Thursday, April 29, 2010

All work, and little pay ... makes for an internist's busy day

Today's New England Journal of Medicine has a fascinating article on how physicians in a five physician general internal medicine practice spend their day. The practice is a level 3 NCQA-qualified Patient-Centered Medical Home with an electronic health record.

Written by ACP member Richard Baron, the article - which was covered by the Wall Street Journal blog, Washington Post, New York Times, and USA Today - describes and quantifies the work that he and his colleagues do in face-to-face visits with patients, reviewing lab and imaging studies and consultant's reports, communicating the results to patients by email or phone, and other clinically related tasks for the 8440 patients seen by the group.

This table shows the average volume of such activities each day and over the course of a year for each doctor in the group. On average, each physician in the group responded to telephone calls or laboratory results an average of 43.2 times, and reviewed 13.9 consultation reports, 11.1 imaging reports and 19.5 laboratory reports, each day.

Not included in the analysis, according to Dr. Baron, are "some high-volume categories of documents are not reported, largely because they are not carefully indexed. Such documents include administrative forms (e.g., for physical examinations for work, camp, and school and Family Medical Leave Act forms), correspondence received from health plans (e.g., disease-management letters), and reports on home care and physical therapy. Although such documents are not reported here, they represent a substantial amount of work in a practice."

Dr. Baron's analysis also doesn't include the considerable amount of time that small primary care practices spend interacting with health insurers. Another recent study found that physicians in primary care practices on average spend 3.5 hours, their clerical staff 35.9 hours, and their RN/MA/LPNs 19.1 hours per week on health plan administrative tasks.

Dr. Baron concludes:

"At a time when the primary care system is collapsing and U.S. medical-school graduates are avoiding the field it is urgent that we understand the actual work of primary care and find ways to support it. Our snapshot reveals both the magnitude of the challenge and the need for radical change in practice design and payment structure."

Dr. Michael Barr, ACP's Vice President of Practice Improvement and Advocacy, echoes his point:

"The resources Dr. Baron's office expends to deliver high quality, patient-centered care are typically not paid for in the current health care system. Patients place a high value on the responsiveness of physicians and their practice teams (see CPI Video). To promote and sustain the type of care that patients desire and physicians want to provide, payment systems much change."

In my view, Dr. Baron's article is a wake-up call to policy-makers. If we are going to ensure that patients have access to high-performing general internal medicine and other primary care practices, we need to develop payment structures and revenue streams sufficient to support the value of the clinical work that falls outside of the face-to-face encounter and the overhead involved. We need to employ team-based models to relieve primary care physicians from some of the clinical work involved that could be handled appropriately by trained non-physician health professionals. We need to streamline and reduce health plan interactions. We need to leverage the functionalities of electronic health records to help primary care practices implement best practices. And we need to ensure that health reform doesn’t impose more unfunded administrative and clinical mandates on primary care clinicians.

Today's questions: How representative is Dr. Baron's group's experience with that of your own practice? Do you agree with his call for "radical change in practice design and payment structure" and if so, what radical change do you think is needed?

Tuesday, April 27, 2010

Guess what? Most aren't angry about health reform

I just got back from a wonderful week in Toronto, Canada. No, I wasn't up there to take tips on how to impose socialized medicine on an unsuspecting public, notwithstanding what some of you may incorrectly-surmise about my political leanings. Rather, I was there to attend ACP's annual scientific meeting, during which I had the opportunity to serve as faculty for three separate scientific sessions that discussed the impact of the new Patient Protection and Affordable Care Act (PPACPA) of 2010 on internists and their patients. Several hundred ACP members attended these sessions.

And guess what? Rather than encountering doctors who were angry at the new law and ACP's support for it, I instead found an engaged and curious group of internists who are looking at health reform in a reasoned, measured and open-minded way.

I would characterize the prevailing mood as hope and uncertainty, not anger and discontent:

Hope that the law will improve access to affordable coverage and provide much-needed support to primary care.

