Thursday, October 9, 2014

Is assimilation inevitable for independent physician practices?

Fans of Star Trek: The Next Generation will recall that the most disturbing aliens encountered by the Federation were The Borg, a part-cyber, part human collective race that functioned as an integrated and cyber-connected whole that existed only for the good of the collective, rather than as distinct individuals with their own thoughts and personalities—much like honey bees work together as a collective for the protection of the queen and the survival of the colony.  When the Borg encountered a humanoid species, they would forcefully assimilate them and their technologies into the collective, or destroy them, preceded by only one warning:


The Borg did not consider themselves to be evil though, explains the data base, because “the Borg only want to ‘raise the quality of life’ of the species they ‘assimilate.’"

I expect that many physicians in independent practices feel the same way as the unfortunate humans that encountered the Borg: they are under unrelenting pressure to be assimilated into hospital-owned or other large group practices, giving up their independence in the process, with the promise (of course!) that assimilation will  “raise their quality of life”!

But is assimilation the only option for independent practices?  Is resistance futile?

My answer: No to the first, and yes to the second.

Let me explain.  I believe that independent physician practices can survive, and even thrive, because they offer something valued by most patients: an ongoing relationship with a physician who lives in the community, and who knows them and their families.  A practice where, like Cheers, everyone knows your name - from the front office receptionist to the practice’s physician assistant or RN to the physicians themselves.

 I don’t believe that patients want these practices and their physicians to be forcefully assimilated into large groups that may be located some distance from their homes, where when they arrive for an appointment they are forced to wait for a long time in an overcrowded waiting room, just take a number please, to be seen by someone—a nurse, or a PA, or maybe if they are lucky, a physician—who they never met before and won’t be around next time they need to be seen.  (Now, before I get angry comments about this characterization from ACP members in large group practices, I am not saying that this is how all or even most large groups operate—most provide excellent and personalized and attentive care, often in community-based practices—even though the individual physicians and have chosen to be part of a larger group.  And there are small practices where patients are treated brusquely by inattentive staff and physicians.  My point is that if assimilation into a larger group means the loss of a personal relationship with a physician they know and trust, many patients will be opposed).

But I also think that for independent practices, resistance is futile—if this means resisting making the changes that may be required of them to survive in an increasingly competitive economic environment. It is futile to reject participation in all performance measurement programs; physicians in independent practices should, however, insist on measures that measure the right things for them and their patients.  It is futile to reject the move to electronic health records, but physicians in independent practices should demand that government and private payers facilitate the creation of EHRs that are functional, interoperable, and useful.  It is futile for physicians in independent practices to try to hold onto FFS and summarily reject bundled payments, risk-adjusted capitation, and physician-directed models like Patient-Centered Medical Homes and Accountable Care Organizations. Instead, they should see how their practices can embrace these changes.  (Many independent practices have done quite well, for instance, by becoming PCMHs).   It is futile for independent physician practices to reject being accountable for their cost of care—especially when they may find, as one recent study concluded, that hospital owned physician practices have higher prices and higher levels of spending than physician-owned independent practices!  Armed with such data, independent practices can demonstrate to  payers that they are the best value in healthcare.

And while big is not always better, smaller independent physician practices should explore ways to share information systems, data, and even risk with other independent practices, achieving economies of scale without losing their independence.

Independent physician practices do not have to be assimilated, then, but they have to have to be willing to embrace changes that will better position them to be successful without losing their values, their relationships with their patients, and their independence.

For the unfortunate victims of the Borg, assimilation meant losing everything they valued—their independence, their creativity, their individualism, their personal relationships, their values.  But Star Trek’s Federation learns how to prevail against the Borg, not by becoming part of them, or defeating them militarily, but by showing that an independent Federation of free people, voluntarily working together for the public good, is a better model of survival then a cyborg collective that snuffs out innovation and creativity.  With the right support, I believe that independent physician practices, provided that they are willing to embrace innovation on their own terms, will be able to show that they offer something of extraordinary value to patients and payers, allowing them to survive and even thrive without losing their independence.

