China questions costs of U.S. health care reform

An interesting read from Reuters Blogs:

"It turns out the Chinese [America's largest creditor] are kind of curious about how President Barack Obama’s health care reform plans would impact America’s huge fiscal deficit. Government officials are using his Asian trip as an opportunity to ask the White House questions. Detailed questions. ..."

Posted at 11:58AM Nov 18, 2009 by Brandi White  |  Comments[0]

How to fix health care in one fell swoop

The House and Senate have drafted literally thousands of pages of legislation aimed at fixing the U.S. health care system, but the single most important reform according to renowned researcher Barbara Starfield, MD, is "to devolve unnecessary services provided by specialists back to primary care. This would, in one mechanism, reduce costs of care and improve quality of care."

(Note to skeptics: She has hundreds of research articles to back it up.)

In a recent editorial in FPM, Starfield warned the family medicine community not to waste this opportunity for meaningful reform by embracing proposals that do little to further the essentials of good primary care, which she describes as:

• "First contact care, which requires accessibility and responsibility for reducing unnecessary specialist care."

• "Person-focused care over time delivered by the patient's chosen physician, who assumes responsibility over long periods for all health care."

• "Comprehensiveness of care."

• "Coordination of care when people have to go elsewhere for problems outside the competence of the primary care practitioner."

Posted at 02:13PM Nov 13, 2009 by Brandi White  |  Comments[0]

Will accountable care swallow up primary care?

If you've heard something about "accountable care organizations" (ACOs) in discussions of health care reforms, but you're not quite sure what they are or where they're supposed to fit in, you might find this "Perspective" piece from the New England Journal of Medicine useful. In short compass it defines the term and relates it to the other biggie in health care redesign, the patient-centered medical home (PCMH).

To get the definition out of the way, "an ACO is a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population." (Harks back to the day when managed care wore a white hat, doesn't it?) While the PCMH has been much discussed in family medicine over the past five years, at least, the term ACO seems to have emerged only recently.

The NEJM article makes the point that the PCMH and the ACO are, or can and should be, complementary: The PCMH is a model for redesigned primary care, and the ACO is a model for ensuring that the rest of the delivery system works in concert with the PCMH by aligning incentives for the rest of the system with those of primary care.

Sounds neat, doesn't it? The ACO is a way to get referral specialists, hospitals and all the rest to see things our way. Except ...

As the NEJM article puts it, "The fact that the ACO model does not explicitly require support for primary care has led to considerable concern that ACOs dominated by hospitals or specialists would not adequately invest in primary care – or that hospitals and specialists would garner a disproportionate share of any savings." The ACO may be a "provider-led organization," but the providers leading it may well be hospitals, large multispecialty groups or other entities who have not so far proved to be far seeing or even to understand primary care. The NEJM article lists three requirements for successful integration of PCMHs into ACOs:

• Alignment of accreditation and certification criteria for the two organizations: "No ACO accreditation or certification process has yet been developed, but when one is, it will be critical to include criteria that ensure sufficient primary care capacity for the patient population and to closely align the standards with those of PCMH recognition."
• A common set of primary care performance measures: "Performance measurement for determining the amount of shared savings or other financial incentives for ACOs must weight primary care measures heavily rather than focus narrowly on metrics related to hospital care."
• Wise alignment of incentives: "The payment mechanisms used must align the incentives of the two models to increase accountability for total costs across the continuum of care while ensuring that a sufficient investment is made in primary care capacity."

So all we need to do to achieve a health care delivery system we can be proud of is redesign primary care, redesign the rest of care, avoid the mistakes we've made chronically in past attempts to fix the system, develop system-wide performance measures with a primary care orientation and, oh yes, shift the center of power of the system from secondary and tertiary care to primary care. I hope we're up to the challenge.

Posted at 10:17AM Nov 05, 2009 by Bob Edsall  |  Comments[0]

Red Flags rule deadline delayed

The Federal Trade Commission (FTC) announced Friday that it is delaying the enforcement of the Red Flags Rule until June 1, 2010. The previous deadline was Nov. 1, 2009, which was pushed back from the original Aug. 1, 2009, deadline.

The AMA plans to use this extra time to persuade Congress and the FTC that physician practices should not be subject to the rule:

 "The AMA will utilize this time to convince the FTC and Congress to republish the rule so that there is sufficient opportunity to formally comment and state the AMA's objections to physician inclusion in the program."

