Wednesday, October 10, 2012

Needed: Less macro, more micro health policy

Much of what passes for debate on health care during this election year is focused on the macro side, on big issues like how do we cover the uninsured or restructure Medicare and Medicaid financing.  But for all of the talk about vouchers and block grants and insurance mandates, the candidates are missing the micro issues that really matter most to doctors and their patients, which is how health care policy directly affects the quality of the patient-physician encounter.

Talk to physicians around the country, as I regularly do, and these are some of the issues that have them most concerned:

1.    Will anyone do anything about the oppressive burden of paperwork and red tape?
2.    Will the candidates' "macro" proposals for reforming healthcare and entitlements result in more or less paperwork and red tape?
3.    I already don't have enough time to spend with patients but now I am expected to counsel them on preventive care, lifestyle choices, and the effectiveness of different treatments?   How is this possible?
4.    Electronic health records, great concept, but they don't really streamline the process as advertised, if anything, they just make things more difficult, and besides, they still don't communicate with other systems.
5.    Everyone wants to measure me, but the measures don't agree with other, they measure the wrong things and they are difficult to report on.   And who is measuring the value and effectiveness of the measures themselves?
6.    Okay, I am supposed to practice cost conscious care, but who is going to stop a lawyer from suing me if I don't give a patient the test they asked for?
7.    Why is my cognitive care paid so little while procedures and drugs are paid exorbitant rates?
8.    Payers and government keep imposing more penalties, for not e-prescribing, for not converting to ICD-10, for not meaningfully using my electronic health record, for not complying with their pay for performance schemes.  By the time they get done fining me for noncompliance, I will have had to shut my office. Then who will take care of my patients?
9.    And who has the time to keep track of all of these mandates, incentives, rules, and penalties?  I would have to hire a full-time person keep on top of everything. Who is going to pay for that?
10.     So I am supposed to transform my practice?  Well, we all want to do our part, but who is going to pay for that?  Besides, my patients seem to think my practice is just fine as it is

Now, I don't really expect Obama and Romney to come out with plans to address these micro health policies.  But it is reasonable to hold their macro proposals to a standard of whether they will make all of these aggravations and intrusions better or worse.  And at some point, policymakers--no matter their political leanings and plans to reform healthcare at the macro level, need to pay attention to what is happening at the micro patient-doctor encounter level.  After all, the boldest of big ideas won't make healthcare better if it makes it harder for physicians to give their patients the care they need.

Physician advocacy organizations also need to pay attention to the micro issues.  ACP prides itself on taking on the big issues like controlling health care costs and allocating health care resources rationally.   But the College puts at least as much effort into the micro issues, from objecting to the latest EHR mandates to offering alternatives to ICD 10 coding to advocating for higher payments.

The goal must be to fashion public policies that improve care at the macro level -- universal access to coverage, spending health care dollars more wisely, and improving healthcare delivery systems -- while also removing barriers at the micro level that intrude on the patient-doctor relationship.  Both are equally important.

Today's question: what policies do you think are needed to remove the barriers to the patient-physician relationship?


ryanjo said...

The Federal Paperwork Reduction Act of 1980 requires that the government both track and justify the paperwork burden its actions place on citizens and economic entities. During Fiscal Year 2005, the Federal government imposed an annual paperwork burden on the public of about 8.2 billion hours, an increase of 269 million hours over 2004, one of the largest increases since reporting began. The OMB report of that year found that almost half of the increase resulted from the implementation of the new Medicare Prescription Drug program. As we all know, this is just a fraction of the abuse that government bureaucracies have directed at physicians since that time, and the dozens of new entities created by the ACA will soon add to the avalanche. And yet can any proven benefit be found from all this document swapping? The value of the information being collected by the feds and private insurers from my office must be truly worthless, resulting from hours-long signing/faxing sessions of boilerplate care reports, preauths & DME forms. Anyone who doesn't think that this is not affecting quality and access to care isn't paying attention.

