Thursday, July 29, 2010

What can a '68 Chevy Impala tell us about Primary Care?

When I was a much younger man, I had a 1968 Chevy Impala. I loved its V-8 engine and spaciousness, but I paid a steep price for it. It consumed gas like a drunk on a binge. It was prone to break downs, usually in the left lane of a busy highway. Even as it consumed my limited financial resources, I couldn't count on it to reliably get me to where I wanted to be. Yet I held onto it. One day, though, its transmission gave out, and I finally had to resign myself to buying a new, more reliable, more modern, and efficient vehicle. Yet to this day, I miss my clunker.

I am reminded of this when I think about the state of primary care today. Many of us are attached to a traditional primary care model that may no longer be economically viable - for physicians, for patients, and for purchasers.

We hold onto a model where primary care doctors are paid based on the volume of visits, not the quality and value of care rendered. We hold onto a model where patient records are maintained in paper charts in voluminous file folders, instead of digitalizing and connecting patient records. We hold onto a model that generates enormous overhead costs for struggling physician-owners but generates insufficient revenue. We hold onto a model that most young doctors won't buy, as they pursue more financially viable specialties and practices. Most of the time, traditional primary care still gets patients to where they want to be - high quality, accessible, and affordable care. But like my Impala, traditional primary care is at constant risk of breaking down, as established primary care doctors close their practices, leaving their patients without a regular and reliable source of care.

Most of us are unwilling to trade in the brand we know, even as we are told that there are better models of primary care in production.

Now, I know that some readers of this blog will be offended by my comparing traditional primary care to a gas-consuming clunker. Let me be absolutely clear: I have an enormous appreciation and respect for the work being done by the hundreds of thousands of primary care physicians in "traditional" practices. They work long and hard to provide their patients with the best care possible, even as the system seems stacked against them. But I believe that the traditional primary care is not sustainable, at least not for the long haul. We may be tempted to keep pouring more money into it, but at some point, we will need to face facts and trade it in for a better, more reliable, more modern and more efficient model of primary care delivery - the Patient-Centered Medical Home (PCMH).

The PCMH is no longer just a theoretical blueprint that is years from going into production. Instead, physicians and patients are taking it for a test drive in the dozens of communities across the country that have launched PCMH demos. Federal and state governments, private insurers, and businesses collectively are putting billions of dollars into developing and assessing the PCMH model. The early returns are promising, according to an analysis by the Patient-Centered Primary Care Collaborative. And the new health reform legislation includes funding for PCMHs under Medicare and Medicaid, for community-based programs to help primary care physicians restructure their practices as model homes, to develop PCMH curricula in medical education, and to encourage adoption by Medicare Advantage plans and by qualified private insurers.

Yesterday, the federal Agency for Healthcare Research and Quality (AHRQ) announced the launch of the Patient Centered Medical Home website "devoted to providing objective information to policymakers and researchers on the medical home, ... the site provides users with searchable access to a rich database of publications and other resources on the medical home and exclusive access to AHRQ-funded white papers focused on critical medical home issues."

Physicians now have an opportunity now to test drive the PCMH, by doing their own practice assessment, using ACP's Medical Home Builder; by participating in demonstration projects in their own communities, and by learning more about it from the PCPCC, AHRQ, and from ACP.

There comes a time when a beloved old stand-by must be replaced by a newer and better model. I still fondly remember my '68 Impala, but you couldn't get me behind the wheel of one now. Primary care needs to consider if now is the time for it to trade in traditional primary care for new ways of organizing, financing, and delivering patient-centered primary care around the PCMH model.

Today's question: Is it time to trade in traditional primary care for the PCMH?

Thursday, July 22, 2010

Is having an opinion disqualifying for public service?

Many conservatives are up-in-arms about President Obama's decision to appoint Don Berwick, a pediatrician and renowned expert in quality improvement and patient safety, to lead the Center for Medicare and Medicaid Services (CMS). They object to Dr. Berwick's views on a range of issues, and to Obama's decision to use his office's authority to appoint Dr. Berwick while the Senate was out on a short Independence Day holiday recess. As a "recess appointment," Dr. Berwick was able to take office without Senate hearings and confirmation, but he can only serve through the end of the 111th Congress - that is, until the end of 2011 - unless ratified by the Senate.

