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American Academy of Family Physicians
Saturday Jun 27, 2009

The health care debate heats up

On occasion I am brutally honest with patients about their differential diagnosis.  I tell them of several possibilities, but conclude that the most likely is “God Only Knows.”

This has been an active fortnight for news about reforming our health care non-system, highlighted, I suppose, by President Obama’s frank talk with the AMA and the Congressional Budget Office shooting Sen. Edward Kennedy’s plan out of the water.

As of this writing, and for the near future, God Only Knows is the front-runner.

What I look for is honesty about the real challenges.  And, lo and behold, we’re starting to get a little honesty.  

It started with Dr. Atul Gawande’s New Yorker article (see my June 1 blog post), which President Obama made required reading for White House staffers.  Then he mentioned it in his AMA speech. In his punch line, he referred to “…a system of incentives where the more tests and services are provided, the more money we pay. And a lot of people in this room know what I’m talking about.”

Throughout the speech, the president got a lot of nervous applause, and one standing ovation (“You entered this profession to be healers – and that's what our health care system should let you be"), but the line about incentives got stony silence.

If you want a useful and perceptive commentary, read Dr. Abraham Verghese’s article, “The Myth of Prevention,” in the June 20 Wall Street Journal.

If you don’t have access to these articles, or the time to read them, here’s an executive summary of the debate to date:

The CBO decided that Sen. Kennedy’s bill would cost roughly $1 trillion over 10 years, and still leave 37 million Americans without insurance.  That was a big "OOPS!" for congressional Democrats.

Dr. Gawande usefully observed that doctors make a lot more money when they decide to order tests and procedures which make them a lot more money.  He did not have a solution to this problem. The solution I favor, Health Savings Accounts, he dismissed by noting that no one shops for price when chest pain strikes in the middle of the night, which is true. He failed to point out that lots of people shop for price in the course of my routine office practice, which, to be fair, is completely outside his limited experience as a surgeon and author.

Dr. Verghese, an internist and infectious disease specialist, writes:

“Cut, poke, sew, burn, insert, inject, dilate, stent, remove and you get very well paid; if you learn how to do this efficiently, maybe set up your own outpatient center so you can do it to more people in a shorter time (which is what happened when this payment system was put in place in 1989) and you are paid even more. If, however, you are a primary care physician, and if, just like the young doctor who saw my parents yesterday, you spend time getting to know your patients, and are willing to play quarterback when your patient enters the hospital, so that you can herd the consultants and guide the family through a bewildering experience that gets surreal if you are in the intensive care unit, then you may have great personal satisfaction but you will make five to tenfold less than your colleagues in the doing-to disciplines.”

No argument there. But aside from “behavioral things – eat better, lose weight, exercise more, smoke less, wear a seat belt,” he is skeptical about preventive medicine. Primary prevention through the use of statins may not be cost-effective (unless you are careful to use generics when possible); there are lots of technological gimmicks, like CT scans for coronary calcium, which don’t add much except anxiety.  

Dr. Verghese is also skeptical about electronic medical records: “…an electronic medical record (EMR) may or may not save money (it won’t be anywhere as much as is projected) but what it will do is ensure that we doctors, nurses, therapists, particularly in hospitals will be spending more and more time focused on the computer, communicating with each other, ordering and getting tests, buffing and caring for our virtual patient – the iPatient is my term for this phenomenon – while the patient in the bed wonders where everybody is. Having worked exclusively for the last seven years or so in hospitals that have electronic medical records (EMR), I have felt for some time that the patient in the bed has become an icon for the real focus of our attention, the iPatient. Yes, electronic medical records help prevent medication errors and are a blessing in so many ways, but they won’t hold the patient’s hand for you, they won’t explain to the family what is going on.”

He asserts “the single most important fact about health care in America that you or I need to know. ... all of us – doctors, hospitals, pharmacists, drug companies, nurses, home health agencies, and so many others – are drinking at the same trough which happens to hold $2.1 trillion, or 16% of our GDP. Every group who feeds at this trough has its lobbyists and has made contributions to Congressional campaigns to try to keep their spot and their share of the grub. Why not? – it’s hog heaven. But reform cannot happen without cutting costs, without turning people away from the trough and having them eat less. If you do that, you have to be prepared for the buzz saw of protest that dissuaded Roosevelt, defeated Truman’s plan and scuttled Hillary Clinton’s proposal."

