The ACP Advocate Blog

by Bob Doherty

Wednesday, March 9, 2011

You say you want a revolution … Part 2

I knew that wading into the issue of retainer practices—and getting into a friendly debate with my friend Bob Centor (although I don’t think we really disagree on that much, as discussed later in this blog), would get a spirited reaction from some readers.

Yesterday’s posting, though, really didn’t say much of anything about the merits of retainer practices. My point was that whatever any of us may personally believe about retainer practices, the evidence so far is that they are a small—but slowly growing—niche found mostly on the East and West coasts and certain metropolitan areas. And whatever we believe about primary care physicians turning away from Medicare, the evidence (so far, at least) is that Medicare participating rates are at an all time high, and only a very small percentage of Medicare patients report “big problems” in finding a physician or getting a timely appointment. Our individual beliefs and personal experience matter, but good policy requires that our belief be tested and validated by evidence and data to the extent possible.

As I wrote yesterday, “I don’t question [Bob Centor’s] overall hypothesis, which is that more and more primary care physicians are dissatisfied with current practice models and looking for alternatives.” No one wants a good internist to go out of business, and if “their choices are retainer practice, cash only practice, hospital medicine or retirement” they shouldn’t be criticized for choosing the retainer option.

It is one thing, though, to say that retainer practices are a reasonable and sometimes necessary reaction by individual practices and patients in response to economic pressures, and another to offer them up as solution to problems facing primary care.

According to a studies done by the University of Chicago and the Government Accountability Office (GAO), “retainer physicians tend to have smaller patient loads and fewer appointments daily, compared to their non‐retainer counterparts. The retainer physicians who responded to the GAO survey reported having, on average, 491 patients. The average number of patients physicians had the year before they started their retainer‐based practice was 2,716.”

Let’s do the math. If more primary care practice go the retainer route, they will have to offload as many as 2000 patients, made up mostly of patients who can’t afford to pay an average of $1500 in annual retainer fees. They will have to find care somewhere else, but busy non-retainer practices won’t have the capacity to pick up them, leading to even longer waits for appointments and more trips to the emergency room. And for each primary care physician seeing fewer patients, the country would have to train even more primary care physicians to keep up with demand, or train non-physicians to take care of them.

We could end up with a two-tiered primary care system, one for those who can pay more to participate in a retainer practice, and one for people who can’t afford the retainer fee and will have to queue up for care from underfunded clinics led by non-physicians.

A more promising solution is to reimburse practices for providing team-based, patient-centered care led by a personal internist or other primary care physician.

This is the idea behind the Patient-Centered Medical Home. Under the PCMH model, patients would have access to same-day appointments when needed, just like in retainer practices. Internists would be able to spend more time with the patients who can benefit from internal medicine specialist care, because health professionals in the practice who have less training could see the less complex patients, and some of the follow up would be handled by electronic communications rather than a face-to-face visit. Instead of the practice asking patients to pony up a retainer fee, Medicare and private insurers would pay the practice a monthly, risk-adjusted payment per patient for the time spent managing and coordinating care and to help cover the investments in information systems and team-based support staff. Physicians in the practice also could share in savings from preventing unnecessary hospital admissions and achieving quality benchmarks.

Six years ago, I wrote in ACP’s monthly magazine (then called the ACP Observer, now called the ACP Internist) that:

“The medical home would, in other words, offer the best elements of what is known as ‘retainer’ or ‘boutique’ practices—without the accompanying inequities. Like the medical home concept, retainer practices appeal to growing numbers of patients and physicians because they offer patients the promise of timely access to a personal physician. But boutique practices typically require patients to pay a larger retainer fee not covered by insurance, making such practices more suitable to wealthier patients. The medical home model would be financed by insurance coverage so it would not be limited to patients with higher incomes. And unlike boutique practices, medical homes would be publicly accountable for the quality and efficiency of care they provide.”