If that effort succeeds, physicians everywhere will wave a flag of victory.

Posted at 12:02PM Nov 04, 2009 by Lynn Hofeldt  |  Comments[1]

A detour on the way to the medical home

Last week the Centers for Medicare & Medicaid Services (CMS) published an update on the long-delayed Medicare Medical Home Demonstration. The September announcement from the Department of Health and Human Services of a Multi-Payer Advanced Primary Care Practice Demonstraton initiated by the Obama administration had raised more questions about the future of the medical home project. The explanation from CMS was brief and to the point: “At this time, CMS believes it would be impractical to pursue clearance of the Medicare Medical Home Demonstration, which has been under review at the Office of Management and Budget, given the pending legislation that would repeal it and replace it with a similar pilot.”

CMS describes the similar pilot as “an independent practitioner-based medical home pilot.” The pending legislation that describes it is the House of Representatives health care reform bill (HR 3200). The two pilots do appear similar in many respects, but one needs to read no further than subsection (a)(4) of Section 1302 “Medical Home Pilot Program” to discover a significant difference between the proposed pilot and its would-be predecessor. Under “Participation of Nurse Practitioners and Physician Assistants,” the bill stipulates that nurse practitioners and physician assistants may lead patient-centered medical homes as long they are acting consistently with state law and other requirements are met.  

Family physicians concerned about turf issues may see this as a setback. The good news is that primary care and medical homes are still the focus of discussion and legislation in Washington, even though the first Medicare medical home demonstration, which many believed would help breathe new life into family medicine, is apparently at death’s door.

Posted at 01:58PM Nov 03, 2009 by Leigh Ann Backer  |  Comments[0]

Ten steps from ordinary practice to PCMH practice?

This new article from FPM says the trick is to start with steps that increase practice revenue, then use that revenue to support later steps.

• First, stop undercoding; get the revenue you deserve.
  
  
• Second, use the revenue to hire more nurses or MAs.
  
  
• Third, increase your productivity and revenue by offloading work onto your newly enlarged support staff.
  
  
• Fourth, ... well, why not read the article?
  

Posted at 10:10AM Oct 17, 2009 by Bob Edsall  |  Comments[3]

Beyond PCMH: Is your practice an "accountable care organization"?

The patient-centered medical home model, which has been in the spotlight over the last few years, may soon have to share the stage with a new model: the "accountable care organization."

What's an accountable care organization? According to a recent report from Harold Miller, executive director of the Center for Health Care Quality and Payment Reform, an accountable care organization is "a health care provider or group of providers that accepts accountability for the total cost of care received by a population."

What does a practice need in order to act as an accountable care organization? Miller identifies eight elements:

1. Complete and timely information (including cost information) about your patients and the services they are receiving. Miller notes that most practices will need "significant assistance" from payers in order to obtain this information.
2. Technology and skills for population management and coordination of care, such as using clinical guidelines and monitoring compliance with them, analyzing data on resource use and utilizing a patient registry.
3. Adequate resources for patient education and self-management support.
4. A culture of teamwork among the staff of the practice.
5. Coordinated relationships with specialists and other providers.
6. The ability to measure and report on the quality of care.
7. Infrastructure and skills for management of financial risk.
8. A commitment by the organization’s leadership to improve value and create operational accountability.
   
   

How does an accountable care organization differ from a patient-centered medical home? According to Miller, "Most initiatives today to help primary care practices become Medical Homes do not require that the primary care practice accept any accountability for the total costs of care for their patients or for population-level quality outcomes. Even though many of the enhanced resources and tools being developed and used by Medical Homes, such as electronic health records, patient registries, patient education on chronic disease management, and more responsive scheduling, could help improve quality and reduce total costs, there is no guarantee that they will do so unless the primary care practice actually focuses on improving those outcomes as an explicit goal and uses the medical home tools to achieve the goal. Indeed, the Congressional Budget Office, in evaluating various health delivery reform options, estimated that paying for Medical Homes for chronically ill beneficiaries in Medicare would increase spending by $5.6 billion, rather than reduce costs."

