Tuesday, September 30, 2008

health care and the economy - Will Health Care Follow the Dow?

Will collapse of the health care economy follow the U.S. economic meltdown? That’s a question Dr. Brian Klepper address in a current article in Healthleadersmedia.com “Will Primary Care Be Re-Empowered by the Ailing Economy?” In our article, we suggest Big Business may step in by re-empowering primary care.

There are others asking this question as well. David Nash, MD, MBA, Professor and Chairman of the Department of Health Policy at Jefferson Medical College, is worried about the health system crisis. In the September Health Policy Newsletter he cites this evidence of the crisis.

• Chronic illness is epidemic and unmanaged, accounting for nearly 80% of all health care spending and affecting 133 million Americans(45% of the population).
• Health insurance premiums have risen almost 90% since 2000.
• 47 million Americans are currently uninsured and 16 million are underinsured.
• Poor and minority populations have limited or no access to healthcare of any kind.
• The aging of the U.S. population is increasing demands on all sectors of the healthcare system.
• The Institute of Medicine estimates that almost 100,000 die annually in U.S. hospitals due to medical errors.
• The failure to incorporate the latest in evidence-based medicine leads to misdiagnosis and inappropriate care.
• Threats of national disasters (Katrina) and global epidemics (Avian flu, MRSA) are ever present and can easily overwhelm local or national health care resources).

He concludes the “need to address the healthcare crisis in the United States , is incontrovertible.” And, though we spend nearly twice as much on care as any other country, we rank at the bottom for even the most fundamental quality indicators such as infant mortality and life expectancy. One of his answers to the problem is to set up a School of Health Policy and Population Health at Jefferson to study the problem.

To me Professor Nash’s words are part indictment, part overstatment, part idealism, part reality, and part ideological academic spin. He cites the worst and ignores the best in our health system. Nevertheless, the crisis he cites is real, even though there is often another side to the arguments he presents in the real world outside the ivory tower.

Sunday, September 28, 2008

Harvard, Herzlinger - Eight Things I Learned at Harvard Business School (But Mostly After)

In 1976 I attended an 8 week post-graduate course at Harvard Business School on “Health Systems Management.” Each quarter, I receive The HBS Alumni Bulletin. It chronicles alumni exploits.

The September issue contains two health-related articles:

1) “In Africa, Porter Sees Lessons for Health Care.” Professor Michael Porter is HBS’s guru on competition as the best way to contain cost and improve quality.

2) “Customizing Health Care.” This is an interview with Mara Aspinall of Genzyme Corporation, and Dana-Farber. She believes “personalized” drugs, based on a person’s genome, are the future.

Here’s what I’ve learned from that 1976 course and since.

1) Imminent health reform isn’t inevitable. The 1976 course was based on the notion national health reform was inevitable. It was not and is not. U.S. health reform will always be incremental, evolutionary, and in flux. As a nation, we distrust government, as evidenced by the current 100/1 public sentiment against the bail-out plan.

2) You can’t achieve reform without having hospital executives and practicing physicians participate – In the 1976 course, of 60 students, not one, with the exception of me, was a hospital CEO or practicing physician. Hillary Clinton repeated this mistake with her 1200 person reform task force in 1993.

3) The business culture doesn’t understand the medical culture. Business thinks the key to reform is getting doctors to fold into and believe in a corporate culture in which doctors are “managed.” The failure of managed care is a testament to the failure of this belief.

4) Hospitals can’t do everything well or even competently - Regina Herzlinger, a HBS professor, argued then, as now, that hospitals can’t be everything to everybody in the highly specialized and entrepreneurial U.S. economy. This may be so, but in many towns, hospitals are the only ones with enough structure, scale, brand recognition, and capital to serve the visible center of care. Hospitals are often the only game in town.

5) Consumer-driven care will be the future - In theory, I agree consumers can make intelligent health care decisions and can learn from their mistakes. But in the real world, government promises trump or neutralize market potentials. Health care is too emotional and political an issue to be left solely to markets, as shown by slow HSA and high deductible plan growth.

6) Customized drug therapy will not soon impact clinical medicine – Genzyme, Inc., is growing fast because of bio-engineered drugs to treat cancer and other diseases based on the patient’s DNA and tumor DNA, but presently the field is too complicated and the drugs too expensive and doctors have too much on their plate to prescribe or test these new drugs.

7) That hospitals will split into centralized “focused factories,” each with expertise to treat a specific disease, remains a dream - But it may be a dream with legs. The Minnesota Commissioner of health has signed off on a bill to take place in 2010 that will provide seven sets of health-related services into “baskets of care” = primary care, preventive services, coronary artery and heart disease, diabetes, asthma, depression. Physicians may set a price for each basket.

8) Whatever goes around comes around
- Here I refer to re-empowerment of primary care in the form of medical homes, a national movement gathering steam and centered around payment reforms that will reward primary care clinicians at an estimated rate of $50 per month per patient for offering coordinated, comprehensive, best-practice based care. Consumers, physicians, and payers alike embrace the idea of a personal physician for every patient.

To conclude,

What you learn at business school isn’t always in medicine the rule. Business people may say reform is surely inevitable, but experience shows that argument is easily refutable. Hospital CEOs and MDs have to be at the table. Otherwise reform will remain strictly a fable. “Managing” physicians may seem easy and logical, if you’re corporate-minded and pedagogical. But the medical culture is often indigestible to the corporate vulture. Never underestimate the community hospital’s power, though to overall for competence for every task hospitals may be inhospitable. Business may maintain centralized hospitals should be split into decentralized centers of expertise, but hospitals and other special interests will retain the profitable status quo with ease. Business may depend on consumer-driven care to turn health care upside down, but vested interests still know where the critical data is to be lost and found. You might think the future resides in the medical genome, but right now the action is found in the medical home. Suddenly what goes around has come around. Patients, doctors, and business payers agree primary care doctors acting as personal physicians offer the least costly and most efficient care. Welcome back, Marcus Wellby.

Primary care, Paul Grundyd- The “Disintermediation” of Primary Care

“ Disintermediation”– The elimination , i.e., wholesalers and retailers, between producers and consumers. The diversion of funds from lower yield to higher yield areas

Dictionary definition

I prefer short words to long ones. One hallmark of good writing is short words.

But when it comes to health care, “disintermediation” is an exception. “Disintermediation,” a 7 syllable 17 letter mouthful and mindful, is the perfect word for what has happened to primary care.

Primary care doctors have been cut off from direct human
contact with patients as the traditional source from whom ordinary citizens gain information, sympathy, compassion, and above all, context about their health.

This has occurred, often insidiously, in these ways.

• In most medical schools, primary care is a poor step-child to specialty programs. Specialists dominate the faculty, specialists get the grants, specialists are perceived to be on the cutting edge, and specialists command respect of the medical students, who learn early on that the specialties are where the glory and the money are. They learn pay-off reside in ordering and performing high tech procedures, rather than human interaction, listening, and questioning. They learn transactions not time spent are the essence. They become technicians rather than physicians.

• The coding system “disintermediates” primary care and tilts towards specialists, for the system rewards procedural transactions over time spent with patients, coordination of care, comprehensive services. Things important to patients – being seen on the day one calls, prompt responses to phone calls and emails – are not reimbursed and become secondary. When one realizes that some generalists spend as much as 1/3 of their time on the phone, this oversight is ridiculous.

• The legal system “disintermediates” primary care and rewards specialists because it is based on the premise that doctors should leave no stone, and no specialist consultation, unturned. The typical primary care specialists dreads that moment in the court when the malpractice attorney, asks, “Why didn’t you order a CT scan doctor, when you know one cause of a headache, no matter how rare, might be a brain tumor?” Or “Why didn’t you order that C-section, when you know prolonged labor deprives the baby of oxygen and cause cerebral palsy.”

• Managed care “disintermediates” the primary care physician because it steps in between the doctor and the patient through utilization review and second guessing and because it disregards personal relationships and instead focuses on the “network,” on anonymous “ and algorithm-driven ranking of providers who comply and offer services at the lowest price. As one doctor told me, “You know, Dick, it doesn’t pay to be a good doctor anymore. You’re just another number on the spreadsheet.”

• Direct-to-Consumer Advertising of drugs and medical devices “disintermediates” the doctor because it makes a direct pitch to patients without going through the doctor. Sure, the DTC advertisements always say, “Ask your doctor,” but only after making a direct, and
sometimes often misleading pitch based on the perceived prevalence of a condition. I often wonder how prevalent “ED” is among those handsome young men and lovely young women displayed on the TV ads.

• Perhaps the biggest “disintermediator” of them all is the Internet. The appeal of the Internet is that it cuts out the human intermediary in seeking information. In business terms, it shortens the “supply chain.” Instead of having producer + supplier + wholesaler + retailer + consumer, you have producer + consumer. You remove the human intermediary, the expense of distribution channels and retail outlets. This makes business sense, but it cuts out traditional channels, such as the need for a primary care physicians, to interpret and filter the information are removed. One can always use the phone and consult the “menu,” another ways of eliminating human interaction. One can become one’s own doctor. I realize the efficiencies of such a model, but something is lost in the process, including a personal relationship with a physician who can put things in context based on experience rather than on one’s personal concerns based on one person’s perspective. There something to be said for the old adage that those who treat themselves have fools for doctors. The world may be moving on Internet time, but that time may be too fast for some.

