Exemplary primary care stonewalled

At a meeting today I ran into a colleague.  She's lectured around the country on her primary care network's efforts to deliver exemplary care to their patients.  They have invested huge sums of money  to bring their practices into the electronic age, have invested large amounts of human capital and cash in improvement and have a lot to show for the effort.

Their combined population health outcomes are very good.  The average patient experience of care is very good.  People who receive care in these practices are less likely to have unnecessary visits to the emergency room and are more likely to avoid hospitalization.

The docs and staff in the practices are much happier with the high level of care and how much better things are after years of improvement efforts.  So far so good.

The problem is that this doc wants to go even further.  She wants to invest in a health coach because she's read about and even participated in some pilot work with health coaches that leads struggling patients to better outcomes.  People are more likely to achieve their own health targets and avoid bad health outcomes (nice study by Tim Ahles et al @ Dartmouth describes the coaching model and outcomes).

The doc wants to hire a coach but she can't because her practice and the network are just scraping by financially after all the investments they have made in technology and improvement and extra time and effort to reach out to and help their patients.

She wants to hire a coach to help her patients but the current payment system won't fund that work.  The current payment system bottlenecks all care through the doctor and fails to recognize the value of well coordinated care with the help of other professionals.

Just as any good primary care physician will call in the help of a specialist for the patient who needs it, the PCP should be able to call in a person with special skills to help patients who would benefit.  The payment system blocks this work and my friend is hogtied. 

If she hires the health coach she'll have to ramp up the hamster wheel of care with all the attendant bad outcomes and miserable experience of care. 

Her group has terrific data they have used in negotiation with the regional insurers.  For all the insurer's professed interest in good outcomes and satisfaction of their members, they won't budge.  Her group has been at the negotiating table with these insurers for years and are getting nowhere.

In settings where insurers systematically thwart well documented interventions that truly lead to good outcomes and reduce the total cost I am at a loss for what to do other than walk out of the room.

My friend doesn't want to move.  I'm hoping that she and her group will begin to negotiate directly with local employers, unions and other groups who may show more interest in the results.  When insurers continue to stonewall progress while pocketing profits it is time to bypass them and create new means of financing health care.

I'm perfectly happy to work with insurers if they agree to fix two fatal flaws in their policies:

1:  Fund the full scope of exemplary primary care - shift 5% of the overall health budget to primary care and use the 15-20% net savings to make premiums more affordable.

2:  Dump the crushing burden of administrative trivial pursuit that keeps us from attending to the needs of our patients.

Primary care and insurers can work together in good faith negotiation with legitimate proposals, but if they are lacking it is time to step around the roadblock and do what's right for our patients and our country.

Comments

[R Watkins]

And isn't this an excellent description of the fundamental flaws (that the AAFP refuses to acknowledge) in the PCMH concept?

As you have written, the PCMH is based on dramatically increasing the crushing administrative burden, in the hope that, out of the goodness of their hearts, insurance companies will increase payment.

It is irresponsible for the AAFP to refuse to address these concerns, which are common to many (most?) practicing physicians.

[gjudd]

what kind of data does your primary care friend have on patients' employers? If there are any indicators, "follow the money" to the bigger, more likely self-funded employers. If they have any mgmt skillz at all, whoever runs their health benefits is all ears for programs that have data to demonstrate results you mention - and will introduce incentives that reward your friend & other docs like them, or at very least pester the insurers/admins they contract with to run their plans about their reluctance to support your friend's practice approach.

Sounds more arduous than it is. Contact me; I can help them make some progress, & won't charge for the pointers.

Or, if that sounds dicey, have your friend check out http://www.vbhealth.org. There are groups of such employers actively seeking out examples of practice innovations & innovators like your friend. I'm one of the founders. Tell Cyndy I sent you.