Primary Care, Physician Payment - Nonintendo and Hardening of the Categories.

Nonintendo and Hardening of the Categories

An article in the December 5 JAMA, “Unintended Consequences of Resource-Based Relative Value Scale,” from the department of medicine at Massachusetts General Hospital, prompts this blog.


Its author, Dr. John Goodson, argues RBRVS is responsible for the impending collapse of primary care in America.


Here is how Dr. Goodson puts it:


Medicine's generalist base is disappearing as a consequence of the reimbursement system crafted to save it—the resource-based relative value scale. The US physician workforce is unique among developed economies of the world. Virtually all European countries have a broad generalist foundation comprising 70% to 80% of practicing physicians. The United States is the opposite. Starfield has summarized the benefits of a generalist workforce as access to health service for relatively deprived populations; care equal to specialists in most situations (recognizing the invaluable contribution of the specialist physicians but acknowledging that the diffusion of knowledge increases the ability of the non-specialist to provide up-to-date care); improved preventive service delivery; efficient management of multiple simultaneous medical, surgical, and mental health problems in active and fully functional patients; provision of continuity in the health care experience, advice, and counsel where appropriate and access to appropriate diagnostic, consultative, and specialty.


And here is what Goodson sees as a solution:

The medical profession needs to reformulate the way the value of clinical services and the infrastructure expenses of practice are determined, needs to make the process open and accountable, and needs to solicit input and oversight from those who have the health of individuals, the nation, and the economy as their highest priorities. The resource-based relative value scale system originally developed to achieve full value for cognitive services currently threatens the sustainability of the generalist base. As a result, a large portion of the population will lose access to the continuous and personalized care provided by generalist physicians whose repertoire of clinical skills and interventions coupled with access to specialty and diagnostic services are essential for ensuring efficient and effective health care delivery.

I agree with Dr. Goodson, and I’m reminded of the law of unintended consequences. It refers to situations where an action results in an outcome not intended. The unintended consequences may be foreseen or unforeseen, and may fall into three categories.

1. A positive unexpected benefit, usually referred to as serendipity or a windfall.
2, A potential source of problems, according to Murphy’s Law ro system engineering
3. A negative or a perverse effect, which is the opposite result of what is intended
RBRVS falls into the third category, and to me it indicates the government and other creators and enforcers of RBRVS are suffering from a dire disorder known as “hardening of the categories, “ which, in the case of Medicare, may be irreversible.

Quality - “Quality:” It Depends on What “Is” Is

President Bill Clinton will be remembered for saying, “It depends on what ‘is’ is.”


Similarly quality of care will be judged for what “is” is in the eyes of beholders.


For years, a debate has waged as to what makes for the best “quality” – solo, small, or large practices. As pointed out in the November 26 AMA Medical News, “Bigger Practice, Better Quality?” it depends on what you think quality is.


If you think quality is a more intimate, responsive, and closer relationship with your patients, solo or small practices may be your gig. Solo doctors, such at L. Gordon Morre or Rochester, New York , or John Brady, of Newport News, Virginia, family physicians both, feel they are delivering higher quality care than they did as members of larger groups.


They do so be cutting overhead, using EMRs, taking a proactive approach to caring for patients with chronic disease, being available 24 hours a day, answering their own phone, and seeing patients on the day they call. There are now about 100 similar solo groups operating in the U.S, along with roughly 500 concierge or retainer practices.


But if you think quality is defined and measured by more acceptable and concrete measurements, the big groups win hands down. A cross-sectional study of 119 California groups pitted against small groups found the following.


Quality measures, large groups vs. small groups

1. Mammography, 73%, 58%

2. Pap smear screening, 53%, 30%

3. Chlamydia screening, 235, 9%

4. Diabetic eye screeing, 42%, 29%

5. Asthma-control, medication,77%, 76%\

6. Beta blocker after acute MI, 80%, 69%

Quality improvement strategies, large groups vs. small groups

1. have an EMR, 37%, 2%

2. Offer quality bonuses to physicians, 32%, 13%

3. Provide reminders about missed:

--Mammography appointments, 74%, 28%

--Diabetic eye screening, 53%, 18%

--Well-child immunizations or visits, 47%, 10%

-- Influenza vaccine, 54%, 25%.

Like I said, the perception of quality depends on what “is” is – on what you perceive quality to be. Whoever is “right,” more doctors are switching from smaller to larger groups as indicated.