The Ultimate Irony

The ultimate irony of the “disintermediation” problem for primary care is this.

To “remediate” themselves with patients, to reconnect, primary care doctors are turning to the Web, usually in the form of electronic medical records, as a powerful tool to offer prompt, friendly, patient-responsive, educated, best-practice-based, coordinated, and comprehensive care

Saturday, September 27, 2008

Hospitals as Source of Physician Capital: Opportunities and Dangers

Judy Brown, the editor of the Journal of the Association of Staff Physician Recruiters, located in St. Paul, Minnesota, called the other day. She said the association had tripled in size in the last couple of years, and she was looking for material for her journal. Would I consider writing for them?

I said I would. I have a soft spot for Minnesota, where I spent 25 years, 15 years as the editor of Minnesota Medicine. She said Minnesota, typically a state with a sufficient supply of primary care physicians, was having a hard time recruiting generalist physicians. And she added multispecialty clinics, the dominant mode of delivering care in Minnesota, were having an especially hard time. Finally, she noted large hospital systems were buying out major multispecialty groups who needed hospital capital to survive and too, among other things, recruit new physicians.

None of this surprises me.

• Everybody, in Minnesota and elsewhere, is having a tough time recruiting primary care doctors. There are simply not enough of them out there to recruit, and the supply is drying up.

• Physician groups simply do not have sufficient capital to recruit new primary care doctors, or specialists for that matter, retain existing doctors, upgrade facilities, invest in information technologies without entering into partnerships or ownership arrangements with hospitals. It’s a variation of Sutton’s Law. Willie Sutton, the bank robber, who, when asked why he robbed banks, and responded. “Because that’s where the money is.”

Here, in an article in the Group Practice Journal in early 2007, is what Daniel Zismer, PhD, and Peter Person, MD, of Essentia Health System, anchored in the St. Mary’s Hospital System in Duluth, say drives physician sell-outs, or more politely “acquisitions” by hospital systems.

Said simply, the fully integrated model has greater economic leverage. It aggregates more of the total health-care dollar within a unified business model. The model has superior capital re-generation potential, and debt markets see the model as being more credit worthy over time.

Put even more simply, hospitals have the capital, and doctors do not. “Integrated models, “ i.e. hospitals with medical staffs in too, simply have the organizational structure and the scale to invest in information, diagnostic, technology, and data to be economically robust and to offer one-stop shopping and diversified products to consumers. An exception to this are some high tech specialists – orthopedists, cardiovascular specialists, and other proceduralists – who have profit margins and economic cushions to resist hospital adsorption.

Is this a good thing? I have mixed feelings.

• On the positive side, integrated models, backed by hospital capital, helps physicians survive and recruit and compete. And these models facilitate the bundling of care for a given hospitalization to be paid to a single provider entity composed of a hospital and its affiliated medical staff.

• On the negative side , these integrated entities may be just another nail in the coffin of physician autonomy. And these integrated systems may drive health inflation over the roof. Owned physicians will be obligated to refer all high-ticket referrals for diagnostic and surgery procedures to the hospital, which may cost 2 to 3 times more than what one could obtain on the outside. It’s the nature of the hospital beast, with its embedded facilities fees, which often exceed the cost of the procedure, and the overhead associated with offering diversified services to a mixed population needing services, some of which must be provided at a loss.

Oh, well, in modern health care, money isn't everything, physician independence is two percent.

Thursday, September 25, 2008

Physician demoralization - Who Cares: Dimensions of Disappearing Doctor Dilemma

Almost one in three Connecticut physicians are thinking about changing jobs or moving out of the state because they are sick and tired of practicing medicine here

Hillary Waldman, “Docs Grow Sick of Their Jobs,” Hartford Courant, September 24, 2008

The practice environment in Connecticut appears to be having a demonstrable impact on the supply of physicians in certain medical specialty areas and on the patients’ access to care.

Robert Aseltine, Jr, and Matthew Katz, MS, “Connecticut Physician Workforce Survey: Initial Perceptions and Potent Impact on Access to Medical Care, Connecticut Medicine, October, 2008

Doctors in Connecticut, perhaps the most affluent state in the country, have a serious morale problem. If it’s bad here, how bad is it elsewhere? That will be the subject of another blog.

A survey by 1077 practicing doctors by the Connecticut State Medical Society indicates 1 of 3 physicians are considering quitting or leaving the state.

Here are the numbers.

1) Doctors who say they’re contemplating a career change.

Yes, 19.3%, No, 65.1%, Not Sure, 15.6%

2) Doctors who say they’re planning to move.

Yes, 10.8%, No, 71.0%, Not Sure, 18.2%

Doctor critics are likely to say.

So what? The clinical Cassandras are at it again. Doctors are just whining. When push comes to shove, they will never quite practice or move.

Concerned students of the unhappy doctor problem may say. Look. This data discourages medical students from becoming primary care doctors, the most unhappy segment of the physician population, and contributes to the escalating primary care shortage.

In the Connecticut survey, 40% of family medicine and internal medicine reported decreases in their numbers while those in more affluent specialties reported increases: cardiovascular diseases (59%), gastroenterology 54%, orthopedic surgery 45%, and oncology 44%. This is symptomatic of a looming primary care shortage.
Only 2% of medical students plan a career in family medicine.

Why don’t we take steps to improve the situation, like making medical school more affordable for potential primary care doctors, partially forgiving their medical school debts, and paying primary care doctors more, and creating medical homes with increased pay?

Yet another school of more cynical thought exists. Who cares?

• Who cares if primary care doctors feel they’re underpaid and overworked? “Everyone knows” they have the biggest house on the block.

• Who cares if primary care doctors aren’t the first responders? After all, there are growing numbers of foreign medical school graduates, physician assistants, nurse practitioners, “doctor” nurses now being trained at 75 nursing schools nation wide, alternative practitioners, naturopaths, chiropractors, and self-care, and if all else fails, health food stores. .

Doctors care. Doctors know they’re the only ones that have gone through rigorous training needed to diagnose and treat disease, to handle nuances and complications of chronic disorders, to make difficult diagnoses, to administer life saving drugs, to perform procedures to restore life styles and life itself.

And we know this: most people most of the time want to see “the doctor,” not some less well-trained and less-qualified substitute. They want to see “the doctor” they know personally promptly and conveniently who can offer them coordinated and comprehensive care without long waiting lines and without running through a gauntlet of anonymous specialists.

Wednesday, September 24, 2008

Medical home - Middle America Internist Seizes Medical Home by Horns

Occasionally I receive a comment on my blog, medinnovationblog.blogspot.com, that is so direct, commonsensical, refreshing, and, yes, innovative that I feel compelled to reproduce it.

Such is the case with the comment rtsmd.com to my recent blog “The Medical Home: The Bottom-up Problem,” in which I noted the eligibility criteria imposed by Medicare, health plans, and the states might be so convoluted and burdensome that few primary care doctors would even bother to sign up for medical homes.

I know little about rtsmd except what he ways about himself in his blog,” The world as I see it, from the point of view of a practicing internist and concerned citizen in the USA. I am a strong believer in market capitalism and small government. Rtsmd is from plain ole middle American.”

Here is his comment on my blog:

Great article and outline of the chief problem in medicine. Namely, that at least two generations of physicians have been "asleep at the wheel" when it comes to guiding policy and payment.

The "bottom up" approach as you call it is part of the perception issue. Why should physicians view themselves as at the bottom and administrators/payors at the "top?" At best, aministrators/payors should be in the middle somewhere. Physicians should assume the leadership role that their patients demand and that their profession demands.

As far as my practice goes, we will be implementing the patient-centered medical home starting next month on our own, with patients paying the monthly fee. We are structuring the payments to cover "non-covered" services by insurance and Medicare, which is permissible. In concept, Medicare does not cover wellness visits or longitudinal disease management (in fact, there is no CPT code at all for this one).

The cost: an astounding $50 per quarter. Give me a break, docs, we should have done this a long time ago. At this relative pittance of a fee, we financially revolutionize our practice. Do the math.

EHRs should be a quality issue, not a management edict. Remember quality? You know, that elusive non-definable thing that will elude all PQRI or other administrative attempts to measure it. As has been said of pornography, "I can't define it, but I can tell you when I see it" the same is true of quality.

E-prescribing with decision support in the EHR is a great example. I can tell from two years of experience in doing this...IT IS JUST BETTER QUALITY FOR PATIENT CARE. I am giving a speech to our state ACP meeting next month on this and I will be likening NOT using e-prescribing to drunk driving. Actually, to defend drunk driving, it kills less people per year.