Our leaders in the AAFP are, at this moment, trying to shoulder their way into this trough. And I wish them well, I really do, because their ideas are better than the proceduralists’ ideas. In a perfect world their proposals would be enacted. This is not a perfect world.

Meanwhile, I know this from personal experience: If I am given complete control of medical dollars through a full-capitation model, I will make a lot of money, because I practice evidence-based, cost-effective medicine. If I am simply scored against my peers based on costs that pass through my fingers, even if there is no monetary incentive, I will rank high for the same reason.

For around $200 per patient per year, you can have all of my services, including office visits, labs, x-rays, and obstetrics. My Job One, except for delivering babies, is to keep patients out of the hospital. I'm good at it, Dr. Verghese. Prevention works for me.

Based on proposals he has entertained thus far, President Obama is suffering from delusions about what it will take to reduce health care costs. I am not.

What we need is a system in which patients trust their family physicians, internists and pediatricians to direct their care in a cost-effective, patient-centered, wise and humane manner. This system should not interpose itself between me and my patient, and it should not raise questions about my motives. The inevitable and necessary rationing decisions must be made by patients and their families with the advice of their personal physicians, not by insurance companies or government commissions.

Aside from a universal system of Health Savings Accounts with refundable credits for the poor, I am waiting for alternative proposals that meet these criteria.

But this is beyond my pay grade. In the meantime, I’m Making It just fine, and you should be too.

Friday Jun 19, 2009

Whatever happened to hard work?

As often happens, it was advertisements that made me think.

Two arrived the same day from Merritt Hawkins & Associates, the headhunters. Both were looking for family physicians and offering $300,000+ earning potential, which would be at the 90th percentile for our specialty. 

Shouldn’t that be enough to allow a modern medical student to consider family medicine? Or was there a catch?

The first flier offered a $240K salary with a production bonus, a four-day work week, no state income tax, no non-clinical hassles, golf at the 29th toughest course in the nation, a host of outdoor sporting activities in “the high-desert playground of the Mountain West” and a 13 percent lower cost of living than the national average – what’s not to love?

The second was to take over the practice of a retiring physician. The starting salary was $200K, with a $40K signing bonus and $10K relocation allowance, and you could keep your lab and x-ray revenue. The community was “safe and friendly” and “a great place to raise a family,” which probably translates to “boring,” which is why it also offered an “easy drive to two metropolitan areas.”

The former specifically noted “average three to six deliveries per month.”  The latter specifically noted “25 to 35 patients per day.”

There you have it. That’s the catch.

Both practices expect to hire, and I’m sure will hire, family physicians whose knees don’t shake at the thought of 60 deliveries or 7,000 patient visits per year.

Numbers like that would not have intimidated my great-grandfather Dan. He would have considered $12K (the equivalent of $300K in 1900 dollars) to be a princely sum, and as for the four-day work week – well, had he died and gone to heaven?

Even in my era (now we’re fast-forwarding to 1980) $116K would have made me salivate. And 60 deliveries per year? I trained for a couple of Boston marathons, raised four kids and started a private school while I was doing that.

Is this the real “crisis” for which the Patient-Centered Medical Home provides the “solution”?

In order to become one of the top 10 percent of earners in family medicine, do you just have to work about as hard as I expected in 1980, or half as hard as Dr. Dan in 1900?

It’s a question worth asking, because if that’s the answer, God help the AAFP in wringing enough money out of the federal health budget to lure more students away from urology.

Thursday Jun 11, 2009

PCMH meets the real world

The “preliminary” report on TransforMED is out, and it isn’t pretty. It also isn’t much different than Evaluators’ Report #5 from over a year ago. If you’ve never heard of the Patient-Centered Medical Home (PCMH) or TransforMED, I’m not going to help you today. See old blogs here and here, which will link you to the big picture. 

