Tuesday, April 23, 2019

If they build it, will they come?

On April 22, the Department of Health and Human Services (HHS) unveiled new alternative payment models that it hopes will “transform” primary care to support high-value care. Released at a briefing hosted by the American Medical Association and attended by me and other ACP officials and members (and hundreds of other “stakeholder” groups, plus the news media), the proposals would create more voluntary options for primary care physicians and their practices to be paid for keeping patients healthy and out of the hospital.

One of the new models, called Primary Care First, “will focus on advanced primary care practices ready to assume financial risk in exchange for reduced administrative burdens and performance-based payments.  The other, called the Direct Contracting (DC), is directed at large systems that have the experience and capabilities to take on substantial financial risk for large numbers of patients.
In today’s post, I am only going to summarize the key elements of the Primary Care First (PCF) model, taken mostly from CMS’s fact sheet, because it’s expected to be available to far more internists than the Direct Contracting model.

Practice Eligibility: To be eligible to participate in the PCF model, a practice must include “primary care practitioners, (MD, DO, CNS, NP and PA), certified in internal medicine, general medicine, geriatric medicine, family medicine and hospice and palliative medicine.”  It must have 125 attributed Medicare beneficiaries at a particular location, have primary care services account for at least 70% of the practices’ collective billing based on revenue, and in the case of a multi-specialty practice, 70% of the practice’s eligible primary care practitioners’ combined revenue must come from primary care services. It must also “have experience with value-based payment arrangements or payments based on cost, quality, and/or utilization performance such as shared savings, performance-based incentive payments, and episode-based payments, and/or alternative to fee-for-service payments such as full or partial capitation.” 

Geographic locale: The practice must be in one of the 26 regions selected for the program: Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide).

Simplified payment structure: Each practice accepted into the program will be paid what CMS calls a “simplified payment structure” consisting of risk-adjusted per beneficiary per month (PBPM) payments, plus a flat set amount for each office visit. It will get a “performance based adjustment providing an upside of up to 50% of revenue as well as a small downside (10% of revenue) incentive to reduce costs and improve quality, assessed and paid quarterly.”  A different [and higher] payment structure will apply to PCF practices that agree to treat seriously ill patients that are currently lacking a primary care practitioner.

Quality Assessment: CMS will assess quality of care based on “a focused set of measures that are clinically meaningful for patients with complex, chronic needs and the serious illness population.”

Predictable revenue and reduced administrative burdens: CMS believes that PCF will appeal to a wide range of primary care physicians and their practices, including those in small and solo practices, because the risk-adjusted PBPM payments will provide them will predictable revenue each month, with limited downside risk (maximum 10% reduction) and substantial upside potential gains (50% of revenue). Administrative burdens will be also less, because the flat office visit fee eliminates the need to document different levels of office visits. Administrative burdens might also be reduced if PCP practices only have to report on a more focused set of quality measures.

By building the PCF program as described above, CMS believes that primary care physicians will come to it, like the baseball fans drawn to the cornfield baseball diamond in Field of Dreams. CMS needs them to come, because as a completely voluntary program, there has to be enough physicians, practices, and patients participating to assess the model’s effectiveness and reproducibility.  But will they?

It’s too soon to tell.  

 As ACP observed in a generally supportive statement issued today, there are elements of the PCF model that suggest that CMS is on the right track: there are a variety of payment and delivery models offered that support internal medicine and primary care practices, from smaller and independent practices to larger integrated ones; there is a range of risk options available to practices, and the new models aim to reduce administrative burdens—potentially allowing physicians to spend more time with their patients.

However, a lot of details are still missing that may determine how many physicians and practices will seek to participate, including basic things like how the PBPM payments will be adjusted by risk, the amount of those payments, and how they are to be calculated. Also, unless other payers join Medicare in supporting PCF practices with a simplified payment structure and more focused measures, practices may not experience the reduction in administrative burdens and predictable revenue that CMS anticipates. Presumably, CMS will be releasing such information soon, prior to the enrollment period it intends to begin this summer.