So, in brief, docs should not look to the outside for solutions to finances and quality. Do it your damn self, so to speak. Do it for the right reasons, quality first, and finances second (but still important, especially to those many, many students now and in the future that need to be convinced that primary care is worthwhile.)

We should be fixing our own problems and let the administrators/payor follow us...for a change

Tuesday, September 23, 2008

Blogging doggerel - Hardening of the Categories

Oh, I pray I shall never come down,
with hardening of the categories.
Just thinking of it brings a frown.
It’s worse than hardening of the arteries.

It’s manifested by mental sclerosis,
by absolute closemindedness,
by absence of cerebral osmosis,
by intellectual nearsightedness.

It’s common among every computer geek,
who thinks for everything there’s a protocol,
for every problem an algorithm they seek.
that will solve any problem once and for all.

It’s common among those with fixed ideologies,
who suffer from comprehensive myopias,
who to everything attribute pathologies,
but in their beliefs always see utopias.

They forget those with tunnel vision,
never see light outside the tunnel,
never undergo thought revision,
never step outside their narrow funnel.

In foxholes there are no atheists,
In economic meltdowns no ideologues,
There you will find only pantheists,
only those who fear death or going to the economic dogs.

Monday, September 22, 2008

Health Economy - Could the Health Economy Collapse?

I jotted down the outline for this blog on the back of a napkin while eating pizza at a local restaurant. Here were my outline points.

• This week the government felt so alarmed at the state of the financial economy that it decided to spend $700 billion or so to bail out bad bank martgage debts.

• This is not a new idea. Of years, politicians have been proposing to bail out the entire health care industry and the entire uninsured population. If you can cross the free market capitalism line in the finacian markets, why not health care too?

• I am no expert on these matters, but after this week, who is? Anyway, for the last five years or so, the Congressional Budget office has been saying a Medicare bankruptcy is inevitable unless we change our extravagant ways.

• Medicare costs are unsustainable and could trigger a chain of interrelated collapses due patient bankruptices, uncolletable bad debts, collapses of public, academic, and community hospitals followed by a generalized implosion of the whole health system.

• As my dear friend, Brian Klepper, PhD, a noted health care financial watcher, likes to say: “The crisis is real.” Premiums exceed general informtion by 4.4X and workers earning by 3.7X, bad debt is soaring, hospital margins are shrinking, and revnues are dropping.

• As a newly minted back of the napkin expert, I see parallels between the general economy and the health care industry. It’s just a matter of timing, and the general economy went first. Here’s my reasoning.
• We, the royal “we” indicating narrow minded “greedy” experts, have created am untenable situation in which the assets of each are “over-valued.” Why selse would we keep hearing the refrain, “value-based” health care, i.e. better outcomes for the money.

• We have reached a stage at which we have decided we can no longer to “let the market decide’ or let the “risk takers rule.” “ Let the government intervene” is our new mantra.

• We have placed too many of our bets on the “derivatives” in the financial sector and in health care, on big ticket technologies and overly expensive specialists. And we have relied on IT technologies to save the day. The bursting of the IT bubble in the late 90s’s may have been a sign of the future. We can’t google our way to prosperity or depend on PhD computer scientists to get us where we need to go.

• We have overrelied on specialized expertise in financial and health care fields at the expense of genralized common sense which should tell us health care is too expensive, produces uneven outcomes, and results in generalized dissatifaction among patients and primary care doctors. Maybe it’st ime to stop and ask, “Are we getting results for what we’re paying for?

• We hsve too often ignored the complaints of ordinary investors who rely on pension funds, 401Ks, and brokers, and ordinary patients who simply seek to understand how to navigate, to pay for, and to understand a bewilderling fragmented system.

• We have placed too much trust in experts in far-off centalized centers of “expertise” on Wall Street and K-street and Potomac Avenue at the expense of decentralized Main Streets in the U.S.A. Maybe the real answers are in the neighborhood and work floors.

• We have given outsized payouts to executives in investment banks, hedge funds, and strategic investors in universities and other institutions, and to executives in hospitals, health plans, to IT and high tech health fimrs, and to specialists, at the sacrifice of primary care physicians and citizens who want nothing more than affordable, predictable, safe care with catastrophic coverage to avoid bankruptcies.

I have to stop now. My napkin had no more space for outline bullet points.

Sunday, September 21, 2008

The Medical Home: The Bottom-up Problem

There is no consensus definition of the term “patient-centered medical home…in 2007 the AAFP, the AAP, the American College of Physicians, and American Osteopathic Association issued principles defining their vision of a patient-centered medical home. The core features include a physician-directed medical practice; a personal physician for every patient; the capacity to coordinate high-quality accessible care, and payments that recognize a medical home’s value for patients.

John K. Iglehart, National Correspondent for New England Journal of Medicine, September 18, New England Journal of Medicine, pages 1200 to 1201

America is an overwhelming bottom-up society.

John Naisbitt, author of Mindset! and Megatrends, in Mindset!, Collins, Imprint of Harper-Collins Publishers, 2006

When the New England Journal of Medicine publishes three articles in one issue on Medical Homes and related physician payment reforms, you know you’re witnessing a top-down medical trend, in this case articulated by a professor of health economics and policy at Harvard; the Journal’s national correspondent, a dependable Washington-watcher; and a professor of medicine and policy guru at Dartmouth.

But what about the professionals at the bottom – the primary care physicians - the family physicians, the general internists, the pediatricians – the doctors in the neighborhood trenches.

What do they think?

Before I address the primary care mindset, let’s see what the top-down people are saying.

• The Medicare Payment Commission, created by Congress to advice Congress says, Medicare costs will be unsustainable unless something is done, “a fundamental change in the organization and delivery of health care is needed and urges Congress to pursue three initiatives “expeditiously” – medical home demonstration programs, bundled Medicare payments for hospitals and their medical staffs, and accountable care organizations that look like multispecialty groups.

• Medicare, the top sheriff and payer of the system, is saying it
is making a big financial bet that Medical Home reform will lead to great savings by reducing avoidable ER visits and hospitalizations with reduced overall spending.

• The AAFP, the CAP, the Academy of Pediatrics, and the American Osteopathic Associations, the societies sitting atop the primary care heaps, have issued guiding joint principles for medical homes.

• Fortune 100 companies, that purchase care for their employees, have joined an array of other organizations, have been instrumental in forming the Patient-Centered Primary Care Collaborative, and are pressuring health plans to make changes to support the medical home concept.

• Health plans are making token gestures to help practices implement medical homes.

• The states are mobilizing to support medical homes. A total of 108 bills in 26 states have been introduced that mention “medical homes,: and 20 bills in 10 states define the concept and provide for demonstration projects.

• Organizations as diverse as HealthPartners, the Comprehensive Primary Care Payments and the Massachusetts Coalition for Primary Care Reform , Promethesus, the Geisinger Health System, the Medicare Physician Group Practice Demonstration, and Alabama Medicaid have developed or are developing payment reforms compatible with the Medical Home concept.

• Even most primary care physicians, to whom I have spoken and who have expressed opinions in Sermo.com and medical publications, agree that theoretically medical homes are a fine idea.

The Problem

But as the astronauts returning in a crippled space craft from the moon once said, “There’s a problem, Houston.”

The problem, as shown by a recent national survey of all primary care physicians conducted by the Physicians’ Foundation for Health System Excellence, representing the nation’s state and local medical societies, is this:

Primary care physicians have deep morale, cash, adn time problems and are ill-equipped to deal with the extra burden of implementing medical homes. These physicians are struggling to survive economically, are in short supply, face an uncertain future, and are swamped with patients, rules, regulations, and demands to adopt electronic medical records.

Given the low morale of primary care physicians, their dwindling numbers, and their marginal economic circumstances, it is unreasonable to think they will flock to the medical home concept or are, indeed, capable of taking on the medical home’s extra economic, training, and implementation burdens.

Eligibility Criteria and Capacities Needed for Medical Homes

Consider the eligibility criteria and capacities necessary to participate in medical home programs. In descending order or priorities, those selected for medical home status, will be granted based on these points as defined by the National Committee for Quality Assurance.

1) 50 points – Use of data systems – Use data for nonclinical and clinical information to track patients diagnoses, and clinical status and to generate reminders. Track referrals and laboratory results systematically. Use electronic system to order, retrieve, and flag tests, write prescriptions, and check their safety and costs and improve safety and communication

2) 15 points – Care Management and Coordination – Adopt and implement evidence-based guidelines and use reminders for preventive services. Coordinate care with other providers and use nonphysician staff to managed patient care.

3) 15 points – Performance Reporting and Improvement - Measure and report performance to physician sin the practice using standardized measures. Report performance externally. Survey patients about their experiences and take action to improve.

4) 11 points – Improved Access and Performance – Have written standards for key components of access and communication and sue data to document how standards are met. Assess language preference and communication barriers.

5) 9 points – Support for Patient Care - Develop individualized patient care plans, which assess progress and address barriers to achieving plan goals. Actively support patient self-care.

Real-World Barriers

Or consider these real-world barriers to making medical homes a reality.