Miller continues, "This implies that while becoming a Medical Home could help a primary care practice become an Accountable Care Organization, it is not sufficient. Conversely, in order to function effectively as an Accountable Care Organization, it may not be necessary for a primary care practice to meet all of the detailed standards that organizations such as the National Committee for Quality Assurance (NCQA) require of primary care practices in order to be formally designated as a 'Patient-Centered Medical Home.' Indeed, detailed accreditation standards are being used in medical home programs partly because payers are concerned about whether making higher payments to primary care practices to enable them to serve as medical homes will actually result in improved outcomes for patients and lower costs for payers. Since there is not strong evidence that all of the structural and process standards established for medical homes are necessary for improved patient outcomes and some may be difficult or expensive for practices to achieve, and because some practices that would not meet these standards have been successful in proactively managing and coordinating their patients’ care, a primary care practice should not be precluded from serving as an Accountable Care Organization simply because it has not met accreditation standards as a Medical Home."

Posted at 12:37PM Oct 16, 2009 by Brandi White  |  Comments[0]

Is your practice a medical home?

From NPR.org:

"Insurers will also pay [practices participating in a medical home pilot project] bonuses for keeping patients healthy. So, behind the scenes, the office is keeping track of patients, especially if they have a condition such as diabetes or asthma. Dr. Paul Grundy, the founder of a group that's promoting medical homes, says some doctors tell him they already do all that. 'One of the first questions I ask them is, Do you know every single woman in your practice [who is] over 50 and the status of her breast exams? And do you know every man who is over 55 and the status of his colonoscopy exams? If you don't, you don't have a medical home ...'"

Click here to read about the AAFP's definition of a patient-centered medical home.

Posted at 11:20AM Oct 08, 2009 by Brandi White  |  Comments[1]

Medicare's medical home demonstration project: Old news?

A recent press release from the Department of Health and Human Services (HHS) announcing plans for a demonstration project designed around "Advanced Primary Care models" left us, and perhaps many of you, with two big questions: What is the status of the much-anticipated and long-delayed Medicare medical home demonstration project? What is an Advanced Primary Care model? We now have at least partial answers to these questions.

The Medicare medical home demonstration project is at least briefly mentioned in a fact sheet that describes the newer initiative: "CMS will move forward with a separate Medical Home Demonstration required under the Medicare Improvements for Patients and Providers Act (MIPPA) and the Tax Relief & Health Care Act of 2006 (TRHCA)." But the time frame for the project remains unclear. The original schedule called for the Centers for Medicare & Medicaid Services (CMS) to announce in December 2008 the states where the demonstration would be conducted. The application and qualification processes were to have played out this year, and payments to participating practices were to have begun in January 2010. James Coan, a CMS project officer, said in the spring that the eight states have been selected, but CMS is still awaiting approval from the White House Office of Management and Budget to move forward with the project. That approval was first expected nearly a year ago.

The HHS fact sheet says the Advanced Primary Care model that the new project is designed to test is "also known as the patient-centered medical home." The reason for the new term will have to be the subject of a future blog post, but here's what we do know: The project will build on a model being tested in Vermont, where private insurers and the state's Medicaid program are collaborating to develop standards and compensation incentives for primary care physicians. The demonstration project will create opportunities for Medicare to join in similar efforts. Application materials will be developed this fall with the expectation that the demonstration projects will begin in 2010, according to the release. Nancy-Ann DeParle, director of the White House Office of Health Reform, called the project "a jump start on health insurance reform." Given the uncertainty surrounding the Medicare medical home demonstration, you have to wonder whether government health programs are capable of such a thing.

Posted at 02:24PM Oct 02, 2009 by Leigh Ann Backer  |  Comments[0]

What Baucus got right ... and wrong

Senate Finance Committee chairman Max Baucus (D-Mont.) released his committee's health care reform proposal last week to much criticism from his own party. But "despite all the vitriolic complaints from the left -- Howard Dean is becoming living proof that health care reform should offer a universal entitlement to Valium -- Baucus has advanced the historic Democratic cause of providing health security to all Americans by demonstrating that it can be compatible with fiscal responsibility and long-term cost control."

So writes Ronald Brownstein in The Atlantic.

In a Sept. 16 analysis of the proposal, the Congressional Budget Office concluded that the bill would reduce the federal deficit by $49 billion over 10 years and would produce savings equal to .5 percent of GDP after two decades. The bill does not include a public plan but would result in 94 percent of nonelderly people receiving coverage by 2019, excluding illegal immigrants. Notably, it would also provide a 10-percent bonus for primary care physicians on select E&M services under the Medicare fee schedule for five years.