Uncertainty about whether it would pay for itself or solve the primary crisis.

Several expressed disappointment that it didn’t do more to reform the tort system or get rid of the Medicare SGR formula. Yet only one member came to the microphone to accuse ACP of "selling out" internists, and he was vastly out-numbered by the many dozens who expressed appreciation for ACP advocacy. Most said that they are looking to ACP to be the trusted source of information on what the new law means.

Internists aren't alone in viewing the new law without rancor. An April Kaiser Family Foundation tracking poll finds that although the public remains divided on the legislation, only 30% are "angry" about it compared to the 69% who said they are "not angry." The poll also shows that the 56% felt that they did not have enough information on how it will affect them personally, compared to 43% who said they had enough. 55% said they were confused compared to the 45% who weren't. Yet many of the specific policies in the law were supported by large (bipartisan) majorities.

Most also said they got most of the information about the law from cable television, but when it comes to getting information they can trust, they look to doctors, writes Mark Blumenthal in the National Journal online. "For all their cynicism about government and the news media, when it comes to health reform, most Americans trust their doctors" more than anyone else. He cites a recent Gallup poll: 77% expressed confidence in doctors recommending the right thing for health reform, compared to 49% for President Obama, 37% for Democratic leaders in Congress, 32% for GOP congressional leaders, and 26% for health insurance companies. Blumenthal continues,

"Many of the doctors are as confused about the new law as their patients. 'Quite honestly,' one doctor told the Times, 'I don't know how to answer their concerns.' So maybe I should bump up my advice [the Obama administration] to two words:

Doctors. Stat."

This brings me back to why I was so heartened (but not at all surprised) by the measured views expressed by the internists at ACP's meeting. They understood that their patients are looking to them for advice and help, and they in turn are looking to ACP to help them understand and explain the law to their patients. They came to learn about the health reform law, not to throw bricks at it.

Today's questions: Do you think the country is ready to move beyond anger and rancor, to a measured discussion of what the new health reform really means for patients? Do you think physicians can and should lead this conversation? How can ACP help?

Wednesday, April 21, 2010

Is it too late for small practices?

I blog today from Toronto, Ontario, where ACP's elected Board of Governors is meeting to provide direction on the policies to be advocated by the organization.

One issue raised by many of the governors is the enormous economic pressure on smaller internal medicine practices, and what the ACP might be able to do about it.

Today, most physicians work in private practices of ten or fewer. An AMA survey finds "75.5 percent of physicians are office-based (61.1 percent owner, 14.4 percent office-based employee), and that this percentage increases with age from 68.9 percent for physicians under 40 to 81.2 percent for physicians over 54. Twenty-five percent of all patient care physicians, or one-third of the office-based ones, are in solo practice. Another 21.4 percent are in practices with between two and four physicians, and 12 to 13 percent (each) are in practices with between 5 and 9, and between 10 and 49 physicians. Less than 5 percent of physicians work in practices larger than that ... Only 16.3 percent of physicians report that they are employed by a hospital."

As older physicians retire, it is likely that share of physicians in smaller practices will decline relative to larger practices. The AMA reports that "only 13.6 percent of physicians under 40 are in solo practice, 23.1 percent of midcareer physicians and 36.2 percent of physicians over age 54 are in solo practice. More than twice as many physicians over the age of 54 are in solo practice as are institutional employees. At the other end of the spectrum, less than half as many physicians under age 40 are in solo practice as are institutional employees."

A recent New York Times article suggests that small practices may soon disappear; others are more bullish. Jaan Sidorov, a general internist and ACP member, blogs that "despite the dire circumstances, there are still plenty of practices out there that are and will continue to be profitable ... They won't go away and many will thrive."