So how can ACP leadership claim to be focused on universal access and spending healthcare dollars wisely, when their favored programs produce exactly the opposite effect in the average ACP member's office?

Arvind said...

Bob, I commend you for finally coming out with the right set of questions. Why did the ACP not ask these questions in 2009-10 before the passage of the ACA? Here are my suggestions to your questions:
1) Eliminate opt-in/out of Medicare/Medicaid; participation in private plans; networks, etc.
2) Eliminate CPT codes for all cognitive services; allow physicians to simply bill for these services in $/hr
3) Let insurance companies compete across state lines just like auto insurance; and allow them to tailor products that fit different individuals/families
4) Delink employment from health insurance purchase; allow individuals the same tax benefits that employers current enjoy for purchasing health insurance
5) Let health insurance work in its true form - as insurance (hedge against catastrophe)and allow people to accumulate pre-tax $ in health saving accounts
6) Let each insurance plan publish on the Internet their reimbursement fees for all office-based services; let physicians publish their charges for similar services. Then let patients choose who they want their care from - either paying higher/lower OPP payments. Similarly, let patients choose each plan based on how much they cover or how cheap their premiums are.

This will eliminate paperwork, contracts, per-auth, gate-keeping,etc.

Let each physician office deice if they find value in converting to EHR. Those who have spent money converting can charge more for their services, as high as the market will bear. Get rid of MU and HITECH mandates.

Change medical liability from a tort system to a no-fault system and create health care courts for faster access to payments for litigants and less aggravation for physicians.

In other words, dismantle PPACA and allow free markets to dictate innovation in health care.

Jay Larson MD said...

The biggest component to a successful physician-patient relationship is time. Time to get to know each other, time to obtain adequate assessment, and time to provide a customized treatment plan to optimize a person's health presented in an understandable way. Anything that affects the time a physician can spend with the patient is considered a barrier. I have seen many barriers develop over the past 20 years that were not present when I first started. Prior authorizations can be at time sink. Insurance companies have sunk so low as to require prior authorization for generic medications this year. Even though electronic health records improve the ability to manage patient populations and identify gaps in care, EHRs add approximately 5-10 minutes per patient in additional time to document the encounter. Transitioning to an ICD 10 in which an internist will go from knowing a few hundred codes to several thousand codes will consume a substantial amount of time. Comprehensive forms to fill out for durable medical equipment for Medicare patients add to the time burden. Richard Baron had an article in Annals of Internal Medicine a couple years ago showing how much paperwork internists do in a day. For every one person seen in the office for an appointment, 5 other patients receive medical management through answering questions, arranging consults, reviewing data, filling out forms, etc. Meeting criteria for meaningful use, electronic prescribing, and reporting quality data or otherwise face penalties complicate the matter further. Of coarse coding E and M visits correctly using a subjective, outdated (last coding guidelines for E and M were 15 years ago) system or possibly lose money through a RAC audit adds to the anxiety of it all. With all the barriers to provide good medical care, it is a wonder anything beneficial for a patient can get done. Yes there are many barriers that need to come down, but no one is willing to lift the sledge hammer and start swinging

PCP said...

Agreed Jay. You neatly outline one of the larger reasons younger doctors are shunning generalist care. To be sure there are others, but that represents one of them. When I was doing the heroic and underappreciated job you stalwarts continue to do, of all the descriptors of the average day, the one that stuck out for me most was where one colleague described his day as feeling "like he was walking through a field of mollasses".

I have just one question for you and other colleagues. As we continuously see these demands disrespectfully and condescendingly imposed on our time(for which we are underappreciated and uncompensated by all concerned) foisted upon us.......How well do you feel the leadership of the ACP in specific and organised medicine in general have represented us?