Today’s questions: Do you think independent physician practices will be assimilated?  Is resistance futile for them?


Unknown said...

50Well done. The country should not give a hoot about small or big, independent or not. It is the quality of care .BIG practices are being killed by the same "measuremnt as punishment" over-reporting of trivia mandates. It is quality of care.Of course, exploring ways to share data is almost impossible-practices need outside resources to do that, but I have said the same. We need to join together as docs to ensure good access and quality time with a physican the patient has continuity of care with over time; big vs small emlpoyed vs not should be irrelevant. Small pratices are nimble and often doing much better care- see Health Affairs August 2013 Casalino et al. 30% reduction in re admits I believe it was by small practices. What we need in this country is someone who advocates for primary care Instead we have various systems and indepedents and agencies and vendors but no one looking at a big picture Thanks for this Jean Antonucci in MAIne

Harrison said...

I think assimilation is going to be necessary but I think it is important to understand the costs to independent practices.
It is a little bit of a game and if not played well, there are losses.

I work in a mostly assimilated and yet struggling to compete practice. We are a group of 3.
All internists.
We have an EHR. That cost us hardware expenses up front a couple years ago of 15 to 20 thousand. And it also cost us a loss of productivity and lost time with training, and that continues to this day. We do not see as many patients per day as we did on paper.
There are ongoing costs too.
Originally that was around 800 per physician per month for the EHR program. That cost has dropped to about 400 per physician per month. But that is in place of a cost of next to nothing. We were not using dictation. We were handwriting on templates before the EHR.

Of course the federal government did include EHR bonuses in the stimulus package. We are in the last year of that I believe. It offset some of the costs.

There are advantages. At the end of 2015 we are assured there will be a health information exchange icon on our EHR, which will give us access to radiology reports and labs from anywhere in San Diego County just by clicking, and getting through whatever levels of security are built in.
That will have to help the system with cost savings.
Not us so much.
But I'm all in favor of it.

There are other costs and expectations.
Of course without the EHR the expectations would almost certainly drop off, but so too would the bonus money attached to them.
PQRS is one. It may be possible to do this on paper, but I'm sure it would be cumbersome. It is a requirement. Without reporting we will lost 10,000 or more annually. The EHR makes this much less time consuming.
We are part of an IPA. The IPA helps us manage patient populations in order to be more competitive for commercial insurance contracts. These contracts pay better than Medicare, although they are usually capitated payments.

Within these contracts we are expected to keep a1c's checked, and keep a certain percentage of our patients under an 8% range. We are also expected to keep our patient's up to date with mammograms, and colon cancer screening, and cholesterol levels in diabetics are to be managed well.
And without the EHR it would be hard to manage populations in this way.

And then there are the patient satisfaction goals. If you want contracts, you better be competing with the industry leaders -- in our area that means competing with Kaiser.

That brings me to coding for complexity. That is the latest game in town. Commercial payers don't believe we are working very hard, and they use population data to compare groups.
So we have to be sure we are generously handing out diagnoses of COPD and Chronic major depression and uncontrolled diabetes.
Of course it is appropriate, but we never worried that much about it before.
Now it matters, because money will be taken away if your patient complexity isn't among the worst.

There is a lot to lose for a practice that doesn't want to report, or compete for capitation contracts, sign up for an EHR, or do anything beyond showing up every day and responding to the patients on the schedule or who call in.
We still have to do that, but when a patient calls in with a concern about a rash, we will do pre-visit planning to see if they need screening or immunizations, or if they have the proper HIPAA notifications and to be sure they are on our patient portal, and the patient's priority of the rash, will be lucky to appear at agenda item number 4 or 5 on the 'things to do during this visit' list.

Patient centered?
Come on, really?????