The Baucus bill accomplishes all this by "creating a revenue stream [including a 35-percent excise tax on high-end health plans] that rises as fast as health care costs, and reshaping the incentives in the medical system in ways that should help 'bend the curve' on those long-term cost increases. Without those two elements any coverage expansion will prove unaffordable, and thus unsustainable, over time," writes Brownstein.

The bill's strategies for reshaping incentives include:

• Comparing the amount all physicians spend on patients with similar conditions and cutting Medicare reimbursements by five percent for those who generate the highest costs.

• Linking hospital reimbursement to their performance on quality measures.

• Allowing groups of providers to share in any savings for more effectively managing patients' care under Medicare.

• Creating an Innovation Center within the Health and Human Services Department that would fund experiments in coordinated care and payment reform.

• Creating an independent Medicare Commission that would be required to offer proposals for cost-savings whenever Medicare spending rises too fast and whose proposals would be fast-tracked for consideration by Congress.

The AMA has voiced several concerns, including the bill's use of payment penalties for physician outliers and the bill's failure to permanently repeal the sustainable growth rate (SGR) formula that would subject physicians to Medicare payment cuts of 40 percent over the next several years.

The bill is currently being amended in committee. Once approved, it will have to be merged with the Senate HELP committee's bill before going to the Senate floor.

Posted at 10:51AM Sep 23, 2009 by Brandi White  |  Comments[0]

What's behind the success of the most efficient medical community in the nation?

The Dartmouth Atlas of Health Care recently identified Grand Junction, Colo., as one of the most efficient medical communities in the nation (see our previous post on this topic). Its average Medicare spending per capita was $5,900 in 2006, about 30 percent lower than the national average of $8,300, while its quality ratings were much higher. A new report sheds light on why this medical community has been so successful and cites factors such as a local health plan that shares valid, individualized performance data with physicians and provides financial incentives for achieving quality and efficiency targets; cooperation between primary care physicians and specialist physicians; effective charity care and hospice programs; a community-wide EHR system paid for by the local IPA and HMO; fewer hospital beds and employees than the national average; and more primary care physicians than the national average. The report concludes with this:

"Primary care is the core of any high performance health system. Throughout a patient’s life, primary care physicians in Grand Junction are involved in all levels of treatment. Continuity and collaboration between primary care physicians, specialists, and other members of care teams leads to higher-quality care, better outcomes, and lower costs. Most importantly, team-based care refocuses the delivery system on the patient, not on the provider. Nevertheless, Grand Junction’s leaders are concerned by the extreme shortage of new primary care physicians entering the workforce. Primary care plays a central role in every collaborative, high-quality, and efficient health system. Thus, we must support primary care expansion within reform legislation, not as an afterthought. Without increased support for primary care, the miracle of Grand Junction’s health system could prove to be but an inspirational memory."

Posted at 10:30AM Sep 03, 2009 by Brandi White  |  Comments[0]

Medicare's pay-for-performance experiments

The Centers for Medicare & Medicaid (CMS) recently announced the results of three of its latest  pay-for-performance demonstration projects – one for large physician practices, one for solo and small physician practices and one for hospitals. In all three settings, offering financial incentives for meeting or exceeding performance standards improved quality of care and saved Medicare money, according to CMS.

In the first three years of the Physician Group Practice (PGP) demonstration, the 10 large practices involved in the project increased their quality scores an average of 10 percentage points on diabetes measures, 11 points on congestive heart failure measures, six points on coronary artery disease measures, 10 points on cancer screening measures and one point on hypertension measures. All of the practices reached benchmark performance on at least 28 of the 32 measures.

In the first year of the three-year Medicare Care Management Performance (MCMP) demonstration, more than 560 of the 610 small and solo physician practices in the demonstration will be rewarded for their performance on 26 quality measures. The average incentive payment per practice is $14,000 (out of a possible bonus of $50,000 per practice), although some practices will receive as much as $62,500 if they qualify for an additional 25 percent bonus for using an electronic health record (EHR) certified by the Certification Commission for Health Information Technology.

The Hospital Quality Incentive Demonstration (HQID) began in 2003 with hospitals in 38 states. Participating hospitals raised their overall quality scores by an average of 17 percentage points over four years. This number is based on 30 nationally standardized measures for heart attack, coronary by pass graft, heart failure, pneumonia, and hip and knee replacements. For year four of this demonstration, CMS is awarding a total of $12 million to 225 hospitals for their achievements and has shelled out more than $36.6 million during the course of this demonstration alone.