Berwick, though, also has many supporters; Maggie Mahar articulates the "pro" viewpoint on Dr. Berwick's appointment in a recent Health Beat post. She observes that two former CMS administrators who served in Republican administrations have commented positively about Dr. Berwick's qualifications.

Dr. Berwick also is supported by the American Medical Association, AARP, and ACP, which said in a July 7 statement that, "Dr. Berwick's career and work at the Institute for Healthcare Improvement illustrates the drive to provide patient-centered care, patient safety, quality improvement, and care coordination in health care. He is well respected in the health-care community and known for his desire to bring constructive change to health care delivery. We share these objectives and believe Dr. Berwick will be an able Administrator and partner for change."

I think it is fair game to debate the views of individuals appointed to public office - it comes with the territory. I understand why Republicans object to Obama's decision to by-pass the usual Senate confirmation process, just as Democrats objected to President Bush's recess appointment of John Bolton as ambassador to the United Nations.

But I worry though that the hyper-partisan political environment makes it almost impossible to have a serious discussion about the views and qualifications of individuals nominated for public office. People who have a record of demonstrating leadership by taking (provocative) positions on the issues are dissuaded from seeking public service, and if they are nominated, they can expect to have everything they've said dissected, taken out of context, attacked and even ridiculed for political and partisan persons, no matter how strong their qualifications.

Democrats do this to appointees of Republican presidents, and Republicans do this to appointees of Democratic presidents, but I don't think the public benefits if we end up driving away or damaging the people who are most qualified to serve in public service roles, just because they had the audacity to challenge the status quo.

Bob Wachter, Associate Chairman of the Department of Medicine at the University of California, San Francisco makes this point effectively in his post in defense of Berwick's appointment:

"CMS's head honcho now needs to be someone with a point of view, passion, and a backbone. Although I guess there might be a healthcare version of Elena Kagan – a brilliant, charismatic leader who manages to come with a scanty written and oral footprint to be dissected and distorted – most healthcare folks with the Right Stuff will have a public record that illustrates that the person has periodically done battle with the status quo. I certainly hope so."

Think about the alternative: Do we really want government to be filled only with people who have no real record of having anything important to say?

I also believe that conservative presidents, by and large, should be able to appoint persons with conservative views, and liberal presidents should be able to appoint persons with liberal views, barring something in their record that says that they are unfit for office.

In the case of Berwick, it is hard to imagine anyone who could have had stronger credentials to champion innovations to improve patient safety, reduce medical errors, and promote patient-centered care. I personally don't agree with some of his views, including his overly-effusive praise of Great Britain's National Health Service, but he is undoubtedly qualified to serve as CMS administrator. He will bring to the agency the skills honed by a professional lifetime record of advocating for patient-centered care.

Today's question: What is your take on the controversy over Dr. Berwick's views and qualifications?

P.S. I have just joined the world of Twitter! You can follow me @BobDohertyACP!

Thursday, July 15, 2010

Is what you do meaningful enough?

One doesn't usually look to the Federal Register to define meaning or purpose (philosophers, yes, but bureaucrats?), but yesterday, the federal government officially ruled on what constitutes "meaningful use" - for the purposes of distributing dollars to clinicians for electronic health records.

The Wall Street Journal's health blog has an excellent synopsis of the rule and the reaction from different interest groups and experts, and the New England Journal of Medicine has a very clear explanation and summary of its key elements by David Blumenthal, MD, FACP, the federal governmen'’s coordinator of health information technology.

Dr. Blumenthal writes that:

"The meaningful use rule strikes a balance between acknowledging the urgency of adopting EHRs to improve our health care system and recognizing the challenges that adoption will pose to health care providers. The regulation must be both ambitious and achievable. Like an escalator, [it] attempts to move the health system upward toward improved quality and effectiveness in health care. But the speed of ascent must be calibrated to reflect both the capacities of providers who face a multitude of real-world challenges and the maturity of the technology itself."

The final rule appears to offer substantially more flexibility and addresses many - but not all of the concerns - that ACP expressed about an earlier proposed rule.

The final rule has enormous stakes for internists and other clinicians, since it will largely determine who will be eligible for a piece (as much as $44,000 from Medicare or $63,750 from Medicaid, per clinician) of the $27 billion in recovery act dollars to be distributed to clinicians whose EHRs comply with the "meaningful use" requirements.