The shift toward larger salaried practices pre-dates health reform. Yet it is fair to ask whether the Patient Protection and Affordable Care Act will accelerate the demise of small private practices, as some critics argue, or help sustain them. The PPAC actually includes several initiatives that could help the "bottom line" of smaller physician practice:

Streamlined insurance transactions. The federal government will issue rules to require insurers to reduce the paperwork burdens on physicians and patients, including processes relating to eligibility verification and claims status, electronic funds transfers and health care payment and remittance, claims, enrollment and disenrollment in a health plan, premium payments, and referral certification and authorization rules. A recent study found that solo or two-person practices spend 3.5 hours weekly interacting with health plans, significantly more than practices with 10 or more physicians.

Lower health insurance premiums. Small practices, like other small businesses, will be able to buy coverage for their employees through pooling arrangements (called state health exchanges). Premiums won't be based on the actuarial risk of the practice's own employees, but on all people included in the pool. If a small practice chooses not to provide health insurance, its employees will be able to purchase coverage through the exchanges, with subsidies to help them afford it if they earn less than the 400% of the federal poverty level.

Support for primary care practices. The legislation authorizes Medicare, Medicaid, and private health insurers to pay primary care physicians for managing and coordinating care through a Patient-Centered Medical Home, which creates the potential for smaller practices to earn additional revenue from a monthly risk-adjusted monthly care coordination fee in addition to fee-for-service. A new Center on Medicare and Medicaid Innovation will fund pilot tests of broad payment and practice reform in primary care. Local community health teams will be established and funded to provide direct support services to practices, such as care coordination personnel for smaller primary care practices that can’t afford to hire such staff on their own. A new grant program will fund local primary care learning collaboratives to assist practices in implementing best practices and learning more about the PCMH model.

Better collections and higher Medicare and Medicaid fees. The Center for Studying Health System Change found that in 2008 "on average, physicians who provided charity care provided 9.5 hours of charity care in the month preceding the survey, which amounts to slightly more than 4 percent of their time spent in all medically related activities ... Levels of charity care were highest among physicians in solo or two-physician practices (71.5%)." It stands to reason, then, that smaller practices will benefit the most from having more people covered and being able to pay their bills. The law also increases Medicaid payments to primary care physicians to no less the Medicare rates, and provides eligible primary care practices with a 10% Medicare bonus for office, home, nursing home, and custodial care visits.

All of these may help. But smaller practices also need access to trusted advice. ACP’s Center for Practice Improvement and Innovation is expanding its resources, including a new, free, web-based resource, the AmericanEHR Partners Program, to help physicians and other healthcare professionals compare, evaluate, select and learn how to use certified EHR systems effectively. The ACP Medical Home Builder provides affordable, accessible on-line guidance and resources for practices involved in incremental quality improvement changes or significant transformation of their practices.

I think that that the physician practices that do well in the future will be those that are able to demonstrate to buyers of health care that they are able to provide measurable "value" for the money being spent, defined as good or better outcomes at lower cost. With the right mix of supportive public policy and trusted advice and practical resources to help them succeed, I believe that the future for smaller practices may be much brighter than conventional wisdom suggests.

Today's questions: How do you see the future of small private practices? How can ACP help?

Friday, April 16, 2010

The SGR Farce

Once again, Congress is playing with fire by not enacting a permanent solution to the Medicare SGR physician payment cut problem.

Congress got itself tied up in knots trying to figure out a way to reverse a 21% cut in Medicare payments to doctors that went into effect yesterday. It ended up agreeing to legislation, which was signed into law late Thursday evening by President Obama, to restore payments to the pre-cut (2009) levels through the end of May. The action, though, may have come a dollar short and day late: CMS has indicated that it had no choice but to tell carriers to begin processing claims with the 21% cut, starting yesterday.

Even though those payments will now be retroactively restored, it is ridiculous that physicians have had to deal with what ACP President Joseph W. Stubbs, MD, a private practice general internist himself, called the "chaos" created by Congress' dithering on the SGR.

Now, I know that some people are going to somehow try to pin the blame for this on "ObamaCare." But the truth is that even if health care reform had never seen the light of day, physicians would have been dealing with the 21% cut. And it is also a fact that the House of Representatives passed legislation this past fall, with the support of President Obama, to permanently eliminate the SGR and replace it with a system that would provide higher updates to all physician services.