• Lack of time, money, energy, and personnel to fill out the forms, make the plans, and install the systems make Medical Homes go. Keep in mind only 10% or so of primary care physicians now have fully functioning EMRs,

• Lack of confidence that the proposed payment scheme – a mix of capitation, fee-for-service, and pay-for performance – will cover expenses of participating.

• Lack of certainty that hospitals and specialists will collaborate or alter the status quo.

• Lack of integrated information systems among hospitals, specialists, laboratories, pharmacies, and free-standing surgery, diagnostic, and imaging centers that would make data-tracking feasible.

• Lack of certainty that patients would embrace medical homes; after all, patients rejected managed care gatekeepers and most feel they have the smarts and should enjoy the freedom of selecting the specialist of their own choice.

• Lack of certainty that specialists would play ball if medical homes threatened their own income.

• Lack of broad accountability for enforcing population-based care.

A Bottom-Up Problem

It’s a bottom-up problem. You can proclaim from the top-down rooftops of payers, businesses, government, and from medical societies, and health plans – what you want to happen and what you think should happen. But the central players – primary care physicians – in making medical homes happen, may be unable or unwilling to make it happen, and the whole idea may never get off the ground. Furthermore, many primary care physicians may regard medical homes as bureaucratic or electronic prisons, as another nail in their autonomy coffin, and they may choose other options, such as concierge care, cash only practices,locum tenens, refusal to accept Medicare or health plan patients, careers outside of direct patient care, or retirement.


M.B. Rosenthal, “Beyond Pay for Performance – Emerging Models of Provider-Payment Reform,” J.K. Inglehart, “No Place Like Home – Testing a New Model of Care Delivery,” and E.S. Fisher, “ Building a Medical Neighborhood for the Medical Home, “ New England Journal of Medicine, pages 11197-2005, September 18, 2008

Friday, September 19, 2008

Physician shortage, access, medical students - Delivering Bad News to the Public

The public needs to be told the bad news: their present and future access to a personal physician is endangered.

Indeed, within the next ten years, the public may no longer be able to find a primary care physician, or be forced to wait months for an appointment. Yet they yearn to be able to find a physician in time and on time.

This is hardly news to newly insured Massachusetts residents who are having a hard time finding a doctor, to newly minted Medicare recipients, to Medicaid recipients in multiple states, to those who live in rural areas where long time practitioners have left or died, to older primary care doctors who can’t recruit a replacement.

The problem is:

• Medical students are completely rational. They are not entering primary care because the hours are longer, the pay is lower, the need for more knowledge is greater, the life style is less balanced, the respect is lower, yet the medical school debts are the same.

• Our society is specialty oriented. We pay specialists two to three times what we pay specialists, we pay for procedures but not for time with patients. And we believe in what doctors do, not necessarily for what they say

• We have built a specialized top-heavy, moneyed suprastructure that dominates the thinking of competing hospitals and health systems, whose leaders know that the growth and profit of their nstitutions resides in recruiting and rewarding orthopedic surgeons, heart specialists, radiologists, and other procedural specialist.

The Trip Down

I was thinking to these things on a recent round trip train ride to New York City. On the trip down, I read “Targeting Beam: New Machine Speeds Radiation Treatment.” Wall Street Journal, September 16. The article reports a new machine RapidArc speeds up delivery or radiation treatment beams from 5 to 10 minutes to less than 2 minutes.

The FDA cleared the machine in January, and it is already in 30 centers in the U.S. and Europe, and orders are in for 150 more. This is a huge and costly piece of good news since 70% of cancer patients receive radiation – either alone or in conjunction with chemotherapy. No doubt, radiation oncologists, who income generally exceeds, $350,000, will welcome the good news, as will cancer patients.

The Trip Home

So mcuh for the good news Now I’m on the trip home after attending a meeting of two large health care organizations who were addressing the problem of the looming primary care physician shortage.

There are some 300,000 to 330,000 of these physicians, and their numbers are shrinking rapidly Less than 10% of current medical students plan to engage in direct patient care as generalists rather than as specialists. Yet general primary care represents the bedrock of any health system. In the U.S. these physicians make up about 1/3 or physicians, in other developed countries they comprise about ½ of physicians.

Low Morale of Physicians and Patients

At our meeting we discussed the low morale of physicians and patients with health care around the world. Dissatisfaction among patients and doctors is rampant in Germany, Japan, Korea, and the U.S., not necessarily in that order. This dissatisfaction has been thoroughly documented in recent surveys and is most intense in those countries with heavy government intervention into the autonomy of practicing physicians, who are restless and who threatening to abandon direct patient care in record numbers in the next 3 to 5 years. The result might be lack of timely access to trained physicians.

It may be these physicians could be replaced by physician assistants, nurse practitioners, nurse “doctors,” and foreign-trained physicians, but we agreed that was not ideal The ideal solution is to rebuild the primary care base, provide medical students with incentives to enter primary care, pay primary care doctors for time spent with patient and for patient-centered services such as same day appointments, prompt responsiveness to emails and phone cares, and preventive and wellness counseling.

What to Do with Survey Information and How to Do It

At our meeting, the questions were: what to do with the alarming information contained in recent surveys, how to release it in such a way to inform but not alarm the public, and how to leverage it in such a way to influence policy makers to take corrective steps.

Should we release the information in an undigested form? What was the best way to get the information out? By going to a large public relations firm to shape the message? Should we hire strategic marketing consultants? Or should we simply wait for developments?

U.S. Developments

In the U.S., conventional wisdom is something big – really, really big – is going to take place in the first six months after the election. Given the realities that the election is likely to be a squeeker, that the economic turmoil will continue, that the budget deficits will remain huge, that these developments have pushed health care to the back burner, it is likely the new president’s options will be limited.

Getting Message Out

How to get the message out? Through existing media contacts, national and international PR firms, through political consultants, through Parade Magazine and AARP Bulletin, through mainstream newspapers and TV outlets, the Internet, or even through talk radio.

What Should Message Be?

And what should the message be?

• That doctors are unhappy. That’s not likely to resonate. How isn’t unhappy?

• That primary care doctors are underpaid? No good. Nobody likes whiners, and “everybody knows” doctors have the biggest house on the block.

• That doctor unhappiness in likely to result in a severe doctor shortage? That’s better, but not enough.

• That you’re unlikely to be able to find a primary care doctor when you’re sick. That could be effective. Personally I think the lack of access to doctors argument is likely to be the most compelling.

• That countries with broad primary care bases have more affordable costs and more satisfaction. Well, maybe, but we live in the U.S. and we don’t care much what happens in other countries.

The End Game

The end game may be to generate enough public outrage and enough rational reasoning to influence federal policy makers to reward doctors for becoming primary care doctors, for spending time with patients, and for other patient-centered activities such as responding to their desires for quick access, coordinating their care, and answering their questions and responding to their needs through efficient, effective communication systems that enhance rather than retard productivity.

Tuesday, September 16, 2008

Government reform - What Health Reform Is Not About

To hear presidential candidates tell it, health reform is about:

• Rewarding doctors and hospitals for better outcomes – lower cholesterol levels, fewer deaths and complications – as monitored by sophisticated algorithms.

• Pooling coverage for individuals to join large insurance pools, thus providing lower premiums, and allowing private plans to compete with government plans, such at the Federal Employee Benefit Plan.

• Equalizing health cost deductions for employees and individuals, who may not receive benefits.

• Eliminating premium differences between states, which may vary by ratios of 4:1?

• Preventing disease and promoting health through regular screenings and more pervasive health life style information.

• Expanding coverage of the uninsured and its hidden costs – ER visits, recurrent health problems, and lack of access.

• Cutting costs across the board

A Laughable Point

The last point is laughable since the Bema plan would cost $1.3 trillion over the next ten years, and the McCain plan’s estimated cost over the same period is $1.2 trillion. Both would expand coverage – Bema by 34 million, McCain by 5 million. Yet as Robert Samuelson reports in the Washington Post, the current obsession with universal coverage “is utterly wrong. The central problem is not improving coverage, it is cutting costs.” Samuelson goes to say, health care spending in the most egalitarian of all social services. Health care spending is nearly the same no matter what your income.

Poorest fifth $4,477
Second poorest $4,426
Middle fifth $4,388
Second richest $4,941
Richest fifth $4,451

If health reform not about coverage and inequality of spending, what is it all about.

1. It’s not about rewarding doctors for performance, which has been pretty much a bust when it comes to saving money and preventing complications and hospitalizations.
3. It’s not about not paying for complications or “never-never” events, such pneumonias, venous thrombosis, or bed sores, of 27 conditions now listed among Medicare non-payments.

4. It’s not about prevention or wellness promotion, which are good things to do, but of marginal effectiveness in reducing costs, perhaps because Americans are individualistic people, who prefer to keep government out of their personal lives.

5. It’s not about those vaunted information systems, data mining, and predictive models that purport to be on the threshold of insuring safety, improving effectiveness, avoiding duplications, and coordinating care among the various stakeholders.

