Ideal Medical Practices

Is HEDIS the right way to measure office practice effectiveness?

I'm concerned about the set of assumptions behind HEDIS and “set of biometrics” as overarching understanding of office practice/PCP performance. No question that many insurers and even employers ask for HEDIS measures – they have nothing else to go with at this point. That doesn’t mean that HEDIS tells us what we need and want to know.
There is some concern that HEDIS is not so much an evidence based engine. Example: the goal of “HBA1c less than 7” has been taken up as an issue that highlights the lack of transparency in measure development, raising the spectre of political and not evidence based approach to measure creation.
Aron D, Pogach L. Transparency Standards for Diabetes Performance Measures JAMA 301(2) pp 210-212
We need the ability to track metrics so that we can find patient gaps in care and address them – including those patients who fail to follow up. Biometrics is one approach with which we are familiar. Registry as “database of biometrics” is familiar to many. Registry as “database of indicators with profound effect on patient health trajectory” is another. There is often divergence between these two approaches. The latter is more pointed in finding patients at risk than the former. There is immense overlap and I’m not making an ‘either/or’ case here.
Understanding practice performance is another issue. We need some way to find - in our practices - systems that help or hinder our work for our patients. Barriers to access, wasted time, effective communication, effective self management support (confidence) – these are the systems we create to help our patients.
HBA1c less than 7 is what we hope to help them achieve (when clinically appropriate). A1c is a proxy for measures around access, communication, etc – the core systems of effective primary care. Because of all the other variables that effect A1c it is in fact a weak proxy for the work we do.
It is not wrong or inappropriate to measure A1c and to have systems that help us track it and reach out to those with A1c at unhealthy levels. I am proposing that it is wrong to use a weak proxy measure when so much more powerful measures exist – measures that tell us when the pillars of effective primary care are weak and need to be shored up.
So the fact that insurers and P4P are going down the wrong track is concerning to me. I know we have to live with their rules for now as they make the rules and their rules dictate payment, but we must also stand up to those rules when the rules are wrong and make the case for new rules based in evidence and aligned with supporting effective primary care.
L Gordon Moore MD

Concerns about the NCQA PCMH

I remain very concerned about the use of the NCQA PCMH guidelines as the measuring stick for quality. There are numerous reasons as to why that particular measurement will not likely improve quality:
1) It is primarily focused on database infrastructure. Although this is
nice and helpful, adding a computer system to a dysfunctional practice
will lead to a dysfunctional practice with a computer system--not a
medical home
2) 60% of primary care docs are in 1-5 doc practices with little time or
money for IT development. They can and should be encouraged to provide
great primary care, but they cannot afford to buy the robust systems
necessary to do all the functions put forward in the PCMH guidelines.
Further, is it right to expect a practice to shell out $100,000 or more
for a new system with simply a promise of potential reimbursement later?
3) By having much of the system set up for database analysis and process
improvement, are we simply creating another industry we get to argue
with? Ex. How many docs like to do their own billing? How many do you
think will like to do their own database analysis? If we don't do it
ourselves, it becomes increased overhead and another potential wedge
between the doctor and the patient.
Some truths we do know--The system is broken. Quality medical care is
rare to find. Docs are not rewarded for quality care. Quality in primary
care is measured (by the patients--who know) as access, efficiency,
continuity, good information and coordination. Anything which distracts
us from focusing on these things is likely not going to help. We also
know that docs whose practices are focused on quality will not likely
improve much by going through this process and those who don't care
probably won't understand/care.
I believe the PCMH designation is something which is well intended. I
believe it has some good things associated with it. But, it will not improve the doctor-patient relationship in most offices and therefore is not likely to save money or primary care. We have to begin looking for the real answer.

John Brady

Newport News, VA

Measuring quality in practice

There are global measures and specific measures of health care quality.  Just as we can take a patient’s temp to rule in and out large swaths of work, we can ask global questions like “the percent of patients who say their care is perfect” or “I get exactly the care ….”

John Wasson is a health systems researcher at Dartmouth with decades of theoretical work on how questions are asked and what they mean, and he has decades of work applying the theory to real practices in settings across the US.

The global questions he asks have been studied (not being a researcher by training I can only posit the regression analysis etc that make up appropriate study).  Remarkably awkward as a sentence, this phrase is powerfully linked to positive responses on a host of more specific indicators:  access to care, continuity of care, no wasted time in the office, having a good understanding of personal medical issues, having the efficacy and confidence to manage those conditions.

 

In turn these secondary issues have been studied and linked to things with which we are more familiar:  Glycemic control in DM, systolic and diastolic blood pressure control in HTN, as well as heavy hitter issues like rates of emergency room use and hospitalization.