% of doctors in small vs. larger groups, 1996-1997 vs 2004-2005

1. 1-2 physicians, 42% to 33%

2. 3-5 physicians, 12% to 10%

3. 6-50, 13%, to 17%

4. 50+. 3% to 4%

5. Medical schools, 7 to 9%

6. Hospitals, 11% to 13%.

One piece of information missing is what patients consider to be quality. This is essential. After all, first visits of some 50% of patients are with primary care physicians in small groups (National Center of Health Statistics, 2005).


John Guaspari, a management guru, has written in his book I Know It When I See It: A Modern Fable about Quality (1991) that anyone who thinks they know quality when they see it is living a myth.

Can the same thing be said of patients? And if not, how can this lack of knowledge of quality by patients be overcome? By health plan steerage of patients to doctors with documented quality? By public disclosure of quality data? By marketing of their quality data by large groups?


I am dubious about the effectiveness and propriety of any of these approaches. There are intangibles of doctor-patient relationships that transcend data. Still I have no doubt large practices, given their resources, can take a more systematic, organized, and purposeful approach towards quality.

Electronic Medical Records, Limits of Technology -EMRs and PHRs Don't Impress Doctors and Patients

Something’s going on out there in the electronic medical world, and the “experts,” government and commercial cyber pushers, don’t know what to make of it or what do about it.


Doctors and patients aren’t flocking to EMRs (electronic medical records) and PHRs (patient health records) as the be-all, do-all, and end-all to eliminate medical errors, coordinate care, and streamline care.


It’s not for lack of trying. There are as least 300 EMR vendors are there, and more than PHR systems are available. And yet only 10% of solo physicians, and 20% of all doctors have installed EMRs, and only 5% of doctors and patients are using PHRs. This is even in face of the fact that the Veterans Administration has a system-wide EMR, and Kaiser has both an EMR, available to its 12,000 doctors, and a PHR, My Health Record, available to 8.7 million Kaiser members.


What’s the hang up? Personally, I don’t hanker to go to a doctor to have my problems documented. There are certain personal things I want to keep personal. I want the doctor to pay attention to me, not to the computer. To me documenting isn’t the same as doctoring. As David Pallestrant, MD, founder of Sermo, commented to me, “Having a computer in the room changes the chemistry of the doctor-patient relationship.” And as one VA patient said to me, “ I hate to go the VA. The doctor is always sitting behind that damn computer.” To have a personal record of the encounter is not sufficient incentive to me. Even Gary Baldwin, the technological advisor of Healthleadersmedia and an ardent EHR supporter, admits that his doctor having an EMR is not a sufficient reason to switch doctors.

So what are the experts to do? Michael Leavitt, secretary of HHS, is resorting to veiled threats. In a recent statement, he said he was inclined to proceed with the 10.1% Medicare payment cut unless doctors installed EMRs. This “or else” comment has the sound of childish playground threat and certainly doesn’t speak to the maturity of Mr. Leavitt.

Doesn’t Mr. Leavitt know,

Only 1/10 to 1/5 of doctors have installed EMRs despite 5 years of government and health plan pressure.

EMRs costs $20,000 to $40,000 per doctor to install, and primary care physicians are already trying to make ends meet.


Current evidence indicate EMR users are not less error prone, quality-enhanced, or productive than non-EMR users.

Most doctors see no tangible return on investment form EMR-use.

Meanwhile on the PHR front, vendors are reaching out to health plans and employers to make PHRs more attractive. They’re expanding the data base to make PHRs more useful to doctors.

But privacy, security, and personal obstacles remain. PHRs have advantages for patients with active conditions requiring transfer from one doctor to another, but they have yet to catch on among doctors because of their costs, negative impact on work flow, and expense to maintain, and among patient, who remain concerned about privacy issues. Going to a doctor is not the same as a routine retail transaction, either for the doctor or the patient.

1. Kevin Freking,"Leavitt: Doctors Need Electronic Records, Associated Press, December 3, 2007.

2. Pamela Lewis Dolan, "Pretty Half-Hearted Reception, " American Medical News, December 3, 2007

Limits of Technology - Why Not Regional Health Information Organizations?

“RHIOs Hit Financial Stumbling Block on Path to National Network ”

AMA Medical News headline



Everybody is looking for the telling phrase that clears the underbrush to assure health reform.


For liberals, it’s the long-held and cherished “universal coverage.” Who could be against protecting everybody against every health eventuality and bankruptcy from disease?