Words of caution

Mathematica Policy Research, Inc., has been contracted to independently evaluate the MCMP project for CMS. In their first report, issued March 4, 2009, the researchers noted that although demonstration practices reported greater awareness of care or documentation gaps, "At the same time, the data submission effort was labor-intensive, according to many visited practices; five had calculated that the cost of their effort was greater than the incentive payment they received for reporting the quality measures. Several were unsure if they would submit data in the coming year, because they were uncertain whether the potential reward was worth the effort. Half of these tentative practices consisted of solo practitioners. Many practices with EHRs felt frustration as their EHRs did not facilitate submission very well, due to system limitations, variations in use within the practice, or both." Mathematica's final report is due in 2011.

Posted at 12:28PM Aug 31, 2009 by Lynn Hofeldt  |  Comments[0]

The more things change, the more they stay the same

Does this sound like your practice today? “[Family physicians] are depressed, discouraged and overwhelmed. They work two to three times as many hours as physicians in other specialties but get paid only half as much (family physicians always rank near the bottom of lists that compare average incomes of various medical specialties). They receive frequent nighttime calls that are devastating to their family and personal life. They practice in an uncertain atmosphere of liability and lack of trust that has led to defensive medicine, over-ordering and anxiety. ... This hellish type of life needs appropriate reimbursement if we expect to attract quality physicians and maintain quality care."

In fact, these words were written nearly 16 years ago, during the last push for health care reform, in an open letter from John Pfenninger, MD, to Hillary Clinton published in FPM. Of course we all know the outcome of the Clinton reform effort. In many respects, President Obama’s strategy for getting health care reform passed seems to be the opposite of the Clinton administration's. Still, as Ezra Klein argued in a recent Washington Post article, “The Ghosts of Clintoncare” are haunting the current debate. It’s hard to predict whether President Obama’s push for health care reform will meet a different fate. The bipartisan negotiations that preceded the August Congressional recess seem to have been replaced with ideological rancor. An article in Sunday’s New York Times breaks down the arguments on both sides.

A decade and a half after its writing, Dr. Pfenninger's letter reminds us that the stakes are high for family physicians and their patients – and have been for a very long time. Let’s hope that the next time we dust off his letter, the problems he describes won’t sound quite so familiar.

Posted at 04:23PM Aug 11, 2009 by Leigh Ann Backer  |  Comments[4]

Good news, bad news

How about starting with the good news? Family medicine is among the 10 best paid occupations in the country, at least according to Forbes. Note: That's not the 10 best paid medical specialties; it's the 10 best paid occupations of any sort. Even better, at $161,490 per year, the average family physician makes $1,050 more than the average CEO. Congratulations! (No way to tell whether the CEO salary figures count golden parachutes, though ... )

You already know the bad news, I'm sure: While family physicians make the top-10 list, they're number nine, behind general surgeons, anesthesiologists, orthodontists, obstetricians and gynecologists, oral and maxillofacial surgeons, general internists, prosthodontists, and a group called "other physicians and surgeons" – those outside the "main specialties."

Don't despair. That doesn't mean that family physicians are the worst-paid physicians in the country. Other major specialties didn't even make it into the top 10. General pediatricians made 13th place, for instance, behind general dentists and psychiatrists. And lawyers show up in 16th place. See? Even the bad news isn't that bad.

Posted at 10:51AM Aug 04, 2009 by Bob Edsall  |  Comments[0]

President Obama discusses family medicine – and he gets it

Speaking at a town hall meeting on health care in Raleigh, N.C., yesterday, President Obama was asked by the wife of a family physician what he would do to address the hardships of family physicians and entice more students to enter the specialty. He replied by emphasizing the value of family medicine and primary care, and had this to say:

"When we pass health reform and more people have access to the system, it is going to be vital that we increase the number of primary care physicians. The best way for us to do it is two-fold. One is to change how we reimburse ... so that the incomes of primary care physicians are more comparable with specialists. The second thing is to provide scholarships and financial incentives for young medical students who are willing to go into primary care."

View a short video clip here or the entire video here. (The above quote appears at the 36:40 mark.)

Posted at 10:52AM Jul 30, 2009 by Brandi White  |  Comments[0]