The medical home has come a long way since then, and unlike retainer practices, we now have a lot of evidence to support the effectiveness of the PCMH model. But the concept remains the same. Patient Centered Medical Homes can offer the best elements of what is known as ‘retainer’ or ‘boutique’ practices—without the accompanying inequities.

Today’s questions: What do you think of the premise that Patient-Centered Medical Homes offer the best elements of retainer practices, without the accompanying inequities?


Blogger Steve Lucas said...

Looking at this from the outside I see this model as not practical for the small or solo practitioner. The resources necessary to make this model function lends its self to a corporate structure.

Once again we have the issue of who is in charge of the decision process which ultimately impacts cost. Not wanting to sound crazy, but a side issue is access to personal information. Under this model both the insurance companies and government could access personal information for whatever purpose they deem fit.

Past performance is an interesting concept in management. Early on in my undergraduate program I took a year of accounting, at the end of that year I switched to finance. While knowing what you have and where you have been is important, it is also a little like trying to drive a car while looking only in the rear view mirror.

Jay’s comments from the previous post need to be taken at face value since they reflect what is coming down the road. Doctors are a smart bunch and they will adjust. They will not just blindly drive off the road.

Steve Lucas

March 9, 2011 at 3:28 PM  
Blogger Jay Larson MD said...

I have a better idea. Why wait for the Patient Centered Medical Home model to materialize, just have Medicare and private insurances start reimbursing patient centered care now. That is what internists are doing already. If the internist was reimbursed more, they could afford to spend more time with patients. They could afford to hire more staff to off load all that busy work that has been shoved onto the internist. They could hire physician extenders to manage the less complex issues. With the extra help and spending more time with patients, professional satisfaction would improve. And....wait for it...patient outcomes would improve. What a concept.

March 9, 2011 at 6:39 PM  
Blogger Jay Larson MD said...

I have a better idea. Why wait for the Patient Centered Medical Home model to materialize, just have Medicare and private insurances start reimbursing patient centered care now. That is what internists are doing already. If the internist was reimbursed more, they could afford to spend more time with patients. They could afford to hire more staff to off load all that busy work that has been shoved onto the internist. They could hire physician extenders to manage the less complex issues. With the extra help and spending more time with patients, professional satisfaction would improve. And....wait for it...patient outcomes would improve. What a concept.

March 9, 2011 at 6:39 PM  
Blogger alan said...

The big difference between retainer practice and PCMH is that in the former the patient is cared for by doctors and the latter by nurses. At if you dont remember Bob, doctors went to medical school and nurses went to nursing school.

March 9, 2011 at 11:38 PM  
Blogger encdinosaur said...

The PCMH IS difficult to implement in a small practice, even if one expects improved reimbursement in the future from quality recognition, productivity, or whatever, to pay for the upkeep. The small practice can not survive the implementation of the EHR that is now absolutely needed under new NCQA guidelines for Level 3 practices, which is the only one recognized by insurers in my locale.
The result is that small practices are being assimilated (not bought, for they have no value) by hospitals and hospital systems, who consider physicians as productivity cogs only, with no intention of putting them in charge or supervision of non-physician personnel or activities. There will be no team building. One acquisition that I am familiar with offered physicians $5000 per year to "supervise" such personnel. That is less than 2.5 days productivity for the physician.
Medicare access may have temporarily plateaued as a result of the 10% primary care "bonus" and particulary the preventive care code that offers $100+ per head per year for each Medicare recipient while I do what I have been doing all along. That will keep my in business until it expires in 2014, but not give me an income level that would compete with what an internist can earn as a hospitalist with no investment up front to open or operate a practice.

March 10, 2011 at 3:55 PM  
Blogger Robert J. Sobel, M.D. said...

I am not sure anyone would be surprised by my comments at this point. Anything that entails greater bureaucracy, which a medical home certainly does, dilutes any value it may have. Retainer fee concepts are historically foreign to the medical world and it is not easy to gauge all of their effects (subtle changes in patient and physician expectations, legal ramifications). I continue to be the dinosaur who feels fee for service has been maligned without any evidence that an alternative strategy exists at the level of small independent practices.