The final rule, though, wasn't the only big development yesterday on electronic health records. The American College of Physicians announced a new, free, online community, called AmericanEHR Partners, to help practices compare EHRs and learn about meaningful use. AmericanEHR Partners was founded by ACP and Cientis Technologies and currently includes eight participating professional societies and 16 participating vendors. ACP's announcement says that the AmericanEHR Partners site will help practices:

- Evaluate readiness to adopt an EHR and provide a list of recommended resources to help overcome identified challenges;
- View comprehensive EHR user ratings on different solutions (ratings are based on surveys of physicians conducted through their professional societies);
- Sort EHR solutions based on medical subspecialty and desired functionality; and
- Provide side-by-side comparisons of EHR systems.

The site also provides educational content though newsletters, podcasts, webinars, blogs, and more.

As a final rule, the "meaningful use" may be the federal government's definitive ruling on what you and your EHR will need to do to access federal dollars, but AmericanEHR Partners provides the practical roadmap, from an unbiased and trusted source, on selecting an EHR that best meets your needs and also satisfies the government's requirements.

Today's questions: What is your reaction to the meaningful use rule? And to ACP's announcement of the AmericanEHR Partners site?

Wednesday, July 7, 2010

Has Medicare access reached a tipping point?

For years, physicians have argued that the specter of annual cuts in Medicare will cause many of them to leave the program, or at the very least, to limit how many new Medicare patients they will accept in their practices. Yet, for the most part, measures of seniors' access show that the vast majority enjoy good access to care.

For instance, in May of this year, the Medicare Payment Advisory Commission (MedPAC), which advises Congress on payment policies, published the results of focus groups of physicians and beneficiaries. It reported that neither beneficiaries nor physicians believe that there are widespread access problems for beneficiaries.

Views of beneficiaries:

"We heard few concerns about access to physicians in any of the three locations selected for this study ... Most beneficiaries felt they could get appointments in a reasonable amount of time as appropriate to the medical situation. For the most part, access issues do not appear to have changed for these beneficiaries over the past several years. Most beneficiaries have no trouble finding doctors, but there were a few more reports of issues with access to specialists than for primary care."

Views of physicians:

"Most physicians were accepting new Medicare patients, but a few were not. All physicians were required to have at least 10 percent Medicare patients in their practice to be invited to one of our focus groups, but a few reported that they had stopped taking new Medicare patients. A few others have given serious consideration to stopping ... Physicians see Medicare as a reliable payer, and appreciate the lack of preapproval requirements."

The focus group findings mirrored surveys of beneficiaries, also commissioned by MedPAC. "In 2006 - the most recent year for which we [MedPAC] have data from the Medicare Current Beneficiary Survey - more than 90 percent of beneficiaries reported good access to care, regardless of the question asked." Moreover, Medicare beneficiaries' reported access was better than for privately-insured persons. The same survey, though, did show that there may be a growing (but relatively modest) problem with beneficiary access to primary care:

"Of the 6 percent of Medicare beneficiaries who were looking for a new primary care physician in 2008, 28 percent reported problems finding one. Although this amounts to less than 2 percent of the total Medicare population reporting problems, the Commission is concerned about the continuing trend of greater access problems for primary care.

Maggie Mahar, blogging in Health Beat, also casts doubt more on the notion that a large number of doctors are boycotting Medicare. Citing the MedPAC surveys and other data, she notes that there is palpable "anxiety" among physicians, "The take-away message is that while the 21% cuts doctors are now facing are an administrative nightmare, they will be fleeting. And reports of a mass exodus by doctors from Medicare are overblown."

She may be right that there isn’t a "mass" exodus from Medicare - yet.

But something tells me that this time, things may be different. The latest cut and the chaos it creates may have reached a tipping point. An ACP member from Georgia told me that it wasn't until yesterday that her practice received the first check from Medicare (with the 21% cut included) since the first of the month, and that as a result, her practice is living off credit and having trouble making ends meet. She predicted that she, and many others, will soon have no choice but to close their primary care practices if Medicare can’t be counted on to pay its bills.

But it more than money, I think, that is behind more and more physicians giving thought to what in the past was unthinkable: finding a way to make a living that doesn't involve Medicare. It is a matter of the government breaking the bond of trust between doctors and the program. Trust that they government will pay them fairly, and on time, for their services, in exchange for physicians honoring their commitment to provide seniors with the best care possible. And as any cuckolded spouse can tell you, once a bond of trust is broken, it is almost impossible to restore.

Today's question: Do you think the latest SGR debacle will create an access "tipping point" for patients?