For conservatives, it’s the new kid on the block, “consumer-driven care.” Who could be against informed consumers making their own decisions?


For liberals and conservatives alike, it’s “patient-centered care.” Who could challenge the notion the nation should focus on patients?


For the managerial and political classes, it’s “transparency.’ Who could oppose open and honest dealings above the table?


For lawyers and technocrats and paymasters, it’s “accountability.” Who could anyone be against holding everybody else for being “responsible” and “accountable” for their actions?


For everybody, it’s “information” and “data”, or “infodata.” If we only all had all that factual and revealing information – on who is good, who is bad, who is naughty and nice, and who get the best results for the least cost, everything would be OK.


With respect to “infodata,” it’s a dream among many that “RHIOs “(Regional Health Information Organizations) will be the backbone or the central data bank for a national health information exchange. This open exchange will serve as the foundation for a national interoperative computer system linking all major health care entities.


When it comes to RHIOs, I’m reminded to the phrase, “when they say it’s the principle and not the money, it’s the money.” In principle, RHIOs are unassailable. Who could be against sharing infodata for the common good? Though data sharing may be good for society, those sharing the data don’t seem to understand what’s in it for the good of their organization or for the good of themselves. The principle of enlightened self-interest seems to be at work here.


Therefore, human nature being what it is, RHIO participants have a hard time raising money. The financial underpinning of RHIOs in the startup and transitional phases depends on gifts, grants, and members fees.


The dreamers seem not to have stopped and asked: why should regional organizations share their data and operating secrets with competitors when there is no tangible financial return? America is, after all, a competitive society, the pillar of Western capitalism. It may take a while for the concept of cooperation and collaboration for the common good to catch on among close rivals.


Americans’ obsession with competition can be destructive. Alfie Kohn. an academic then living in a cooperative household in Cambridge, Massachusetts (where else?), described this destructiveness in No Contests. The Case Against Competition, Houghton-Mifflin, 1986), in this way,


“Unfortunately the case competition does not stand up under close scrutiny .It has been constructed on four myths. The first myth is that competition is an unavoidable fact of life, part of human nature. The second myth is that competition motivates us to do our best. Third, it is asserted contests provide the best, if not the only, way to have a good time. The last myth is that competition builds character, that it is good for self-confidence.”


Well, maybe, but Americans, including health care players, have been trained not only to compete but to believe in competition. That training and belief isn’t going to go away soon, perhaps too late for RHIOs.


To conclude:


Why not regional networks loaded with transparent data? Doesn’t everybody know infodata will end health care errata? Surely everybody will fork up cash to share their numbers, and willingly stop competing and reveal their blunders. When, oh when, will competitors join the infodata intifada?

You can array against evils of our present culture. You can inveigh against the competitive vulture. You can lead people to the very edge of the stream. But you won’t drink if they believe it to be extreme. Or if it goes against their fundamental nurture.

Wellness - The Katz Meow

Critics claim doctors know nothing about nutrition. Our distracters say nutrition’s not in medical school curricula; doctors eschew vitamins, supplements, essential minerals, herbs; home remedies, and oriental concoctions; and have no clue about carbohydrates, fats, and proteins . Furthermore, critics assert doctors’ general advice to eat fresh fruit and vegetables and to go easy on the fat, sugar, and salt simply won’t do anymore.


Meanwhile health food stores, “healthy” diets, farmers markets, food labels, and cooking shows are flourishing. Every chef, retailer, and marketer worth their salt claims their food is “healthier” than the competitors.


David Katz, MD, director of the Yale-Griffin Prevention Center in New Haven, must be purring these days. He has taken a giant step towards silencing critics of doctors’ lack of nutritional knowledge. He and an academic team have created a rating system called the Overall Nutritional Quality Index, or ONQI. The Katz system will ultimately rate all foods in grocery stores on a 1-to-100 basis, with 100 being the healthiest.


Ric Jurgens, president and CEO of Hy-Vee Grocery Stores, a consolidated grocery store chain, has endorsed the Katz system and bought a stake in the Katz algorithm. His stores will start using it on their shelves next summer.


Doctor Katz came up with the idea for his rating system because he was frustrated. He could not explain to his family and his patients how to interpret food labels and eat the right foods. The food labels in grocery stores befuddled, bewildered, and baffled his family and patients.