The problem now is the U.S. Senate, where not one darn thing can get done if a single member objects - that is, without going through a series of procedural votes that require at least 60 votes.

ACP refuses to play the game of helping Congress get the votes it needs for a short-term reprieve. Instead, we are asking our members to tell Congress that the only effective outcome is throw out the SGR and replace it with a system that provides fair, stable and positive updates.

Yes, getting rid of the SGR will result in higher Medicare spending than if Congress allows the doctor fee cuts to go into effect. Some fiscal conservatives therefore object to a doctor pay fix because it will increase the deficit. But they should know that it is ridiculous to pretend that Medicare will save money from scheduled cuts that everyone knows will never take place.

It is the failure of both political parties, over many years, to honestly deal with the SGR, including the cost of getting rid of it, which has resulted in the current ongoing SGR farce. And yet members of Congress wonder why the public holds them in such low regard.

Today's questions: How will the SGR cut affect you? What are you telling your members of Congress?

Wednesday, April 14, 2010

Is Obama Care really a GOP plan in sheep’s clothing?

One of the difficulties in sorting through the points and counterpoints on health care reform is that that many of the critics use sweeping statements to characterize the new law, saying that it is "government-run" health care or "socialized medicine." Proponents of the law then find themselves essentially responding "no it's not. . ." or trying to defend government at a time when confidence in it is at an historic low.

An op-ed today in the Washington Post by Norman Ornstein, a resident scholar at the conservative- and Republican-leaning American Enterprise Institute, argues that if one actually looks at the specific elements of the new health reform law, "ObamaCare" is in line with ideas long-championed by Republicans:

"To one outside the partisan and ideological wars, charges of radicalism, socialism, retreat and surrender are, frankly, bizarre. The Democrats' health-reform plan includes no public option and relies on managed competition through exchanges set up much like those for federal employees. The individual mandate in the plan sprang from a Heritage Foundation idea that was endorsed years ago by a range of conservatives and provided the backbone of the Massachusetts plan that was crafted and, until recently, heartily defended by Mitt Romney. It would be fair to describe the new act as Romneycare crossed with the managed-competition bill proposed in 1994 by Republican Sens. John Chafee, David Durenberger, Charles Grassley and Bob Dole -- in other words, as a moderate Republican plan. Among its supporters is Durenberger, no one's idea of a radical socialist."

(Ornstein has a broader point to make about how Obama's policies have been labeled, but I'm not going there.)

I wish we could get the point where the debate on health care is about what is actually in the legislation, instead of rehashing broad characterizations that are intended to invoke an emotional response of support or opposition, instead informed debate about what the legislation does and does not do.

Today's question: What do you think of Ornstein's argument?

Wednesday, April 7, 2010

Think you know what health reform really will do?

Well you don't. Neither do I, and for that matter, nor does anyone else.

Our health care system is enormously complex, so any law that is designed to reform the system also is enormously complex. The more complex something is, the harder it is to predict its results.

Yet we pretend to know for sure, without one iota of doubt, what the Patient Protection and Affordable Care Act (PPACA) will do. Supporters say that it will provide coverage to everyone, improve outcomes, lower costs, and make just about everyone happier and healthier. Opponents say it will result in rationing, bankrupt the country, and even lead to Armageddon.

Yet the honest, truthful answer is that neither side can really have all that much confidence in their assessments of the law's impact. If they were honest with themselves, and with us, they would acknowledge that there is a tremendous degree of uncertainty about how the PPACA will work in practice. Some elements of the law, like how it will provide access to health insurance coverage, can be assessed with greater confidence than, say, the long-term impact on health care costs and the federal budget deficit.