First, some perspective.   

The AAFP deserves a lot of credit for at least three reasons. First, it recognized several years ago that the specialty was in trouble and came up with an action plan. Second, it put its money where its mouth was, to the tune of $8 million, and funded an experiment to see if its plan was workable. Third, when the results weren’t pretty (see below), it didn’t flush them, and we know that that has proved to be a big problem in medical research. 

The AAFP also deserves three Bronx cheers. First, it has tirelessly promoted the PCMH model (as defined by TransforMED) to its membership without having the evidence to back it up. Second, it is allowing TransforMED to sell its non-evidence-based services to members. Third, it is failing to provide a forum for the vigorous debate that needs to take place immediately. 

What follows below is a cut-and-paste summary of the “Initial Lessons” from the researchers' report with my brief commentary in italics. 

Rush to Judgment; Unintended Consequences; Hold Your Horses: "The PCMH represents an innovative and exciting national conversation that melds core primary care principles, relationship-centered patient care, reimbursement reform, new information technology, and the chronic care model. Unfortunately, the rush to demonstrate operational and financial feasibility of the PCMH, proceeding apace with the recognition process of the National Committee for Quality Assurance (NCQA), risks premature closure of the larger PCMH conversations and potentially stifles evolution of the PCMH to meet important patient, practice, and system needs. … The pressure toward widespread adoption of this model is gaining momentum so rapidly that we feel compelled to share our observations and summarize the early process-evaluation lessons. … The NCQA has taken the lead in defining some essential components and creating a 3-tiered, implementation process for recognizing a PCMH. We fear the details of the recognition process may have reached premature closure, however, before the rich data have emerged from the NDP and other current demonstrations."

A one-size-fits-all approach is usually a bad idea, and TransforMED has proved it. The PCMH is ideally suited to large practices where bureaucracy has created layers of separation between providers and patients. For small group or solo practices, which constitute the bulk of the AAFP membership, the PCMH prescriptions are an insult. (If you’re not insulted, take the TransforMED Medical Home IQ test. You will be.) The authors are pleading for a re-evaluation of the concept. A good starting point would be the proposal by well-known researcher Barbara Starfield, MD, MPH.

Demoralization; Emotional Exhaustion; Financial Disaster: "In the process of working with these practices, our team has seen the day-to-day reality of changing community-based practices into the current idealized model of the PCMH. We have already learned enough from the NDP to identify some potentially dangerous red flags fluttering over the demonstrations just getting underway. Our early analysis raises concerns that current demonstration designs seriously underestimate the magnitude and time frame for the required changes, overestimate the readiness and expectations of information technology, and are seriously undercapitalized. We fear that with current assumptions, many demonstrations place participating practices at substantial risk and may jeopardize the evolution of the PCMH as unrealistic expectations set up demonstrations and evaluations for failure. … All the well-supported NDP-facilitated practices were challenged financially by the project." 

At the AAFP's annual meeting in Chicago two years ago I buttonholed Terry McGeeney, TransforMED's president and CEO, and Jim Arend, its CFO and practice facilitator, and asked them about the lack of “before and after” financial data for the participating practices. Their response: “It’s too hard to gather.” So now we know from the researchers' report that the practices were “financially challenged,” but we have no idea how badly. Somebody in authority needs to know what is going on.

Loss of Focus; Perils of Transformative Change: "Most current practice models are designed to enhance physician workflow. The PCMH should be designed to enhance the patient experience. This shift requires a transformation, not an incremental change. … The work is daunting and exhausting and occurring in practices that already felt as if they were running as fast as they could. This type of transformative change, if done too fast, can damage practices and often result in staff burnout, turnover, and financial distress. … Do not be surprised if the situation seems worse after the first 6 months to a year; the experience of benefits often takes at least 2 years."  

In a one-horse practice, “the patient experience” is right in your mug all day long. If you miss it, you’re too dense to profit from the PCMH experience anyway. In a big group practice, if you can hold your breath for two years you might be OK, except that all of the TransforMED practices were heavily subsidized financially; so while you’re holding your breath, you’d better be applying for Robert Wood Johnson Foundation grants. And get ready to suffer the consequences of staff burnout and turnover.