Given the generally woeful levels of quality in the US (NOT because we don’t care and are not working hard but due to the fact that we’re hamstrung by a toxic environment in health care), we need access to quality measures so we can make the case to clean up this toxic environment. 

One approach is to ask practices to report “percent of patients who have hypertension who have systolic blood pressure controlled”  (with then a paragraph or two defining the appropriate denominator of “hypertension” and “established patient” and another paragraph or two defining the numerator (exclusion factors where tight control might be inappropriate, some patients who won’t engage) and a page or two describing what “in control” means.

(I submit for your consideration the 20 page paper “Implementing the new HEDIS Hypertension Performance Measure”)

http://www.managedcaremag.com/supplements/0004_HEDIS_hypertension/0004.HEDIS_hypertension.pdf

 

This approach appears eminently logical on its face until we realize that we’re treating a lot of people in our practices who don’t have hypertension and we wonder if this one measure can capture the true nature of our work or if it merely represents the work we do to manage this one narrow biometric.

This work appears eminently logical until we start the laborious job of extracting SBP and DBP from paper or electronic system that give them up grudgingly (especially as we try to address the nuances of “in control” and “does this person deserve to be excluded because of X?”).

This work appears eminently logical until we reflect on decades of research that identify effective primary care as the foundation of high performing health systems and not disease management.

We in our offices and with our patients must measure and manage systolic and diastolic blood pressure and use the latest (hopefully untainted) medical evidence to guide our patients to the best possible care.

We COULD use a wide swath of biometrics like this to reflect the bulk of our care, but recognize the impossibility given the limitations of health information technology (the hype gap), the fact that more and more of the primary care work force is walking the financial plank in this toxic ocean of unfunded administrative trivia.    We could spend more and more of our time justifying minutia.

On the other hand, maybe we could explore approaches that give us reliable information without all the heavy lifting. 

If aggregate patient experience in our practices achieve statistical meaning (it does)

If patient experience reflects fundamental attributes of primary care (it does)

If patient experience measures can be easily obtained (been there, done that)

We could then use a handful of global experience measures - like a handful of indicators on your dashboard – as the feedback loop on the office systems we have created, as the quality indicators others are demanding.

“I can get care when I need it” means we have eliminated barriers for our patients in obtaining care – first pillar of primary care

“I have a PCP who knows me”  continuity – second pillar of primary care

“My PCP provides for the bulk of my needs” broad array of services – third pillar of primary care

“My PCP coordinates my care” – fourth pillar of primary care.

There are numerous studies behind each and every one of these metrics.  Patients in aggregate can accurately identify how well we perform these fundamental attributes of primary care.  When we perform well on these elements our patients achieve better glycemic control, blood pressure control, miss fewer days from school and work, and are hospitalized less often.

This approach reflects primary care – not discrete organ systems.  This approach reflects our patients and how we serve them – not simplistic “yes/no” responses to “do you have a searchable field for micrometric X?”

L Gordon Moore MD

Lunch with a Friend

Last week I had lunch with a friend. Then I listened to someone being interviewed on NPR. In a twisted kind of way, the two things got me thinking about primary care.

My friend is a family doctor in a large multispecialty practice. From the outside he appears happy. He has lots of patients, works hard, and is well compensated (compared to other primary care docs). He believes he is giving good care to his patients, but he is constantly running over an hour behind because he likes to make sure his patients get the education they need. His group is willing to listen to the individual providers and work with them to make things better, and he loves the collegiality of the larger system. But sadly, he feels like he has lost his calling. Although he readily admits he could forsee continuing on in this manner until retirement at age 65, he no longer feels passionate about what he does. Financial reimbursment insanities have forced the scope of his practice to narrow to a point where he is doing nothing but geriatrics. He likes geriatrics, but he longs for the generalist vision he initially fell in love with but feels he can no longer attain. After all, there is not enough time to do simple dermatologic procedures when a derm referral is readily available within the group. He has done hundreds of vasectomies, but cannot continue these because in our state, doing one/year pushes the malpractice premium to that of a urologist, so he cringes every time he sends one of these to the urologist down the road. He loves the idea of Family Medicine but admits that if a med student rotated with him, they would not choose family medicine as their calling. There is no more edge, no more variation. Everything has become somewhat vanilla with no spice.

Then I listened to an interview on NPR where an author was discussing her book. The interviewer asked if she was afraid of publishing her views knowing some religious groups would find them offensive. She stated something like she is a writer. She has to write. She cannot be worried about what others might think because if she did not write, she would cease to exist. (Ok, that was totally my take and not the actual transcript. Suffice it to say, her passion was palpable).

