing an "advanced medical home" then, where exactly does that leave a Physician's role?

My view of such a home is where I employ a NP as someone who can assist me in running one, but where I ultimately am responsible and answerable to the patient.
Dr. Poplin's point about adequate reimbursement for the medical home is very important. In the free market, concierge practices are charging up to $5000 a year retainer fees for generally younger and healthier patients. Most practitioners realise that for a public and more broad and public program such fees are not possible. However, given the overall value provided, and given health insurance premiums of now well over 12K a year for the average family. An average retainer of $600 appropriately risk adjusted up or down should not cause heartburn to payers given the central role of the advanced medical home if they are genuine about the needed changes.

Her points about the lack of reliability of guidelines and the elitism of academic medicine are also a genuine concerns. One look at the JAMA controversy, over Dr. Leo's commentary in the BMJ, and JAMA editor in chief Catherine DeAngelis' dismissal of him in such vitriolic terms along with the countless Industry ties of Academic elites speaks to the reason behind the distrust of some of these guidelines amongst the rank and file of Medical practitioners. If we are to use these guidelines in such definitive ways, surely we ought to be more certain about their foundations. Additionally the genuine love of profession of the hardy foot soldiers left in Primary care General IM ought not to be underestimated. Second guessing them and their intentions for their patients is truly sad, and IMHO may just turn out to be the final nail in coffin, for the diminishing generalists left surely are not the greedy, money motivated, scheming types. To them the mere implication that they do not have the best interests of their patients at heart could be more toxic to their morale than any payment cut can. Those of us left are a hardy bunch, we value our autonomy as much as or more than our incomes. We stand accountable to our patients but to the rest we demand accountability. We resent that PCPs are especially selected for scrutiny.
Our cynicism of Academic elites in well founded even if the lay press does not realise this. The academic elites have shown scant regard for the art of medicine because they know nothing of it. Their advocacy for EBM at the political level was never matched in any balanced way by the advocacy for the value of the art of medicine.
Hence advocacy for the Doctor-Patient relationship suffered in our very capitalistic culture, rendering us needy of filling that with concepts such as the advanced medical home.

Finally one of the drivers of costs is the unwillingness of our countrymen to accept death as an inevitable part of life. When this is done alongside a strong doctor-patient relationship, we can truly make a dent in the ridiculous end of life costs.

A few weeks ago, I was called to the hospital by an intensivist to speak with a family of one of my patients. An elderly man who was admitted with a pneumonia, and who developed multi-organ failure. Everyone from the Intensivist to the Cardiologist to the Hospitalist had tried in vain to convince the family to let go.
I didn't admit the patient, I hadn't seen him or his family in weeks. Yet,I went in, looked over the case and spoke with the family members and advised them about my medical opinion(for free) and that was what it took to allow them to let go(saving thousands of dollars to medicare and more importantly probably needless suffering).
That is the power of a strong Doctor-Patient relationship. That is what we have allowed to be trampled upon, and that is what we must pay attention to, if we want to regain our professional role and standing. The vitality of the art of medicine should never be underestimated.

Steve Lucas said...


I found your comments on end of life care and cost of particular importance. A few years ago a friend was battling cancer only to find out his oncologist had called his wife and made the plea for additional "treatments'. The doctor sighted their insurance and assets as the prime driver in this decision. Later she would try to withhold pain medications as a means to coerce compliance with her treatment design. Treatments that would have only prolonged his suffering.

When he needed it most my friend was left without an advocate.

Steve Lucas

Jim Webster MD, MACP said...

You are indeed correct. The unbridled fee for service reimbursement system is THE problem. It determines how care is organized and delivered, encourages overutilization throughout the system and provides cover for the 30% overhead (profits) of the insurers which add nothing to care, but greatly contibute to costs. It also increases the many hassels of running a small business which make primary physicians an endangered species. A total re-engineering of how care is payed, organized and delivewrd is what is needed. Patient centered medical homes are a great start. They would benifit physicians, but more importantly would be a great boon to patients.
Jim Webster MD, MACP

Anonymous said...

I am a primary care internist, who continues to struggle every day to keep a positive attitude. I agree with Dr Gaulte that much of the current problem lies at Medicare and private insures doorsteps. They dictate what, when and how much we are paid for services provided, what medications can be used and when. These are the same people who organized medicine are begging to do something. These latest solutions sound like retreaded ideas from the past which little in reality do little to help patients or doctors. This system can not function unless we give our tacit approval. When do we begin to retake control of our lives, rather than continue to plead for help from the very people who put us in this situation? I am still waiting for dis-organized medicine to do something positive other than trade my future away and tell me to be grateful.