EMR Idolatry: "The hodgepodge of information technology marketed to primary care practices resembles more a pile of jigsaw pieces than components of an integrated and interoperable system. … For example, it is possible and sometimes preferable to implement e-prescribing, local hospital system connections, evidence at the point of care, disease registries, and interactive patient Web portals without an EMR. … New Web-based technologies, electronic clinical information systems, and telecommunications are finally nearing accessibility and utility for both health systems and primary care practices. … Future PCMH recognition and certification processes should focus more on patient-centered attributes and the proven, valuable key features of primary care than on the disease management and information technology features of the PCMH." 

Challenges to the politically expedient push for EMRs are now rolling in from all directions. If you already have one, keep and improve it; if you’re starting practice, research and buy one. If you’re well established, an EMR is not going to make you more money, and will cost you a fortune in purchase, maintenance and lost productivity. 

Productivity and Efficiency: "We should be wary of industrial-like schemes and excessive use of the language of productivity and efficiency. Primary care, like healthy food, works best at a local and personal level."

There are two metaphors for productivity: the factory and the farm. To a good family physician, you cannot view your patients as widgets rolling off an assembly line; they are crops to be nurtured. You can’t hurry the growth of a plant, but you can nurture it more productively. That’s the metaphor this blog is about. On the other hand, the PCMH is more like an industrial operation than anything else; and a bad one, to boot. TransforMED proves it. Now it’s time to move on to greener pastures.

Monday Jun 01, 2009

The roots of medical inflation

The fault, dear Brutus, lies not in our stars but in ourselves.  

In the June 1 New Yorker, Dr. Atul Gawande tackles what he calls the medical “cost conundrum,” to wit: Medicare costs bear no relationship to quality of care outcomes.

He approaches this delicate subject by examining the medical society of Hidalgo County, Texas, which has the lowest household income in the country. It also spent $15,000 per Medicare enrollee in 2006, roughly double the payola in the home counties of the Mayo Clinic and Duke. It is also double the cost of El Paso County, 800 miles up the border, which is demographically identical.

Why? You won’t be surprised.

Hidalgo County physicians are nothing if not entrepreneurial. Dr. Gawande posits a case for a group of them over dinner. A 40-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease.

What did they do 15 years ago? Send her home. Maybe an outpatient treadmill. And today? A stress test, an echocardiogram, a mobile Holter monitor and a cardiac catheterization.

“Young doctors don’t think anymore,” the family physician said.

“There is overutilization here, pure and simple,” the general surgeon said.

I see the same thing in my town. Thinking – that is, making a medical judgment that a test or procedure is not cost-effective – is dwindling. And why should that be a surprise? Every procedure earns a fee for some physician. And if you question the rationale? “You’re rationing care!” is the cry.

This is not family medicine’s problem. It is not primary care’s problem. Primary care’s problem is that entrepreneurial specialist colleagues have so padded their wallets over the past 15 years that medical students – no dummies, they – won’t choose our calling.

We are now under the direction of a new administration, which seems to be more serious about the coming bankruptcy of Medicare than the previous administration. “Nearly thirty percent of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas,” says Peter Orszag, President Obama’s budget director.

He’s right, too. That would push back the bankruptcy maybe a decade.

The solution proposed by the primary care societies is the Patient-Centered Medical Home, with pay-for-performance incentives that will jack up our salaries into the procedurist stratosphere. That’s the basket we’re putting all our eggs in.

In which case bankruptcy comes a decade earlier.

If you believe that’s going to happen, I have a house in Colorado I’d like to sell you.

The solution is going to be rationing by a government agency like Britain’s NICE commission, or self-rationing by the market in the form of Medical Savings Accounts. You can take that prediction to the bank.

In the meantime, we honest family physicians need to do what we’ve always done, which is care for patients in a cost-effective manner – informed by the best medical evidence, and with a close eye on their medical expenses and our administrative expenses.

Which is what I’ve been saying all along.

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