Monday, April 14, 2014

 Team-Based or Single Physician-Based Care

From Chaos to Care: The Promise of Team-Based Care

David Lawrence,MD, Chairman Emeritus Kaiser Permanente, title of his book (Perseus Publishing, 2002)

 These days everywhere you look – whether it be to ObamaCare’s Accountable Care Organizations or the New England Journal of Medicine,  you will run across prescriptions for team-based solutions to U.S. health cost woes and outcomes. (“Transforming Specialty Practice – The Patient-Centered Medical Neighborhood,” “Redesigning Surgical Decision Making for High Risk Patients,” New England Journal of Medicine,  April 10, 2014).

These prescriptions for new practice designs invariably include these words and concepts –  coordination,  integration, transformation, measurements, management, data, information technology, population health, prevention,  tracking, outcomes, performance measurement,  quality improvement, team-based care, and patient-centered.

It gets awfully complicated.  Practice redesign  requires involving  multiple rotating caregivers,  revolutionizing   traditional reimbursement patterns, gathering multiple pieces of information for hungry computers,  multiple managers and systems to interpret the data and to apply it to judge whether costs are reasonable, how  to contain them,  and, among other things, judging what should be done “free” of co-pays and deductibles in the name of “prevention.” (“Discord Over What to Pay the Doctor: Patients Balk at Paying for Care They Deem Preventive Under Health Law Rules, “ WSJ, April 13, 2014).

It is so complicated  that primary care physicians are being forced to double and triple their overhead costs just to comply with regulations and keep track of 3rd party demands.  

It should come as no surprise, then, that many primary care physicians are opting out traditional 3rd party dependent practices to enter into “Direct Independent Practice (DIP)" devoid of insurers to reduce their overhead and increase their practice satisfaction.   This is being met with withering criticism as a “throwback” to the chaos that got us where we are today, or as an “obamanation” (pun intended) leading to a two-tier system where only the rich can get care and the poor are denied access to care.

How is it possible that DIP could possibly work in this modern data, management, government, and big health system-drive era?    

·         In the first place, primary care services account for only 6% of total health spending.  Having them drop out of the practice race  is not likely to effect overall government health spending much.  It might even decrease costs by dropping primary care overhead from 50% to 60% to 20%-30%, the case with most DIP practices.

·         Secondly,  most DIP physicians have found their new patients consist mostly of the uninsured and the uninsured who cannot afford premiums and deductibles of new health plans,  often even  if they are government-subsidized.

·         Thirdly,  physicians entering DIP practices find they welcome “being a doctor again, practicing medicine rather than coding or being drowned in paperwork,” as one doctor explained to me.   Patients, in their turn,  may prefer having a single doctor as their personal physician, rather dealing with multiple physicians and other professional caregivers who are part of the”team.”

There is room for  both team-based and  DIP-based  practitioners :

- team-based primary care doctors operating as part of teams,  particularly in closed systems like Kaiser-Permanente,  networks of hospital or insurer systems , and government-subsidized community clinics are on the rise.  

-         Single or small groups of  direct independent practitioners offering cash-discounted convenient and comprehensive  array of bundled primary services delivered by physicians with an intimate and personal knowledge of their patients.

Tweet:    Redesign of medical practices is taking 2 paths:  1) team-based care involving multiple physicians and caregivers;  2) direct-independent practices based on more personal attention by a single physician.

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