6. It’s not about the current consumer-driven movement, featuring HSAs and high deductible plans, which is said to empower both consumers and doctors.

What Reform Ought to Be About

According to Paul Grundy, MD, Director of Health Care Transformation for IBM, these piecemeal reform factors have their place, but the core issue is much simpler – patients knowing and having “personal” physicians, whom they trust, and primary care doctors being rewarded for offering a high level of personal services – time with patients, prompt return of email messages and phone calls, seeing patients on the day they call, and electronic communication systems that truly “communicate”, rather than retarding physician productivity.

Grundy, after an extensive review of the literature on the effectiveness of personal physicians, says this humanistic, patient-centered approach cuts costs by 30% and improves outcomes by 20%.

Getting to a patient-centered primary care system will not be a piece of cake, considering the current critical shortage of primary care physicians, their low standing in academic teaching centers, the public tilt toward specialists, and possible resistance by vest health care interests, who profit from the status quo.

1.Laura Meckler, “Studies Detail Contrasts in Rival’s Health Care Plans: Bema Proposal Would Insure More but at High Costs, Wall Street Journal, September 16, 2008.

2. David Cutler, et al, “Why Ocala’s Plan is Better,” Wall Street Journal, September 16,2008/

3. Robert Samuelson, “Health-Care Realism, “ Washington Post, September 10, 2008.

Pay for performance, data mining - Realities and Limitations of P4P and Data Mining

Pay for performance (health care), is an emerging movement in health insurance, in which providers are rewarded for quality of health care services.

Data mining is the process of sorting through large amounts of data and picking out relevant information. It is usually used by business intelligence organizations, and financial analysts, but is increasingly being used in the sciences to extract information from the enormous data sets generated by modern experimental and observational methods


The September 8 American Medical News features a front-page piece “Practices Hit Medicare P4P Quality Targets, But Bonuses Still Fall Short.”

The Story

As part of a 4 year Medicare P4P project, the story reports in its second year, 10 large medical groups – Dartmouth-Hitchcock Clinic, Marshfield Clinics, University of Michigan Faculty Practice, Everett Clinics, St. John’s Health System, Geisinger Health System, Park Nicollete Health Services, Middlesex Health System, Billings Clinic, and Forsyth Medical Group – hit 93% to 100% of 27 quality measures, but only four received bonuses, and those bonuses didn’t cover the cost of participating.

Terms of Paying Groups

The idea behind the project is that participating medical groups will receive 80% of savings generated by using P4P to reduce complications and hospitalizations. But the groups will only be paid if savings exceed 2% of the results of a community control group.

The trouble is doctors take the financial risks, but financial rewards are usually lacking or inadequate. Robert Bennett MGMA commented, “It’s taking a lot of money to participate, and they’re not getting it back. It the large groups can’t do, it makes you wonder if the small guys can.”

Mining Data to See Who Gets Paid

Part of the project also involved data mining to see if doctors were meeting their targets and improving outcomes. All of this makes one wonder if the hoopla about P4P and data mining is worth it. Big groups may have the infrastructure to participate, but what about small practices?

If small groups, which provide 80% of health care, don’t measure up or participate will they be excluded or punished financially? In view of the looming physician shortage, the use of data to see who plays and how much they’re paid may be an exercise in futility. Small groups are already under financial pressure and are swamped with patients. Only 7 to 10% have complete EMR systems – which may be necessary to track P4P compliance.

The Numerati

There’s a book just out, Numerati, by Stephen Baker, reviewed in the week end edition of the Wall Street Journal on September 13, The reviewer offers these thoughts on data mining.

The world is buried in data, great banks and drifts of the stuff. In recent years, a new technology has emerged – compute programs that will drill through it all to pick out patterns and trends – information that may be useful to marketers, employers, doctors, matchmakers or national security analysts. Such programs are extraordinarily sophisticated, and their creators need to be very clever indeed. A doctorate in math or computer science is pretty much required. Stephen Baker calls such whizzes the “Numerati” Using “data mining” they can seek out veins of useful ore in the mounts of facts that computers accumulate every day.

Closing Comments

To which I say,

Put me down as deeply doubtful, that all P4P data is useful, even if provided by the snoutful. No matter what your volume and quality of data, you can’t document or erase all human errata. Nor can you discern all clinical patterns and trends, no matter how sophisticated your algorithmic lens. I’m sure if you’re one of those PhD numerati, you may think doctors are haughty and naughty, and data drilling will reveal all, beyond ordinary mortal recall. But doctors are smart, they will find their way around, all those “facts” embedded in that gigantic data mound. You can parse, analyze, aggregate data, and do your data mining, but unless you’re there at the point of care, which in case of data experts is mighty rare, numbers won’t help much in care redefining. Finally, if P4P costs exceed the reward, chances for P4P success are untoward.

Monday, September 15, 2008

Effect of culture - Culture Versus Politics: Random Sunday Reading

It’s Sunday afternoon, and I’m catching up on my reading. On my reading docket are:

Richard Reeve’s American Journey: Traveling with de
Tocqueville in Search Of Democracy in America
(Simon and Schuster, 1982). In the book, Reeves noted that de Tocqueville, a French nobleman, who wrote the first volume of Democracy in America in 1831, said America had a unique culture devoid of matters of birth or status. He equated American democracy with opportunities for upward economic, political, social mobility, and rise of a great popular culture

In other words, America is a bottom-up society rooted in popular culture.

• Lee Siegle’s “Triumph of Culture over Politics in the September 13 Wall Street Journal’s Weekend edition,

There is the Republicans' unilateral mastery of the cultural strategy. The Democrats consider any attention to the practices and prejudices of everyday living a mendacious diversion from the "issues," while the GOP, the party of the status quo, has proven itself astoundingly skillful at using its cultural antennae to adapt to new times. Who knew? The Republicans may or may not be the party that will effect change. But they are certainly the party that knows how to ride it.

The Republicans, in Lee Siegel’s opinion understand popular culture. And how to play it in a presidential campaign.

Lee Siegel's most recent book is "Against the Machine: Being Human in the Age of the Electronic Mob."

• Thomas L. Friedman’s “Making America Stupid,” New York Times, September 14, 2008

No, no, no, says Thomas Friedman, the New York Times international correspondent. It is policy from the top, not culture from the lower echelons of society that America needs. Friedman says we ought to go “green, green, and green” in our energy policies, not “drill, drill, and drill.” We ought to unleash government-led innovative policies that “invent, invent, invent.”

Friedman adds, “I dwell on this issue because it is symbolic of the campaign that John McCain has decided to run. It’s a campaign now built on turning everything possible into a cultural wedge issue – including even energy policy, no matter how stupid if makes the voters and no matter how it weakens America. There in son strong leader without a strong country. And posing as one, to use the current vernacular, is nothing more than putting lipstick on a pig

The Republicans, in short, are stupid and are treating voters as stupid who don’t understand intelligent, wise Democratic leaders who are doing what’s best for the country and the world.

• Richard L. Reece, Voices of Health Reform: Interviews with Health Care Stakeholders at Work (Practice Support Resources, Inc, 2005).

I don’t complete understand complexities of federal decision making, nuances of Democratic policies, or innuendoes of the Republican cultural wars. But I do understand the conclusion of a book I wrote three years ago after interviewing 42 national health care leaders.

Our health system is a creature of our culture. When asked what Americans believe, Garry Orren, a professor of political science at Brandeis, who polls for the New York Times and the Washington Post, said, “A good place to start is to remember we are pro-democracy and anti-government. It comes down to ideas that are essentially antiauthority and tend towards self-regulation. If there were an American creed, I think it might begin.

• One: government is best that governs least.
• Two: majority rules.
• Three: equality of opportunity.

That seems about right to me. It explains why Americans prefer local health solutions, why they reject federally mandated universal coverage with rationing why they feel capable of making their own health care decisions, why they seek equal opportunity access to high technologies, why they prefer pluralistic payment systems, why they allow market-based and public-based institutions to co-exist and compete, and why they permit doctors to behave democratically seeking their locals to practices, often acting independently of hospitals, health plans, and government, and making their own decision, fee of the fetters of outsiders Democracy is a messy business. That’s the way Americans like it

Sunday, September 14, 2008

Malpractice, tort reform - Texas Medical Association and Power of State Medical Assocations to Make a Difference

Other state medical associations must envy the Texas Medical Association (TMA). For good reason. In Lou Goodman, its EVP/CEO, it has had a strong leader for 20 years, and it has more members, 43,000, than any other state society, even more than California, which has 90,000 physicians but fewer members in the California Medical Association. I expect the reason for this difference is managed care dominance in California.

Lou also now serves as president of the Foundation for Health System Excellence, which represents national state medical societies. TMA has solid reserves, and its members accompany many national leadership positions. The power of state medical societies resides in the fact that state medical societies are closer to their physician constituencies that national organizations, like the AMA or national specialty societies. Another factor may be that America is a bottom-up society that understands local and regional cultures.