What to do? Katz assembled a panel of academics to weigh and rate the nutritional value of vitamins, bioflavonoids, anti-oxidants, sodium, minerals, carbohydrates, proteins, and everything else naughty or nice. So far they have rated 20,000 foods and will have 50,000 more done by next summer.


This is a classic example of creating an innovation to fill needs – patients’ needs for better and more specific information on what constitutes healthy foods, doctors’ needs to provide them with that information, and society’s need for better nutrition.

Universal Coverage – Massachusetts, Canada, and the U.S,

The November 25 New York Times, carried this article “Massachusetts Faces a Test on Health Care.” A year after its Universal Coverage bill was enacted, Massachusetts officials say between 200,000 and 400,000 residents haven’t signed up. Meanwhile, health insurers in Massachusetts may raise rates 10% to 12%, twice the national average; and there may be a budget overrun of $150 million. Universal coverage in the Bay State is in trouble.


Two years ago, I published a book Voices of Health Reform, based on 42 interviews with national reform authorities. One interviewee was Dr. David Himmelstein, a Harvard faculty member, who, with his wife, Dr. Stephanie Woolhandler, back a Canadian-type system for the U.S. Himmelstein and Woolhandler claim Canada has lower administrative costs, higher quality care, and better access at every income level.

John Goodman, PhD, a conservative economist, says these claims are myths. These are his words.

The Myth of Low Administrative Costs. Himmelstein and Woolhandler claim administrative costs of the Canadian system are much lower than our own - so much so that we could insure the uninsured through administrative savings alone. However, they aren’t economists. They count the cost of private insurance premium collection (e.g. advertising, agents' fees, etc.) but they ignore tax collection costs to pay for public insurance. Economic studies show cost of collecting taxes is very high. The excess burden of a universal Medicare program would be twice as high as the administrative costs of universal private coverage.

The Myth of High Quality. H&W say that Canadian life expectancy is two years longer than ours, implying the health care systems of the two countries have something to do with that result. Doctors don't control our overeating, overdrinking, etc. Where doctors make a difference, the comparison doesn’t favor Canada. In an NBER study, David and June O'Neill draw on a large US/Canadian patient survey to show that:

o The percent of middle-aged Canadian women who have never had a mammogram is double the US rate. o The percent of Canadian women who have never had a pap smear is triple the US rate.

o More than 8 in 10 Canadian males have never had a PSA test, compared with less than half of US males.

o More than 9 in 10 Canadians have never had a colonoscopy, compared with 7 in 10 in the US.These differences in screening may explain why US cancer patients do better than their Canadian counterparts. For example:

o The mortality rate for breast cancer is 25% higher in Canada.

o The mortality rate for prostate cancer is 18% higher in Canada.

o The mortality rate for colorectal cancer among Canadian men and women is about 13% higher than in the US.

o Among senior citizens, the fraction of Canadians with asthma, hypertension, and diabetes who are not getting care is twice the rate in the US.

o The fraction of Canadian seniors with coronary heart disease who are not being treated is nearly three times the US rate.

Apparently, putting everyone in (Canadian) Medicare leads to worse results than having only some people in (US) Medicare - ensconced in an otherwise private system.

The Myth of Equal Access. The most common argument for national health insurance is that it gives rich and poor the same access to health care. Surprisingly, there is no evidence of that outcome. Indeed, national health insurance in Canada may have created more inequality than otherwise would have existed. (Similar results have been reported for Britain.) The O'Neill's study shows that:

o Both in Canada and in the US health outcomes correlate with income; low-income people are more likely to be in poor health and less likely to be in good health than those with higher incomes.

o However, there is apparently more inequality in Canada; among the non-elderly white population of both countries, low-income Canadians are 22% more likely to be in poor health than American counterparts.

The Nub-of-It-All

Himmelstein and Woolhandler say Canadian medicine surpasses the U.S for three reasons --lower administrative costs, higher quality, and equal access. Not so, retorts John Goodman, of the National Policy Institute in Dallas, an American think tank. He rebukes Himmelstein and Woolhandler with data showing:

Canadians:

· undergo preventive tests and procedures (pap smears, mammograms, PSAs, and colonoscopies) much less often;

· have higher cancer rates with poorer results,

· get less care for diabetes, asthma, and coronary artery disease than U.S. counterparts;

· low-income Canadians are more likely to be in poor health.

Apparently the idea of having universal coverage, appealing as it may be, doesn’t translate into superior performance or healthier citizens.