Today's online edition of the Annals of Internal Medicine, ACP's flagship peer-reviewed journal, has a commentary from me that reflects on the certitudes and uncertainties of health reform. I give my best educated assessments on the potential impact of the PPACA on providing affordable coverage to all Americans, ensuring access to primary care, and reducing health care spending and the federal debt. I also make it clear that it is not possible for me to draw definitive, irrefutable conclusions about how it will work out in the end, even though I believe that the PPACA has the potential to do great good for the country, especially when compared to the status quo. But rather than re-stating my conclusions here, I encourage you to read the article and post your comments, both here and on the Annals website.

Today's question: What is your reaction to my Annals' commentary on the impact of the new law on coverage, primary care access, and health care spending?

Friday, April 2, 2010

But what's in it for me???!!!!

One of the critiques directed at ACP (but also at other physician membership organizations, like the AMA) is that organized medicine didn't get "enough" out of health reform for the doctors. By "enough," they usually mean permanent repeal of the Medicare SGR cuts and caps on non-economic damages in malpractice awards.

To be clear, ACP fought (and will continue to battle) for more effective medical liability reforms, including caps, and a permanent end to the cycle of Medicare SGR payment cuts. There are good reasons why neither ended up in the final legislation, which I will come back to in a future blog.

Today, though, I want to address the broader issue being raised by asking what physicians "got" out of health reform. The implication is that ACP should have approached health care reform more like a labor union or trade association, entities that exist principally to protect and promote the economic interests of their members. They engage in "transactional politics" - that is, they approach legislation - from the standpoint of "what's in it for me?" And if they can't get a deal that gives "enough" to their members, they oppose it.

Five years ago, political strategist Joe Trippi blogged on how transactional politics is diminishing our democracy:

"Transactional politics. I'll give you a tax cut for your vote. Health care for everyone for your vote. I'll keep you safe for your vote. Everything is a transaction with the citizen in a transactional democracy - and both of our nation's political parties fell to transactional politics long ago. It happened so slowly. It's like your eyes adjusting so well to the dark and living in the dark for so long - that you don't realize that the bright light of our democracy has been diminished. Transactional politics breeds the politics of 'what's in it for me?' 'What do I get?' At the expense of the common good - something almost never mentioned by our nation's leaders - in both parties - over the past few decades."

Transactional politics may be the raison d'etre for unions and trade associations, but physician membership organizations like ACP are bound by a higher purpose, which is to pursue public policies to serve the broad interest of the public, not just the economic interest of their members. ACP's mission is "To enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine" and a principal goal is "To advocate responsible positions on individual health and on public policy relating to health care for the benefit of the public, our patients, the medical profession, and our members."

ACP also has endorsed the Charter on Professionalism, which was published in the Annals of Internal Medicine, APC's flagship journal. The Charter states that "the medical profession must promote justice in the health care system, including the fair distribution of health care resources" and "A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession." [emphasis added]

By this standard, then, ACP was bound to look at health care reform not exclusively out of "concern for the self-interest of the physician or the profession" but by how it would improve access for patients and the public.

This doesn't mean that ACP didn't pursue (and achieve) policies that had direct benefit to members, including increased Medicare and Medicaid payments to primary care internists (which, it believes, will also have benefit to the public). But ACP's advocacy put a premium on how the legislation would improve access to affordable health insurance coverage. Some recent comments on this blog have taken issue with this, with one writing "it is time for the ACP to change its name to American College of Patients - this suits its mission better than the current name."

I understand and respect the principled reasons why some ACP members believe that the legislation will not be to the benefit of the public. But I would hope that most ACP members wouldn't want ACP to act like a union or trade association that exists only to engage in the transactional politics of "what's in it for me?" The question that ACP asked itself throughout the legislative process was "Will health reform result in 'public policy relating to health care for the benefit of the public, our patients, the medical profession, and our members?'" In the end, it decided that it would, even though the final law didn't include everything it (and its members) wanted.

Today's questions: Do you think ACP should approach legislative advocacy like unions and trade associations that make decisions on legislation based on "what's in it for me?"