Tuesday, February 10, 2015

Killing the Goose

Last week, I attended a briefing about a new policy report, issued by the influential Brookings Institution, calling for reforms to accelerate the transition to value-based physician payment.  Brookings’ report builds on the framework recommended in a bipartisan, bicameral (House and Senate) SGR repeal bill that was agreed to last year by the congressional committees with jurisdiction over Medicare.

There are some very thoughtful concepts in their proposal, like improving and simplifying quality measures.  Some of their ideas gave me pause, like requiring that physicians in a Patient-Centered Medical Home, or another alternative payment model (APM), accept direct “downside” financial risk for meeting quality and efficiency measures. Brookings could be setting the bar so high that few physician practices could qualify or be successful in achieving the required savings even if they were able to qualify as an APM.

Beyond the specifics of their report, though, one thought kept going through my head: as policymakers keep coming up with well-intentioned ways to “reform” physician payments, we might be at risk of killing the goose that lays the golden egg.  The goose being primary care, and the egg being high quality, patient-centered, accessible, compassionate and cost-effective care, which can only come from a patient having an established relationship with a primary care physician that they know and trust.

We know from hundreds of studies that primary care is highly associated with better outcomes and lower costs.  We also know that relatively few medical students are choosing to go into primary care.  We know that many established primary care physicians are frustrated and discouraged, leading some of them to leave medicine altogether or downsize their patient panels by going concierge.

And we know why this is so.  Primary care physicians are under-paid and over-worked relative to other physicians.  Many are dejected because they feel so disrespected.  Everything they do is being measured, but how often is what they do truly treasured by society?  We stick them with dysfunctional electronic health records that make their lives miserable, and then penalize them with payment cuts if they don’t use their records in a way that the government considers “meaningful.”  We dangle out more money to them—but only if they are willing to work ever harder and ever longer, in “alternative payment models” that involve spending more time on administrative processes (like reporting on measures) and less time with their patients.  Meanwhile, many of their colleagues in other specialties that can bill for highly compensated procedures can still do quite fine under conventional fee-for-service (FFS)—and when they too have to jump through hoops to prove their value to payers, they start out with a much higher FFS compensation baseline than primary care.

Readers of this blog know that I believe that fee-for-service hasn’t been a good deal for primary care—if it was, why has primary care been so underpaid under FFS compared to other specialists?  I also believe that if done rightly, new payment and delivery models, like Patient-Centered Medical Homes, offer the tantalizing possibility of  valuing primary care more highly while improving patient and physician satisfaction, with better outcomes and lower costs.  And just saying no to value-based payments isn’t going to be a winning strategy for primary care.  It is better to mold the changes that are coming than to cling to a hope that it will all just go away.

At the same time, though, a great deal of caution is in order.  When someone comes up with a new plan to change the way that primary care is going to be organized and compensated, we should ask:  Will it add to the administrative burdens of primary care physicians?  Take their time away from patients?  Will they have to run harder just to stay in place?  Will it make them feel even more beleaguered and less valued?

If the answer to any of these questions is yes, then we need to stop and re-think what we are doing to primary care, and come up with a better way.

 Real value-based payments should assign the highest value to the patient-physician relationship. Everything else is secondary.  Because otherwise, in our zeal to re-invent how physicians are paid and care is delivered, we will have killed the goose that laid the golden egg:  the goose being primary care, and the egg being high quality, patient-centered, accessible, compassionate and cost-effective care, which can only come from a patient having an established relationship with a primary care physician that they know and trust.

Today’s questions: do you think policymakers may be at risk of killing the goose, primary care, that laid the golden egg  of high quality, patient-centered care?  And if so, what should be done to make them stop?


Stephen said...

The goose is already dead. I'm a 49-year-old physician. When I started medical school in 1988, all my friend's parents who were doctors told me not to do it. They told me how the medical profession was being ruined by regulations and cost controls. I didn't listen to them. I followed my heart and ended up being an infectious diseases physician. Here is my education and training. College from 1984 to 1988. Medical school from 1988 to 1992. Internal medicine residency from 1992 to 1995. Infectious diseases fellowship from 1995 to 1998. Add it up. Including college that is 14 years of incredibly difficult and expensive education and training after graduating from 12th grade. For two years in a row now infectious disease is the lowest paid medical specialty. Lower than pediatrics and family practice. What you are seeing is what the generation of physicians before me predicted. You are witnessing the last gasps of a dying profession. The surgeons and procedure-based physicians will hold on for a while longer. The rest of us are dead men and women walking. This is economics 101. Cost controls equal shortages. And we have been cost controlled out of business. When the last family doctor and pediatrician and general internist and all the other non-procedure doctors who actually take care of patients in a longitudinal fashion turn off the lights, then it really is over. If you think the years of education and training are unnecessary then I hope everyone with complicated diseases is happy with their nurse practitioner's diagnosis and treatment plan. The 1% (not me) will always find a way out of the system you are forcing on the rest of us. I don't even make enough money to send my three children to the same college (Stanford) that I went to. What a waste. What a tragedy. What will the central planners come up with next?