The TMA is perhaps proudest of pushing through a constitutional amendment in 2003 which limited non-economic damages in medial liability cases to $250,000. Texas voters backed the amendment.

The result of this amendment has been an influx of much needed specialists to Texas. The cap on damages makes a difference. High malpractice premiums are a hot bottom issue among physicians, and lower premiums such as those indicated below are a real drawing care.

Rate Changes since 9/23

Texas Medical Liability Trust -31.3%

Medical Protective -19.7%

American Physicians Insurance Co. -17.4%

Advocate, MD Ins. Of the Southwest -29.5%

All Reporting Members -25.1%

With these premiums has come an immigration of badly needed specialists who are tired of paying exorbitant premiums in other states.

Number of Texas Neurosurgeons

2003 407 +12.4%
2008 456

Number of Texas Obstetricians and Gynecologists

2003 2830 +7.2%
2008 3035

Number of Texas Orthopedic Surgeons

2003 1790 +9.1%
2008 1953

But Texas doctors aren’t out of the malpractice woods yet. Opponents have taken the cap to federal court saying it is unconstitutional and violates patient rights to a jury trial and due process rights. Perhaps now we shall see who counts most – doctors providing the care or lawyers limiting the care.

Saturday, September 13, 2008

Documentation Hassles - The Chart Before the Horse, Part 2

Data entry has thus become King of the Ward, Supreme Ruler of the Dark Data Domain, and health care professionals have become data entry serfs. Nurses are now the chart police and paper tigers. They spend more time policing and prowling through the chart than nurturing, observing, and caring for patients and collaborating with doctors.

The Chart Before the Horse, Medinnovation blog, March 9, 2007

The question is, which is to be master – that’s all.

Humpty Dumpty, Alice in Wonderland

I have a renewed observation to make:

Obsession with computer documentation can interfere with physician-patient-nurse relationships and distract from observing, paying attention to, listening to, and treating patients.

I offer the following personal anecdotes as evidence. I do so, knowing full well, that this “string of pearls” approach, i.e., series of anecdotes, is no substitute for data.

• In a previous blog, I described my experience on a medical ward in an academic teaching center. Nurses, doctors, and other paramedical personnel were so firmly glued to their computer screens that I found it difficult to find what was going on with my brother-in-law, who had Parkinson’s disease with pneumonia. Anonymous medical personnel on the ward, who by the way, bore no name tags, made it even tougher to find who was responsible for care. They seemed preoccupied with “treating the chart,” documenting his disease, rather than treating the patient.

• I interviewed Daniel Pallestrant, MD, general surgeon and CEO of Sermo.com, and he said a computer in a room placed between a doctor and his patient negatively changed the human chemistry of the encounter.

• I have spoken to VA patients and doctors regarding the VA’s vaunted “integrated” computer system that links all VA hospitals and clinics. This system represents the state of the art in computer communication and tracking systems. One patient commented, “I can’t talk to the doctor. He is always sitting behind that damn computer, typing in what I say.” Said one doctor, a plastic surgeon, “It takes me 15 minutes to do the procedure, and a half hour to enter the damn data.”

• I interviewed a well-known Florida nephrologist, a computer geek of the first order, and he complained, “EMRs are nothing but giant computer invoices for documenting events. They have no utility as devices to communicate with patients, doctors, or hospitals.”

• Paul Grundy, MD, director of IBM’s health transformation efforts, told me the story of a Danish doctor who took 2 clicks on an EMR to refill a prescription and related a similar story in the American Midwest in which the physician required 156 clicks to accomplish the same thing.

• A medical school classmate, who teaches internal medical residents, has repeatedly told me young doctors in training no longer know how to interview or examine patients, instead relying on computer-based technologies to provide the answers.

• An 82 year old woman with thromboplebitis on anticoagulants was admitted to a local “well-wired” hospital with a decentralized nursing system and rotating hospitalists for generalized bleeding. According to her companion, a nurse who had been head of a major nursing school, the experience was a nightmare, with multiple caregivers, not knowing what the others were doing and the patient being taken on and off anticoagulants, going into shock, and being subjected to a colonoscopy despite being previously dehydrated from diarrhea. Said the nurse companion, “All of this could have been avoided had people got out from behind their computers and looked at the patient.”

• On an unrelated front, my son, who has just returned to graduate school after 12 years in retail, told me, “Dad, it’s a totally different world out there. People go class with their laptops, type their notes, and don’t even listen to or look at the professor. And I can’t even talk directly to the professor. I have to communicate by email.”

I am not a computer curmudgeon, but I want to bring attention to the fact that obsession with computer documentation, no doubt engendered by the desires for
managerial measurement and tracking and avoidance of malpractice suits, can distract from patient care and commonsensical clinical observations.

Friday, September 12, 2008

Primary Care, Paul Grundy - Fixing a Broken System

The following appeared in today's Healthleadersmedia.com. It is Lee Masterson, senior editor of Health Plan Insider. It describes the growing momentum of the Medical Home Movement. RLR

Many believe a recently implemented Physician Group Practice demonstration project could be the future of quality care. Employers are tired of spending billions on healthcare programs that are not adequately caring for their employees. In fact, the current system is "garbage."

That powerful statement was given by one of the biggest proponents of the advanced medical home on Monday. Paul Grundy, MD, MPH, director of IBM's healthcare, technology, and strategic initiatives and chairman of the Patient-Centered Primary Care Collaborative (PCPCC), said IBM and other large employers are funding a broken healthcare system that doesn't prevent illness—and they want a coordinated healthcare system.

Grundy spoke during a Webcast presented by DMAA: The Care Continuum Alliance. He and Bruce Bagley, MD, medical director for quality improvement of the American Academy of Family Physicians, were supposed to speak in Hollywood, FL, that day as part of DMAA's annual forum. But Hurricane Ike had other plans and forced DMAA to postpone its event until November.

But, given the growing momentum behind the medical home concept, DMAA decided to host the two men on a Webcast for those who would have attended the annual forum. The fact that these two men, one from the employer side, the other from primary care, came together to speak on a population health Webcast shows the breadth of support for the medical home. Many healthcare leaders view the concept as the answer to the question: How do we repair a healthcare system that does not pay for keeping people healthy?

On Monday, Grundy promoted the "ideal payment environment," which would include a blended model that combines current flawed payment systems that alone are not working: salary, which creates problems with productivity; fee for service, which causes overuse; capitation, which leads to underuse; and pay for performance, which ignores health issues not connected to payment.

Instead, the PCPCC recommends the following three-part payment methodology:

A monthly care coordination payment for the physician's work that falls outside of a face-to-face visit and for the health information technologies needed to achieve better outcomes
A visit-based fee-for-service component that is recognized for services that are currently paid under the present fee-for-service payment system
A performance-based component that recognizes achievement of service, patient centeredness, quality, and efficiency goals
There has been growing support for the medical home, but there are still those who are afraid of what these changes would mean. Some in disease management/population health are worried that the medical home will take away their power—or much worse that their services will become unnecessary. Some physicians, meanwhile, are concerned about how care coordination will affect their practice and workload—and whether they would get paid adequately for the added work.

There is no question that population health's stature will change under a medical home model. But Bagley said the industry should not fret—population health will play a key role in the potential success of the medical home.

Bagley said under the medical home, population health companies will move from helping individual patients cope with chronic illness to assisting primary care practices help patients cope with chronic illness and integrate their services into the practice flow to help care teams.

There are great opportunities for population health, Bagley said, such as supporting office transformation, training office staff for registry and care coordination functions, supplying patient safe-management support, providing community-wide care coordination services, and offering 24/7 nurse help lines.

The medical home will change population health, but its leading advocacy group, DMAA, is already behind the idea. Tracey Moorhead, president of DMAA, said her organization sees the possibilities and is building relationships with physician groups, which traditionally have been cool to DM.

For supporters like Grundy, the issue goes beyond payment models and shifting control. The current system is "immoral" and the medical home is about doing the right thing. "I want to buy this kind of care because it's the right thing to do."


Les Masterson is senior editor of Health Plan Insider. He can be reached at lmasterson@healthleadersmedia.com.

Thursday, September 11, 2008

Primary Care- The Primary Care Shortage and the Coming Reform Crisis

"All I know is what I read in the papers."

Will Rogers

I read in the papers - USA Today and Reuters - and in Netscape, Yahoo, and countless blogs that only 23% of medical students have any interest in Internal Medicine as a career, and only 2% plan to become general practitioners.

This information has been gleaned from a September 10 article in the Journal of the American Medical Association "Factors Associated with Medical Student's Career Choices Regarding Internal Medicine." The article, based on interviews of 1777 medical students completing an Internal Medicine clerkship, concludes; “Medical students valued the teaching during IM clerkships but expressed serious reservations about IM as a career."

Small wonder.

Medical students aren’t stupid.