ACP concluded its statement with a note of caution: “The success and viability of these models will depend on the extent that they are supported by payers in addition to Medicare and Medicaid, are adequately adjusted for differences in the risk and health status of patients seen by each practice, are provided predictable and adequate payments to support and sustain practices (especially smaller independent ones), are appropriately scaled for the financial risk expected of a practice, are provided meaningful and timely data to support improvement, and are truly able to reduce administrative tasks and costs, among other things. ACP will continue to evaluate the new payment and delivery models based on such considerations, and we look forward to working with CMS and to continue advocating for ways to support the value of primary care for physicians and for all patients across the health care system.”

If CMS really wants primary care physicians to come to the models they've built, these - and other practical considerations - need to be included in their design. We'll soon find out if they will.

Wednesday, January 23, 2019

Reflections on 40 Years of Advocacy for Internists


Yesterday was the 40th anniversary of my career in representing internal medicine doctors, first with the American Society of Internal Medicine, and then with the American College of Physicians after the ASIM-ACP merger in 1998.   My first day on the job for ASIM was January 22, 1979.

To understand how long ago it was when I started working for ASIM, in the month of January 1979:

Jimmy Carter was President. He proposed on 1/14 that Martin Luther King’s birthday become a national holiday.

The Village People's Y.M.C.A became their only UK No.1 single.

The Shah of Iran fled Iran during the cultural revolution. 1 million marched in Tehran in a show of support for the exiled Ayatollah Khomeini.

In Super Bowl XIII, the Pittsburgh Steelers beat Dallas Cowboys, 35-31; MVP: Terry Bradshaw, Pittsburgh, QB.

Tom Brady was only 17 months old.  Really.                               

The Dukes of Hazzards premiered on CBS.

The “Wiz" closed at Majestic Theater NYC after 1672 performances.

Pope John Paul II embarked on his first overseas trip.

Midnight Express, starring Jane Fonda and John Voight, won the Golden Gloves award for Best Picture.

I was 22, a few months out of college; my hair was brownish (not white), quite a bit longer, and parted in the middle; and I weighed quite a “few” pounds less than now.  Had you asked me then if I would still be advocating for internists four decades later, I’d have said you were crazy.

So how is it that I am still here 40 years later?

I work for internists—a special breed of doctor that almost without exception, has been caring, thoughtful, engaging, creative, supportive of me and others on the [ASIM, ACP] staff, and fun!  There is no better group of physicians to work with, or for, than internists.  Many of them are my friends.

I’ve had great mentors and supporters of my career, from every one of the bosses that I reported to, from Bill Ramsey (ASIM), Mark Leasure (ASIM), Joe Boyle, MD (ASIM), Alan Nelson, MD (ASIM, and ACP), Walt McDonald, MD (ACP), John Tooker, MD (ACP), John Mitas, MD (ACP), Steve Weinberger, MD (ACP), and now Darilyn Moyer, MD (ACP).  Their management styles couldn’t have been more different, yet I’ve learned so much from them, and I’m still learning.

I was able to contribute to the successful merger of ACP and ASIM in 1998, working with Alan Nelson, Mark Leasure, John Tooker, and Walt McDonald to bring together the staff from the then-ACP and then-ASIM Washington offices into a team of equals, after years of being rivals.  The result has been the most effective physician advocacy organization on the planet (IMHO).

I am privileged to work in an organization where there is mutual respect between our internist-members/leaders and their staff, recognizing that we each bring different skills to the organization. This organizational culture of staff and physicians being on the same team is rare in American medicine.

I’ve been to all 50 states on business trips, and seen the beauty and diversity of our country in ways few are able to experience.  I’ve talked to many thousands of internists in my travels, learning from them what can be done to make things better for them and their patients.

I’ve been able to write often about health care, feeding my inner journalist.

I’ve been invited to author/co-author some of ACP’s most influential policy papers, many published in the Annals of Internal Medicine, addressing topics from universal coverage to gun violence to reducing administrative burdens to improving payments for internists’ services, and many more.

I’ve had the best staff colleagues, and still do; many are among my closest friends.

And, at the top of my list, my career has allowed me to make a difference, improving health care for patients and improving the professional lives of internists.  Is there anything more defining than that for a successful career?