Consolidation is obviously the wave. Staying independent is more and more difficult. Going out of network (whether it is private or public payor) has become the only way to get paid fairly in most circumstances (at least for the primary care, cognitive specialties that must perform the bulk of the unreimbursed activities of managing the modern patient). Unfortunately, as insurers channel resources elsewhere, the patient is left with the bill.

I am not sure we should continue to debate the structure of primary care. Instead, we should retract the forces that have put it at such a competitive disadvantage. See the lawsuit against CVS for using patient data to advertise to MD's. It is these modern processes that have usurped our ability to prescribe medicines in a sane environment. You know my proposal for this. The middle man of pharmacy benefit structures is far more dangerous than the independent physician who fails to spend the resources to comply with a third party bonus competition. I would much appreciate support against this reality and less concern about how to reform my practice strategy.

March 10, 2011 at 9:08 PM  
Blogger w said...

"Retainer" practices are a blunt instrument around the centrally-planned and centrally-set pricing of Medicare.

In economics, with price controls you generally get two outcomes classically: degradation of quality and shortages.

As an alternative to retainer models, how about following ACP's own recommendation (I believe still in place) and allowing for transparent pricing for M.D. services above Medicare reimbursement levels and letting patients vote with their feet?

This would have the virtues of often costing the patient less than the retainer fee, of not resulting in rising federal outlays, and of enabling a more honest price to develop.

Oh, and it requires zero federal employees and task forces to put in place.

March 15, 2011 at 7:35 AM  
Blogger doc777 said...

This has been an interesting discussion, but it has been like having a detailed discussion about a pimple on the elephant in the room. Until we have a serious discussion on how to rein in the escalating health care costs in this country, nothing else will matter. Health care costs can only be cut in three ways: decrease payments for goods and services, improve efficiency, and/or decrease utilization.

Primary care physicians will need to convince purchasers of health care that increased payments to primary care physicians can save money. This should not be a hard sell. There is a growing body of evidence showing that increased primary care access in a community decreases utilization of high cost services like emergency room visits and hospitalizations. I think the VA system understands that return on investment and therefore gives their primary care physicians the time to do what they are trained to do. The advantage the VA system has is that they are a vertically integrated health care delivery system. All the pieces are working together in a more efficient way to increase quality, improve efficiency, and reduce costs.

Unfortunately the health care delivery in most areas of the country is fragmented, inefficient, and highly productivity driven. Our productivity based payment system encourages over utilization of services, especially high cost, better reimbursed procedures and imaging studies. Primary care physicians have migrated to employment with large hospital systems to survive the decreasing reimbursement of primary care services in relative terms. More than 70% of primary care physicians in our state our now employed by these systems. As employees of these hospital systems, the primary care physicians are looked at as costing the system money. Their salaries are often (at least initially) subsidized by the systems. The system does not receive any benefit from high quality primary care. In fact, it loses money. A decrease in hospitalizations, fewer high end imaging studies, less surgeries, and fewer other high cost procedures does not benefit the hospital system. The systems therefore do not have any incentive to provide an environment for primary care physicians to do what they are trained to do. Instead, the systems push the primary care physicians to produce more, (i.e. see more patients per day). It is not uncommon for physicians to be asked to see patients every 10-15 minutes. Obviously, complex primary care patients cannot be adequately cared for in a 10 minute visit. The primary care physician often has no choice but to refer their more complex patients to specialists, who often order more expensive workups and perform increased numbers of procedures.

The patient centered medical home model is an interesting concept, but only if accompanied by significant payment reform and surrounded by a health care environment where all the pieces are working together in an efficient manner to improve the quality of care delivered to the patient. A patient centered medical home model placed in a hospital system optimized for productivity based reimbursement, is doomed to fail miserably.

March 15, 2011 at 11:50 AM  

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Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

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