They know:

• The average medical student finishes school $140,000 in debt.
• Medical students typically spend 8 years going through college and medical school.
• Specialists – in fields like radiology, orthopedic surgery, cardiology, and other tech fields – take home 2 to 3 times the income of primary care physicians, and have more time off.
• Primary care doctors work longer hours, deal with more complicated diseases, more often treat the elderly, and need a more extensive knowledge base than specialists.
• Specialists in general work shorter hours and have more balanced life styles and more time with family.
• Most of their classmates, with equivalent educations, are choosing to enter specialty training.
• Many of the graduating seniors have married to classmates or are women – both factors contributing to the desire for a sensible balanced life.
• The current coding system is biased against primary care.
• It is simpler, often more gratifying, and more lucrative to perform curative procedures than to offer cognitive services to the elderly..
• The American population is aging, the number of adults over 65 will double in the next 20 years, and many will be afflicted with Alzheimers, Parkinson’s disease, incurable malignancies, and irreversible degenerative diseases.

Small wonder, then, that the JAMA article, concludes, after interviewing 1777 medical students who had just completed an internal medicine stint, ”Medical students valued the teaching during IM clerkships but expressed serious reservations about IM as a career.”

A serious primary care shortage is upon us, and I question the tardiness, indeed, even the intelligence, of policy makers in addressing the problem. Instead, it seems to me, they are talking about cosmetic adjustments. You can make all the surface reform changes you want – more EMRs, more preventive and wellness measures, more coordinated and comprehensive care, more insurance coverage - but these measures will fall short or fail if there are not more primary care physicians engaged in direct patient care. And patients will become more and more dissatisfied with the system, if we don’t have personal physicians to care for them and who care about them.


Sunday, September 7, 2008

Personal Physician, Paul Grundy - From Anonymous to Personal Physician Care:

Accentuate the positive.
Eliminate the negative.
Don’t go with Mr. In-between.

Lyrics of World War II Song

The law of unintended consequences is perhaps less of a “law” than a simple statement of fact: We cannot accurately predict all the results of our actions.

Janet Rae-Dupree, “When Academia Puts Profits Ahead of Wonder,” New York Times, September 7, 2008

Too many people have no relationship with a personal physician who cares about them. It’s not the disease, or the organ system, you have to focus on but the patients themselves.

Paul Grundy, MD, IBM, Director of Health Care Transformation, Personal Communication, September 4, 2008

Powerful managed care companies, prestigious academic centers, wondrous high innovations, insatiable consumer demand for access to specialists who deploy the technologies, and unfettered Internet information, good and bad, has consequences – distancing of patients from personal physicians, “disintermediating” of the patient-physician relationship.

I recently interviewed Paul Grundy, MD, who leads IBM’s efforts as a major health care buyer, to transform health care by strengthening doctor-patient relationships
and paying primary care doctors more to do the right things.

Towards that end, he and others founded the Patient-Centers Primary Care Collaborative in September 2006 in collaborative with other major big business buyers and a quartet of primary care physicians representing 330,000 physicians – The American Academy of Family Physicians, the College of American Physicians, the American Academy of Pediatricians, and the American Osteopathic Association.

Grundy’s thesis – based on IBM’s experience as a buyer of care in multiple countries, a large literature on primary care efficiencies, and visits and talks with hundreds of American primary care physicians -is this: an intimate bond between patients and their personal physicians fosters prevention and wellness, reduces costs by 30%, and improves outcomes by 20%.

Achieving these results, Grundy says, requires three things;

1) Big business and federal buyers focusing on “buying care” through medical home type arrangements that offer coordinated comprehensive care.

2) Payers rewarding primary care doctors that offer convenient patient-centered services – rapid responses to emails and phone calls, same day appointments, advice on wellness and prevention, and frequent communication and follow-up care.

3) Payers, public and private, helping develop physician-led efficient and affordable electronic record systems that help patients, physicians, and hospital communicate with as few clicks as possible.

Grundy is the first to admit it’s a long way from Tipperary to the tipping point to achieve these goals. It will take a high order of collaboration and a change in mindset from consumers and stakeholders in our top-heavy over-specialized culture. That’s the main reason Grundy calls his efforts “transformational” rather than “reformational.” But Grundy believes Big Business wields a big stick – its financing of nearly half of U.S. health costs.

As an aside, it seems to me Senators Obama and McCain are missing or ignoring a big bet in their health reform plans. As the AMA News reports in its September 1, 2008 “Campaign Case Report,” “neither candidate addresses the physician work force issue.” Neither says that there’s a desperate shortage of primary care doctors, that these physicians are struggling to survive, that they are not entering or are fleeing primary care, that increasing numbers of them are declining to see Medicare or Medicaid patients, that one of six are considering switching to retainer or cash-only or locum tenens practices, that they are not adopting EMRs because they are already overwhelmed with high costs, no time, or swamped with patients, that universal or even expanded coverage is meaningless without access to primary care physicians.

Now is an apt time for the good Senators to:

1) Accentuate the positive and irrefutable fact that a well-paid primary care base is the single best way to satisfy patients, cut costs, and produce superior results.

2) Eliminate or reduce the negative by openly admitting that 25 years of managed care and other technological advances have separated patients from their personal physicians.

3) Saying that “Mr. In-Between”, 3rd party intermediaries with all their rules, regulations, and data-parsing have done little to satisfy patients or doctors or improve results.

But take heart. As I concluded in the closing paragraph of my 1988 book “And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota.

Perhaps I’m looking through the glass too darkly. Perhaps with an aroused profession with a closer relationship with patients, we’ll be able to help patients make more informed choices, prevent their diseases, promote their health, and choose among the innovate therapies, ideas, and technologies only a dynamic and competitive system can produce.

Saturday, September 6, 2008

Political language - Election Kool-Aid Primer

Zippy Zingers, Negative Pot Shots, and Unfounded Accusations from Left and Right

Now that the conventions are over, the time has come to hone your best shots at your political opponents. Here is a starter kit. “They,” as used below refers to your despicable, untrustworthy, and hypocritical adversaries. Political Kool-Aid has come to mean blind allegiance to one’s idealogy, no matter what the consequences. Kool-Aid, as applied to politics, has its roots in the mass suicide of 900 in Guyana in 1978, when 900 followers of Jim Jones took cyanide laced kool-aid at the request of Jones.

1. Left. “They” are greedy and only care about enriching the rich and exploiting the middle class and the poor.. “They” believe in taking advantage of the huddled helpless masses.
1. Right. “They” only want to take your money and redistribute to others to gain votes and political power. “They” believe in government growth at any price, i.e, higher and higher taxes.

2. Left. “They” systematically undermine the Constitution and Rule of Law.
2. Right.“They” don’t even know what the Constitution is.

3. Left. “They” will overturn Roe B. Wade and will bring back clothes hanger abortions in back alleys. “They” don’t get it; a woman should have control of her body.
3. Right Why should we listen to baby killers? “They” don’t know what “adoption” and “life” mean. “They” get ii alright: It’s about the body politic, not the baby’s body.

4. Left. “They” go to war for unsavory reasons, like profit, greed, and revenge.
4. Right. “They” trust our enemies and seek peace at any price, including our liberty.

5. Left. “They” are ruthless torturers.
5. Right. “They” are na├»ve wimps.

6.Left. “They” have no diplomatic skills, and other nations hate us.
6.Right “They” fail to mention that respect and strength trump sweet talk.

7. Left. “They” have no compassion for the common people..
7. Right. “compassion” is “their” word for reshuffling the D.C. power deck.

8. Left. “The” never tell you: business is evil, deeply flawed, and badly needs rules and regulations.
8. Right. “They” will tell businesses what to do, who to hire, and what wages to pay.

9.Left. “They” cannot be trusted to set commodity prices – the staff and stuff of life.
9. Right. “They” will set all commodity, wholesale, and retail prices.

10. Left. “They” believe in a pitiless market driven health system, which ought to be profitless.
10. Right. “They” want to replace all private health care with an impersonal bureaucratic government system.

11. Left. “They” would undermine our public school systems
11. Right. “They” don’t realize public schools are a disaster, and need private competition.

12. Left. Bush and Cheney ought to be impeached or criminalized, even in retrospect.
12. Rihgt. “They” don’t know it yet, but they’re beyond reach and hating your opponents has limits.

13. Left. “They” want to pollute the environment and warm the planet with fossil fuels, build big gas guzzlers, kill polar bears, destroy the rain forests, flood the coastal cities, and erect unsafe nuclear plants.
13. Right. “They” neglect to say the economy will continue to run on oil and coal, not on hope, change, and political wind. If “they” are in charge, we will have to turn off the lights and freeze in the dark.

14. Left. “They” are irresponsible and rely on fickle markets rather than stable serious wisdom dispensed from on high.
14. Right. “They” should lighten up and stop taking themselves so damn seriously.

15. Left. “They” believe consumers are intelligent people who can be trusted to do the right thing. Only a protectionist government knows the “right thing to do.
15. Right. “They” don’t yet realize this is a capitalist not a socialist country, which depends on responsive markets not centralized command and control government.

16. Left. “They” believe terrorists are killers, not human beings who have been oppressed by the West, and who deserve U.S.civil rights.
16. Right. “They” have been slow to recognize that terrorists are enemies who deserve to be killed or judged in military tribunals.

