Let's call her Dr. M. She's a rural solo independent doc in a rural state with a high poverty rate, lots of unemployment. Most of her patients are on Medicaid or Medicare with a smattering of patients with commercial insurance.
Dr. M does not live large. She drives a car with >150K miles clocked and sweats blood when she has to replace her fax machine. She earns one third of the typical primary care income and one tenth what a cardiologist earns in a modest year.
Conventional wisdom tells us that only large health systems are capable of pulling off quality improvement in health care, that solo independent docs are either unwilling or unable to step up to the plate, and that we just don't know what the heck to do with rural practices.
The solution to these problems in the conventional thinking is that we have to take the solo docs and mash them up into large groups and attach them to hospital systems so that we can achieve the 5000 Medicare beneficiaries researchers require to be sure of their predictive models.
If the predictive models require 5000 Medicare beneficiaries they'll never be much use in the real world of practice where each doc responds to their individual performance data. Patients may be curious about how a network performs, but they're much more interested how their own doc performs.
If the model can't get there, then maybe the model is wrong. If we are ever going to get out of this mess we're in we need to start with a little bit of unconventional thinking.
It turns out that Dr. M performs quite well. In a report from her state Medicaid agency she stands out. In fact they called her up to find out what she's doing because she stands out a lot.
By delivering exemplary primary care (oh by the way, her quality indicators are great as well) she saved her patients from unnecessary care that may have hurt them. She saved the State more than $50,000. Dr. M would really like to invest more in technology that would help her reach out better to her patients. She would like to have tools and/or time to better manage the coordination of care for patients of hers who need specialty intervention. With adequate funding of primary care she would be able to do these things.
Her State has a quality bonus system in place to reward docs who do good things. She received $800. She has the new fax machine but she and her patients deserve so much more.
It's time to stop writing off rural practices. It's time to start funding the full scope of work of exemplary primary care. The practices can deliver and are willing to be held accountable if the accountability paradigm makes sense.
Let's do right by Dr. M and fund her work. Use modeling that accurately represents her work and stop with the conventional wisdom that flies in the face of what's right.