Wednesday, December 17, 2008

Interviews, Reece, personal musings - An Interview with Dr. Goodenough, a Primary Care Bottom-up, Bottom-Line Expert

Despite the conceits of New York and Washington, almost nothing starts there. In the course of my work, I have been overwhelmingly impressed with the extent to which America is a bottom-up society. Trends are bottom-up, fads top-down.

John Naisbitt, Megatrends, 1982

It's all about the health care deficit.

Pat Reignier, “Bottom-Line” Column, Money Magazine, 2008

Build a good-enough vision and provide minimal specifications rather than trying to plan out every detail.

Brenda Zimmerman, Curt Lindberg, and Paul Pisek, Edgeware: Insights from Complexity Science for Health Care Leaders, 1998

Q: Dr. Goodenough, I understand you’re a primary care expert.

A: Yes, a bottom-up, bottom-line expert.

Q: Explain.

A: First, America is a bottom-up society. Care trends begin at the bottom of our society, in neighborhood and local communities, in cities and towns and states far removed from Washington, D.C., where people seek access to care, and that is primarily in primary care doctors’ offices. Care doesn’t begin at the top, in government, corporate, and executive health plan suites. It begins at the bottom, where the doctors and patients are.

Q: Go on.

A: Second, primary care doctors are at the bottom of the doctor food chain, which is why there are so few of them. Don’t take my word for it. Here’s what Dr. Grattan Woodson, an Atlanta primary care physician, has to say in the December 18 New England Journal of Medicine,

The payment system has failed primary care. Payment for procedures provided by these physicians has been restrained, while those for newly introduced ones have been excessive. This inequality in reimbursement is a major factor explaining why new graduates choose highly paid specialties rather than the relative drudgery of primary care.

Q: What has that got to do with the top-down?

A: Top-down policymakers and politicians are saying it’s our moral obligation to have universal coverage of our population, perhaps in the form of Medicare-for-all. Can you imagine what would take place if that happened with not enough doctors to supply the care? Universal coverage without access is meaningless. It would precipitate a monumental political crisis, the magnitude of which is hard to imagine.

Fees for doctors are set from the top-down, by an organization called the Reimbursement Update Committee, an organ of the AMA dominated by specialists that works with government to establish codes for re-imbursement. To quote Dr. Woodson, The only thing that primary care has gotten out of this deal is the economic shaft while our partners in this enterprise have prospered beyond their due.

We don’t need a food fight between primary care doctors and specialists. But we do need to reconfigure the Sustainable Growth Rate Formula(SGR). a creation of Congress that will result in a 21% cut for all physician fees next year. The SGR assumes a fixed amount of money to be divvied up between primaries and specialties. That assumption is faulty.

Q: So what is the answer?

A: An overhaul of the reimbursement system combined with a new way of coordinating care from the bottom-up. The one most commonly talked about is medical homes, whereby primary care doctors are paid through a blended payment system – fee-for-service, a capitation fee for coordinating comprehensive care, including care between office visits in conjunction with nurses and other care professionals, and bonus for responding to patients, such arranging for a same day appointments, and consulting through emails and telephone calls.

The general attitude towards medical homes among primary care doctors right now is positive with these caveats: show me the money and lower the bureaucratic gates, and we’ll climb on board.

Q: Will medical homes work?

A: They’re a good start. Until they kick in, we’ll have to fill in the gaps with more medical students choosing primary care, more care teams, more nurses and physician extenders, more subsidizing and streamlining of EMRs, and more incentives to medical students and residents, with debt relief, more residency slots, and more pay to work in underserved areas. All of this will take a decade if we are to have enough access to primary care.

Q; Anything else?

A: Yes, we’re going to have to be more open to care innovations from the bottom-up. These innovations include: more direct pay and concierge practice models, more productive micro- practices, more care delivered by primary care doctors for self-funded corporations outside of the usual managed care prepaid model, more retail and worksite clinics, and more innovations engendered by consumer-driven care, driven by HSAs coupled with high deductible health plans.

Q: Do these approaches share anything in common?

A: You bet. They’re closer to the patients, more direct, more devoid of third parties, cost less, are more convenient, offer greater access, and have more predictable, reliable, and understandable pricing.

Q: Are there obstacles?

A: Of course, health care is fraught with rules, regulations, and special interests. Specialists, hospitals, health plans, and supply chain vendors – such as drug and device manufacturers – may fear revenue loss and may resist sweeping changes of the status quo.

Q: Any concluding remarks?

A: Yes. It’s all about the bottom-line of the U.S. health system, and indeed, the bottom-line of our whole economy. Medicare and Medicaid, at federal and state levels, programs covering 100 million Americans, are rapidly running out of money, and could go bankrupt by 2015 if present cost trends continue.

Countless studies have shown broad primary care based delivery systems provide better care, with more satisfaction, with 30% less costs and 20% better outcomes. In other words, there’s more bang for the buck, and that’s what the bottom-line is all about. I might add the federal treasury is not a top-down bottomless pit. It needs to be filled in from the bottom-up.

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