17. Left. “They” usurp the rights of Americans when “They” electronically monitor email traffic.
17. Right. “They” don’t get it – America has terrorists who are sympathetic with other
terrorists and who help them plot attacks.

18. Left. “They” believe all is fair in war, even if it violates the rights of Americans. We believe in love and hope.
18. Right. “They ”forget to say we have not been attacked for 7 years, no thanks to ACLU lawyers.

19. Left. “They” label us as elitists because we represent an intellectually and morally superior secular society.
19.Right. Much of what “They” say is strictly bullshit; “They” have no lock on morality, compassion, and intellect.

20. Left. “They” have unfairly influenced society through
uninhibited, bigoted talk radio, Fox News, and the Wall Street Journal, all of whom spout the conservative line.
20. Right. “They” forget the main stream liberal media elite – CBS, NBC, ABC, CNN, Time, Newsweek, the NYT, and the Washington Post still controls the lion’s share of audience and media dollars.

21. Left. “They,” the people don’t seem to know that “they,” the Republicans, are bad for the collective good of the American people.
21.Right. “They,” the Democratic , don’t seem to take note that “they” have lost 7 of the last 10 presidential elections.

22. Left. “They” are short on eloquence and noble goals

22. Right.“They” are short on direct talk and what works.

23 Left . “They” are afraid to expose Sara Pilan to questioning by “serious” objective main stream journalists.
23. Right. “They”, i.e. Obama and Biden, will not appear on Limbaugh, Hannity, or other conservative venues to answer “tough’ questions.

24.Left. “They” are a close-minded party who move in lockstep behind mean-spirited pols.
24. Right. “They” are a left-leaning disorganized crowd led by the nose by moveon.org.

Thursday, September 4, 2008

Physician Payment - Doctors Vindicated

In John Goodman's Health Policy Blog, August 29, "Doctors Vindicated," Doctor Goodman, PhD, a conservative economist who founded the National Center for Policy Analysis in Dallas, says there are two schools of thought about what's wrong with modern medicine.

1) Doctors are at fault.

2) The payment system is at fault.

Most commentators, including many doctors, he claims, belong to the first camp. Doctors, they say, are stuck in a rut and refuse to use computer, work in teams, and deploy all of those best practice protocols. Goodman disagrees. He asserts doctors are just like other professionals. They respond to economic incentives.

Goodman uses dermatologists as an example. They practice two kinds of medicine: 1) that paid by third parties; 2) that paid in cash for cosmetic procedures.

Patients in the first camp face long waiting times, shoddy reception rooms, and often are seen by nurse practitioners and physician assistants. Patients in second cmmp receive prompt treatment by the doctors themselves, have multiple options, have short waiting times, and are often seen in luxurious settings.

According to Goodman,

1) People in the first camp want to figure out and to dictate how medicine should be practiced and to pay doctors only if they doctors do it the right way, the 3rd party way.

2) People in the second camp want to liberate doctors to make continuous improvement and to financially benefit from that improvement.

To which camp do you belong?

Wednesday, September 3, 2008

Medical Trends, future - Are Megaclinics The Wave of the Future?

The August 30-31 Wall Street Journal reports "Carilion Buys Imaging and Surgery Center." The Carilion Clinic, a $1 billion dollar enterprise in Roannoke, Virgina, has bought the Center for Advanced Imanging and the Center for Surgical Excellence in Ronaoke. These purchases follow by several days Carilion's acquisition of the 9 percon Consultants in Cardiology group, also in Roanoke and the largest cardiology group in Southwest Virginia.

What's going on here? It is quite simple. The Carilion Cliics is following a Mayo-Clinit-type strategy of forming a dominant regional health system by either buying up or hiring its competitors. This strategy is apparently succeeding despite opposition by some 70 independent physicians in the Roanoke valley and concerns about monopolstistic behavior.

About 20 years ago, Paul Ellwood, M.D., father of managed care, envisioned a health system controlled and channeled through 10 or so major megaclinics, clinics like Mayo, the Cleveland, Temple, Geisinger, Marshfield, and Mayo Clinics.

Is Ellwood's vision materializing? Yes, but it's spotty, and is led by a small group of medical leaders and visionaries, who feel they are doing the "right thing." It may be happening with Carilion, an eight hospital enterprise that employs 11,000, has hired 150 physicians over the last year bringing its numbe3rs to 500, is erecting a large clinic building in Ronaoke, and has received approvoal of establishing a new medical school, the Carilion-Virginia Tech medical school.

The basic thought here is that every region needs a comprehensive, integrated health system with salaried primary care and specialty physicians and with sufficient infrasctructure to meet most patient needs and to connect physicians and hospitals and ancillary facilities with an electronic medical system to measure quality and outcomes.

Monday, September 1, 2008

Book Review - Review of Disaster Planning for the Clinical Practice, Jones and Bartlett, 2009

Review of Disaster Planning for the Clinical Practice

By Neil Baum, MD, and John W. McDaniel

The art of losing isn’t hard to master;
So many things seem filled with the intent
To be lost that their loss is no disaster.

Loss something every day. Accept the fluster
Of lost car keys. The hour badly spent.
The art of losing isn’t hard to master.

Elisabeth Bishop, 1911-1979, Poems: 1976

This is a chance to review a book by authors I know well. For years I have been speaking off and on to Neil Baum, a practicing urologist and an accomplished author of many books on the ins and outs and ups and downs of clinical practice, and to John McDaniel, president and CEO of Peak Performance Physicians, a practice management firm best known for keeping medical practices up to code.

Neil and John reside in New Orleans, and thanks but no thanks to Katrina and Gustov, they know a thing or two about disease planning for washed out and occasionally washed up clinical practices. Katrina forced Neil out of New Orleans, forcing him and family to flee to Texas, and John has resuscitated a number of flooded practices.

In their book, Neil and John categorize disasters by size, shape, and type, then lay out ten chapters – technological disasters (mostly relating to hardware and software) , disaster planning, resuming practice planning, protecting and recovering assets, creating a backup plan, working with hospitals, getting the proper insurance, finding an alternative site for your practice, and disaster planning for your employees.

I like these features of the book.

• An appropriate quote serving as a prelude to each chapter “There’s no disaster that can’t become a blessing, and no blessing that can’t become a disaster.” ”Technology is a queer thing. It brings you great gifts on one hand, then stabs you in the back with another.”(I am a sucker for apt quotes.)

• Check-lists of what to do and how to do it.

• A crisp bottom line summary following each chapter.

• A CD at the back of the book for those seeking forms to fill out to check their level of preparedness

• A well-written no-nonsense text.

• A thirteen page index to help you find what you might lost on first reading.

• Timing – who would have dreamed I would be writing this review three years after Katrina and the day Gustov struck.

Bias Against Primary Care; Tilt Towards Specialists:

There has long been an institutional bias in medical education against primary care. Many doctors we have spoken with have recounted how they were steered away from primary care by preceptors in medical school. The general sentiment conveyed to medical students long has been that surgical and diagnostic specialties are for the most accomplished students and that primary care is for the less accomplished

Allen Dye and Troy Fowler, “The Recruiting Challenges for Internal Medicine, “Healthleaders Media, August 28, 2008

In the course of human events, the pendulum may swing too far, over-shifts may occur, and reality may become distorted.

No where is this more true than the bias against generalists and the shift toward specialists. Today only 1/3 of American doctors are family physicians, general internists, or pediatricians. Seventy percent of internists subspecialize. Only 40 percent of those trained in primary care deliver direct care, and 40% are employed, rather than practicing independently.

Many factors and forces drive these imbalances – more money, prestige, intellectual security in the specialties, and usually shorter hours and more balanced lives. Moreover, it is easier as a specialist to master a circumscribed sphere of knowledge, and to be better at what they do. Further, most technology innovations are geared towards specialists, and specialists provide most profits and marketing edges for hospitals and health systems.

But buried in these obvious truths, clear to doctors young and old, are consequences.

• Relentless cost rises, for medical technologies make up 70% of health inflation, with talk of “disruptive technologies” lowering costs remaining a fantasy.

• Over reliance on information systems and informed consumers as a cure-all for what ails the system.

• Fragmented overspecialized care with patients failing through the cracks, unable to find a personal physician to guide them through the maze.

• The hard truths that aging patients with multiple chronic illnesses are the single major cost to the system – costs that can only be reined in by intelligent, coordinated, and comprehensive care delivered by personal physicians with the breath of knowledge and commonsensical humanity.

• Technology, no matter how sophisticated, and data and information, no matter how honed, analyzed, and aggregated, has limits.

• There are no magic replacements for clinical judgment and wisdom, talking to patients and spending time with them, a broad liberal arts education as opposed to premature specialization, and the dawning realization that those who treat themselves, as the old saying goes, may have fools for doctors.

Context in sometimes necessary for understanding and treating and comforting humankind, and that can only be supplied by sufficient numbers of generalists who look at health care through broad angled lens.