So, I could not help but wonder what happens to the passion of most primary care docs. We all had the passion of that author at one point. We all remember the first unusual diagnosis, the first procedures, the fear of leaving the shelter of residency, and the excitement of spreading our own wings and doing our own thing. During that time, we too were passionate. What happens? Do we become like dogs in our own Skinner Box being inundated by random insanities until we succumb to learned helplessness? If we told the author she could only write about noncontroversial topics, would she lose her passion and desire to be an accountant instead?

Life without passion is not something I am willing to resign myself to. I have to believe we can change the system so those of us who are passionate can continue to be so for years to come and those whose passion has been lost in the ashes can potentially be rekindled. Doing this is essential for our lives and the lives of our patients.

John Brady, MD, FAAFP

Newport News, VA

I have a dream

Welcome to the Ideal Medical Practices blog! I was invited by Dr. Gordon Moore to share my thoughts along with those of various other physicians involved in the Ideal Medical Practice or IMP movement, a grassroots attempt at solving our nation's dysfunctional healthcare system. 

I am a family physician located in South Pasadena, CA and have been operating a solo micropractice for the past 5 years. I left a large HMO after 13 years frustrated at the lack of time available for me to do the job I was trained to do, and I got tired of running on the hamster wheel. Now I am like over a hundred other physicians and health care providers around the country, trying to find a better way to care for patients by keeping my practice small and personal.

In light of it being Martin Luther King Jr. Day today, I thought I would voice some of the dreams I have for the future of healthcare in America.

I dream of the day when every person in America has access, not just to insurance, but to affordable healthcare. Because insurance without access is like a key with no door or a fork with no food -- not very useful.

I dream that there will come a time when there are no restrictions to healthcare due to "pre-existing conditions" and that people can continue to receive healthcare no matter what their job is and even if they have no job at all.

I dream that America will wake up and realize that the foundation of healthcare is in basic primary care; that it will finally fix the perverse incentives that reward procedures over thought, specialists over generalists, rescue over prevention.

I dream that the proposal being made at http://www.patientsatcenter.org/petition.html comes true, and that a consistent stream of healthcare money goes towards basic primary care, maintaining wellness and preventing disease.

I dream that young and idealistic men and women will once again heed the calling to provide primary care to the people, and be financially and spiritually rewarded for their hard and caring work. That they won't be beaten down by the crying masses, long hours and endless paperwork that has been forced upon them in an misguided effort to save a few bucks on the backs of overworked primary care doctors.

I dream that mental illness will be recognized as being no different than bodily illness and that healthcare providers and patients can be given the resources necessary to treat them, and that insurance companies no longer discriminate against the people who happen to suffer from them.

I dream that the CEOs, board of directors, stockholders of health-related companies, be they insurance plans, pharmaceutical companies, hospitals, medical groups, place the value of the health of their customers above that of profit and greed. 

I dream that pharmaceutical companies will price their products affordably, stop direct marketing to consumers, stop developing medications that have no significant benefit other than to maintain their profits, and stop slanting medical research to favor their products.

I dream that vitamin and nutritional supplements will finally be regulated in the same manner as prescription medications, and have to prove safety before they are allowed to be sold, as well as efficacy before they are allowed to claim that it is helpful in maintaining the health of any bodily organ. 

I dream that malpractice lawsuits are replaced by a fairer judicial system that doesn't depend on sympathy, specialists who act as "hired guns" or skilled jury selection, that utilizes consistent medical guidelines/standards and an understanding that no doctor, being human, can be flawless.

I dream that each person in American learns to take responsibility for his or her own health care, and realizes that it is what we do every day that determines our health; that taking care of our bodies with healthy foods and regular exercise; that keeping harmful habits and substances away from our bodies will do far more in keeping us healthy than any pill or medical treatment.

I dream that the American public learns to accept mortality, and that there are limits and medicine, like life, is imperfect; that death is not optional and is a necessary part of life; that heroic efforts to stave off death at any cost are costing other lives by draining limited resources.

I dream that the health of the planet we call home will be recognized as vital to the health of humanity, and that appropriate actions will take place to make our home a healthier place for all to live.

While I know most of these will not take place in my lifetime, we've got to start somewhere and that somewhere is usually in a dream. After all, MLK's dream led to the fulfillment of Mr. Obama's dream. Who knows what other dreams may come true tomorrow? 

Dream on.

Gary Seto, MD

South Pasadena, CA

Primary care is ready to step up - Please make it possible

 

Our country lags far behind others on health care quality in spite of spending more than twice as much per person as other countries.  Decades of research identifies our lack of investment in primary care as the essential flaw.  This flaw results in missed opportunities for preventive care and early intervention, leading to high incidence of avoidable illness and complications of chronic disease that drives up health care costs.