It’s been a great 40 years of being an advocate for internists and patients.  I plan to keep on doing it, until . . . well, I’ll know when it’s time.   But not yet, not too soon; there is still too much to accomplish and still too many good times ahead!

Thanks to all of you for your support and friendships over the past 4 decades.

Friday, December 7, 2018

How a single tweet from the NRA helped ACP reach millions of people on gun violence


On November 7, the National Rifle Association tweeted this about ACP’s new policy paper on firearms violence, published in the Annals of Internal Medicine:

Someone should tell self-important anti-gun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.

As a co-author of the ACP paper, I immediately posted a reply to the NRA:

Passing laws to stop kids from getting shot by unsecured guns, reducing the lethality of mass shootings, keeping guns from domestic violence offenders who will use them to kill their intended victims—oh yes, these are all in doctor’s lanes.  Like any other public health threat. 

Within hours, thousands of physicians tweeted why gun violence was in their lane, accompanied by the hash tags #ThisIsOurLane and #ThisIsMyLane.  Many included graphic photos of the carnage and blood they’ve experienced in treating gunshot patients; I continued to tweet often on the topic, sharing their testimonials and information about ACP’s policy recommendations.

I just learned that in the past 4 weeks since I first replied to the NRA, my tweets on ACP’s behalf reached 8,300,000 people!  Think about that: 1 tweet from the NRA, resulted in more than 8 million people being exposed to ACP’s advocacy message on gun violence (and a few other topics sprinkled into my tweets) in just 30 days.  Never before has my efforts to spread the word on ACP advocacy garnered so much visibility.

Yet it’s hardly just me that helped get the word out.  As of this hour, there are over 23,000 responses to the NRA’s original tweet, overwhelmingly in support of physicians’ speaking out on gun violence. The backlash from physicians has received extraordinary coverage in the mainstream press, from the New York Times (Doctors Revolt After NRA Tells Them to ‘Stay in Their Lane on Gun Policy’), to the WallStreet Journal (After NRA Rebuke, Many Doctors Speak Louder on Gun Violence), to CNN (Doctors Start Movement in Response to the NRA, calling for more gun research), to NPR (After NRA Mocks Doctors, Physicians Reply: This Is Our Lane)—and hundreds more print, digital, cable and TV outlets.  That the NRA’s tweet appeared just hours before another mass shooting at a Florida night club, and just a few weeks before another one at a hospital in Chicago, no doubt contributed to physicians’ fervor to take them on, and the coverage that resulted. 

Altmetric, a firm that tracks how much attention published research is getting from the news and social media, found that Annals’ publication of ACP’s firearms policy paper is now one of the top attention-getters, all time, of the millions of research outlets it has tracked:

Altmetric has tracked 12,258,221 research outputs across all sources so far. Compared to these, this one has done particularly well and is in the 99th percentile: it's in the top 5% of all research outputs ever tracked by Altmetric.  [Ranked 224 out of more than 12 million research outputs, and #2 out of the over 10,000 research outputs published by Annals and tracked by the firm.]

The NRA’s attack on physician advocacy on gun violence has also spawned editorials from physicians in the most prestigious peer-reviewed medical journals, including in Annals (Firearm Injury Prevention: AFFIRMing That Doctors Are in Our Lane,  co-authored by Annals editors Drs. Christine Laine and Darren Taichman, and Dr. Sue Bornstein, chair of ACP’s Health and Public Policy Committee); and in  NEJM (#ThisIsOurLane — Firearm Safety as Health Care’s Highway, co-authored by Drs. Megan Ranney, Marian Betz, and Cedric Dark).

For too long, the NRA has dictated much of the debate over gun violence, bullying those who offered other ideas.  No longer: the NRA has awakened a sleeping giant, the hundreds of thousands of physicians and their professional societies who feel both obligated and emboldened to speak out on the dangers to the health of their patients of unrestricted access to firearms.  Now, the challenge and opportunity going forward is for ACP, and other professional societies that share our commitment to reducing gun violence, to make sure that This Is Our Lane becomes a sustained movement, not just a moment.

Today’s question: What do you think about physicians’ and ACP’s response to the NRA and the This Is Our Lane movement?