PCP said...

The goose has long been killed stewed and fed to various special interests. I'm not aure what you are even talking about.
A survey of gneral internal meeicine residents(which is the most pertinent one since they have optionality and have traditionalky been the bqck of primary care in america) will nowadays reveal perhaps a single digit percentage choosing OP primary care, and even fewer choosing traditional primary care. Most are either specialising, becoming hospitalists, concierge, working for industry or some such variation of the theme. What is more, most of the OP doctors are employed by a corporate or insurance behemoth that indirectly influences care in a way that most neutral observers would feel is unjustified.
We all know the reasons for this,as they have been discussed on this blog ad nauseum. What is lacking sadly is the courage to tackle them head on, instead we get more of the slow shaft and acquiescence.
I've said it time and again. Our representatives have failed us miserably.
If ACOs and other alternative payment models were going to be the salvation of primary care, then surely there ought to have been some checks and balances on that. Was it not foreseeable that hospitals and insirers with their medicare fattened pockets and size would domintate? Is it then not foreseeable that doctors and patients alike would be made pawns in their corporatized practice of medicine?
It is sheer folly to beleive we can shape a darn thing, considering the track record of our lobby.
We stood a better chance demanding primary care collaboratives of 50-100 PCPs a piece, contracting and collaborating with various service provides. The budget by necessity should be managed by these groups. The rest of the players in the system ought to be kept from conglomerating to thwart competition. Many medium sized cities often hqve a single large GI group, or only two hoapitals systems etc. when just a mere 20yrs ago there might have been 8 separate hospitals and 4-5 groups. Who allowed that conglomeration of power?
This is a very complicated issue, but sadly the die is cast. This 11th hour analysis has more of a ring of a eulogy for physician driven primary care than a dialogue.

W. Bond said...

If you’ll excuse me answering a question with two questions:

1. Do you have any interest in or a passing familiarity with economic theories on prices? Prices communicate – however, imperfectly – information, opinion and knowledge about a dynamic and complex world from dispersed sources. Classically, the central and arbitrary setting of prices results in shortages and degradation in quality. What you are comparing here are centrally-set arbitrary prices (fees for service set by Medicare, say), with what is ultimately an equally arbitrary price/fee mechanism. To the extent in the non-Medicare world that prices reflect any information it is the worst sort and “top down”: federal regulators interacting with oligopolistic health care systems, oligopolistic insurers, large corporations, etc. In the end, there is no way to square this circle Mr. Doherty. I am not proposing anything, simply pointing this out.

2. When will this blog present the ACP’s response to Dr. Cutler’s very alarming allegations of financial “poor stewardship” at the ABIM ? In light of the facts he presented two months ago (and others that are coming to light), the ACP, and any serious leaders in internal medicine must, perforce, take a position on the integrity of the ABIM and its leadership past and present. I hope and trust that such a statement is forthcoming. The ACP stands to gain or lose much credibility by its response to this matter.

southern doc said...

The goose has been roasted, carved, served, and digested. The ACP and ABIM both enjoyed very tasty meals.

If this post had been written 20 years ago, it might have been relevant - now it's just post-prandial flatulence.

Jay Larson MD said...

When the RVU system came into effect some 25 years ago, the intent was to equalize pay between the primary care providers and the specialists. We all know how that turned out. E and M values were left on the compost heap while newer and more expensive procedures dominated the market. So a new reimbursement system is being kicked around. IF that new system does not continue to pay the procedurists well, then there will be a huge backlash.

Yes, primary care providers are overworked and underpaid, but they can do that for only so long before they burnout. A burned out PCP does not practice high value care. I recently heard about adding a fourth arm to the Triple Aim and that is the wellbeing of the physician and their staff.

A couple of years ago I made a practice change, I stopped seeing Medicare and Medicaid patient. It was the hardest and best decision I could make. My practice is now full of vibrant people who are not deteriorating before my eyes.

I recommend all PCP's look at their practice and make the necessary changes to make it worth going to work every day.

victorgettinger said...

All of the prior comments say the same thing. The horse is out of the barn & the barn has burnt down. I loved being an Endocrinologist (the 2nd lowest compensated physician group just above, but not by much, ID). But I had to retire one yr ago not because my brain or body failed but because my spirit & sense of joy dissolved. The business of medicine is overwhelming & replacing the art of caring for people in need. G_d save us all..

walide said...