Effective primary care improves quality, improves the experiences people have with care, and makes health care more affordable for all.  The pillars of effective primary care are in place when patents say:

• "I can get care when I need it"
• "I have one doctor/health care provider who knows me"
• "My primary provider takes care of most of my needs"
• "My primary provider coordinates my care"

The work of effective primary care is punished by our current fee-for-service environment, which rewards volume of services rather than quality.  We are paid for "volume of office visits," while much of the essential work of primary care is considered valueless.  Effective primary care is much more than what happens in an office visit.  It also includes:

• Reassuring a new mom at 11PM
• Helping an elderly woman deal with the grief over loss of her husband
• Getting the full story behind a biopsy result to be able to explain it to a frightened family
• Taking the time to listen as a person comes to grips with their alcohol abuse
• Searching for answers in the medical literature
• Spending time coordinating care for patients receiving care from several doctors

Attempts to improve quality and reduce costs through current regulation and policy have created an untenable burden of administrative trivia.  This crushing burden drives up costs by forcing us to hire clerks to respond to endless "mother-may-I" authorizations.  Our attention is diverted away from actual care for our patients to address countless inquiries about the care we deliver.

The primary care workforce is stressed to the breaking point.  It has become a repugnant and illogical career choice.  Finishing medical school deep in debt, a student is unlikely to take a pay cut of $100-$200,000 per year for primary care versus specialty practice.  It is no wonder medical students avoid the long hours, low relative pay, lack of autonomy, and impossible frustrations of primary care.

We know how to do this work.  We want to do this work.  We need real reform so that we can do this work.

Real reform will provide primary care with the resources to do all that we were trained to do.  For less than 10% of our nation's health care tab we can provide excellent primary care for all Americans.  This will afford us the tools and time we need to improve communication with our patients and to coordinate care across the current health care silos.  We will:

• provide access for all
• engage in reliable prevention
• deliver superb chronic disease management
• work for our individual patients as well as the populations we serve
• coordinate care across the health care continuum

Real reform will lift the administrative burden that yokes us to legions of clerks who mire us in trivia while restraining us from real care.

Real reform will not take the form of Health Information Technology vendor hyperbole but will enable us to use technology that actually works in the front lines of care.

Real reform improves health care access for all Americans by enabling effective primary care for all and not merely providing another windfall for the insurance industry through "insurance for all."

We in the front lines of care are ready and willing, and hope you can hear our desire to be among the solutions our country so desperately needs.  Please look beyond the usual cast of characters and include us.  We can help you craft policies that promise to make us not only ready and willing but ABLE to deliver on the full scope of our profession and your desire for real health care reform.

Respectfully,

L. Gordon Moore MD
Ideal Medical Practices Project - a volunteer community of front line providers collaborating on delivering superb care in spite of a toxic environment

Seattle

WA

writing in to change.gov

I am grateful that the new administration is offering to  listen
I suspect that President Obama's team  has long ago formulated their approach . But i hope their ears a re still open, as the approach they put  forward is not what we need  and not what will work
Many people write in, each with their own "cause."

Everyone's special interest can be met if we  increase access to care and lower costs to improve the population's overall experience of care.

This is not done by forcing docs to buy computers that often  serve only the companies that manufacture them.
This is not done by medicare for all- though there is some merit there,  this is not done by increasing access to insurance.
Insurance as we know it fails miserably. Docs are buried under layers of administrative trivia so deep, and silly concepts like coding and reimbursements so obscure that docs and patients have become enemies.

Make primary care the heart of a system as in every other country.
Pay primary care a dollar a day not per visit.
Help college and med school be affordable for  everyone.
Realize that access to insurance is not access to care.
Insurance companies as we know them work against a healthy care system. Single party payors ,even if regional, even if for profit, even if not the government,must be established with oversight for  quality not  "productivity."
Stop the needless suffering. Mr Obama.

Jean Antonucci MD

Farmington ME

Our patients can't afford to come in for needed care

"Compared with their counterparts in seven other countries, chronically ill adults in the US are far more likely to forgo care because of costs."

C. Schoen, R. Osborn, S. K. H. How, M. M. Doty, and J. Peugh, In Chronic Condition: Experiences of Patients with Complex Health Care Needs, in Eight Countries, 2008, Health Affairs Web Exclusive, Nov. 13, 2008, w1–w16.

Numerous studies point out what Uwe Reinhardt has said: when an individual's personal threshold of out-of-pocket spending is exceeded, they will perceive health care as a luxury.  In microeconomic terms, “luxury” means “I will do without in dire times.”