In my opinion, and as I go through the littany of time killers you have listed, they(organised medicine) are supportive in some form or the other of pretty much all of them. EHRs, ICD10, e-prescribing, quality metrics reporting (derived from EBM) and soon to morph into the the more powerful IPAB 'recommendations' and coverage decisions.
The so called solutions such as advanced medical homes and ACOs will only serve to worsen the situation and lead to further erosion of our professional standing and autonomy, to say nothing of income decline and morale destruction. Heck even the gradual and now accelerating trend toward employed models is tacitly endorsed by them if you read between the lines of policy endorsements.

When our so called representatives endorse so much of this, and practitioners are busy just trying to keep up with the speed of the treadmill, why would anyone begin to lift the sledge hammer and swing as you suggest?

Harrison said...

The Micro issue challenge must also take into acct the evolution of the working relationships that physicians establish.
Increasingly primary care physicians are becoming employees.
They don't have the overhead business concerns that someone who owns their own practice will have.
They may not even be under the gun to produce money...but instead have to focus more on access and patient satisfaction and generating referrals to other parts of their organizations.
And of course there are also SNF specialized internists now, with low overhead or who may be employees. And Hospitalists who also may be employees.

Hospitalists don't have many paperwork concerns.
They let the outpatient primary care doctors take care of the paperwork -- even though the hospitalists get paid more.

Go figure.

The Micro interests are infinite.
ACP represents a diverse group of doctors who all have their own Micro interests, and those can change as job roles change.

I think that the ACP should focus on advocating for our patients.
If we as an organization focus on good patient care, and safety, and access, and best practice guidelines -- then we will be fine.

And I'm one who believes that the biggest mistake in the ACA (Obamacare) was that it delayed implementation until 2014.
That is a whole lot of anticipatory angst!


Jay Larson MD said...

PCP, years ago I was angry at the progressive extinction of the outpatient general internist. In the past 10 years about 30,000 internists have become hospitalists, taking them out of the outpatient pool. The number of medical students choosing outpatient general internal medicine has plummeted. When I came out of residency 20+ years ago about half of the residents went into general medicine, now if a residency program produces a general outpatient internist, it is a statistical outlier. As time has gone on, I have experienced the increasing demands on the general internist to the point of absurdity.

Organized medicine societies are designed to support that medical specialty, even at the cost of high cost medical care. Have you ever heard of a proceduralist wanting to make less money doing procedures for the greater good of society? If they did, we wouldn’t have the most expensive health care system in the world.

Of the many medical societies, the ACP is about the only one that has worked on what is best for patients…striving for universal health insurance coverage, patient education, and Choosing Wisely among other things. To accomplish this, compromises had to be made. The ACA has many flaws, but it has some good stuff too. I look forward to being able to get health insurance without being denied for pre existing conditions. Until then, my wife will continue to work at her job and provide us with health insurance.

Sure it would be great if the ACP focused only on the general internist and told the RUC to take a hike and increased RVUs for E and M codes, got extra reimbursement to do prior authorizations, use an EHR, and for all the non-face to face work we do, but that is just not possible. I have been to Washington DC many times to visit my senator and have been told on several occasions, there is reality and then there is political reality. Political reality is what we have to live by.

ryanjo said...

There is no employed model for physicians in which productivity is not a concern. The most prevalent employment contract can be succinctly described as "you eat what you kill". In other words, your income is dependent upon what is collected on the patients that you see, minus an overhead deduction (determined by the healthcare corporation that you work for). Even academic positions (except those at the pinnacle) require either patient care in the Private Diagnostic Clinic, or obtaining grants for self support. So let me ask, does that sound like a setting that allows physicians to advocate for patients, when their contract depends on producing income or medical studies for their employer? Will ACP be happy with patient centered care dictated by a for-profit corporation, instead of independent physicians?

And if you long to see Obamacare in action before 2014, just sign up with Medicaid.

southern doc said...

Great list!

Only problem is that ACP policies over the past 20 years have directly caused and/or exacerbated every item on the list.

The original post qualifies as "concern trolling." Those of us who are a little more old- fashioned will just ask that you spare us your crocodile tears.

Anonymous said...

They definitely need to work out the need to cut the tape with medical records scanning so things will be easier for patients.