Our patients are facing dire times.  Primary care is facing dire times.  We and our patients are suffering from an illogical and harmful system that rewards volume of services over care.  Insurance industry maneuvers to manage care and cost result in untenable costs added to everything we do for our patients.

This toxic brew stems from how our system is designed.  Change can happen if policy makers can find the will to face those with deep investment in the status quo.  We can have an effect on policy makers if together with our suffering patients raise our voices in local and national media.

Here are some suggestions on what one might say:

Other countries achieve vastly superior health outcomes while spending less than half what the US spends per capita on health care

• The main difference is that the other countries support excellence in primary care
• Adequate funding for primary care would take less than 10% of current health care spending
• This funding would
  • Provide all Americans with primary care
  • Make health care affordable because of the savings from improved prevention and early management of conditions
  • Re-invigorate primary care as a career choice

We do all we can to help our patients but we can’t provide inadequate or inappropriate care. 

The current system is blatantly absurd.  Most of the suggested “solutions” are incremental modifications which maintain the fatal flaws of the current system.  We need real change.  Real change can happen if enough of us speak up.

Gordon

Welcome to the Ideal Medical Practices blogs

Those of us who have lived in the front lines of health care need to help the public an policy makers understand what stands between us and the work we would do for our patients. 

I am a family physician who has worked as a salarydoc as well as an independent solo practitioner and has had the phenomenal opportunity to work with the Institute for Healthcare Improvement and with other terrific individuals lead the Ideal Medical Practices Project (funded by the Physician's Foundation).

This work allowed me to engage with a terrific community of passionate health care providers and others interested in helping create ideal practices across the United States and the globe. 

We have a vibrant listserv on yahoogroups and think that a blog may prove to be another helpful vehicle for communication.

Our goal is to help any individual or group within health care develop ideal practices - those capable of delivering superb care in a vital and sustainable practice.  In doing so we have been exploring what it takes to create sustainable practices in an environment that is rather toxic (unsustainable insurance driven beurocracy and paperwork, inadequate funding that hamstrings our efforts to meet all of our patient's needs, our professional obligation to serve but our societal willingness to allow tens of millions in our country to go without adequate access to our services).

We hope that our posts might foster a greater recognition of the benefits that accrue to our society from unfettered access to effective primary care, and we hope to help policy makers understand what it means to create an environment that truly supports this work.
L. Gordon Moore MD
Seattle WA  January 14 2009

Affordable health care for all

If on average each primary care provider had 1500 patients (adjust as needed for part time, case-mix, etc)

And each patient came with a payment (a voucher maybe?) for $350/year (adjust for case-mix etc)

Then the practice would receive $525,000 per year.

 

With 305,000,000 Americans by last count, this would be $107 billion per year for primary care.

This is less than 5% of the $2.1 trillion the US spent on health care last year.

 

It is incomprehensible to me that we systematically withhold adequate resources from primary care.

 

A dollar a day per person.   

 

I could do so much more for my patients if I had resources adequate to the work at hand.

 

A pilot group in the IMP project has been working on helping patients get the most out of specialty consultations [Core attribute of primary care – coordination of care across the continuum]. 

 

• Janice Pegels coaches her patients with complex issues to create a “no more than two page” summary to capture the essence of the complex history to save the specialist having to weed through an inch of chart while simultaneously eliciting the patient’s agenda (evidence shows that eliciting patient agenda improves visit efficiency as well as the probability of meeting patients’ needs)

 

• Because he continually updates the problem and med lists Larry Lindeman is able to very quickly type out the reason for consult and print it all out to hand to his patients before they leave the office so that they never show up at a consult where a specialist has nothing to go on (Larry finds that many specialist offices lose incoming faxes of new patients)

 

• Jean Antonucci uses a tickler system and then contacts her patients the day after the scheduled consult to find out how it went, catch up on any details and manage the coordination of care

 

• Judy Zettek spends time negotiating health behavior change plans during office visits and then follows up within a week and then ongoing to help patients problem solve around the issues of daily life.

 

Each could spend time playing Billing Twister to figure out how to squeeze a dollar from the insurance stone, but by and large this essential work of primary care is without value in the current paradigm.  It is time for an entirely new paradigm.

 

The www.PatientsAtCenter.org proposal sets the stage for a conversation about a new paradigm.  As you see from the numbers above the total price tag is affordable.  

 

Based on decades of research, unlocking the potential of primary care through adequate resources should be the foundation upon which a high performing health system is built and the cornerstone of any serious effort of healthcare reform.

Gordon