Ideal Medical Practices

Firsthand knowledge and personal relationships: the keys to better outcomes and lower cost of care

A large study of diabetes management just published in Health Affairs (1) provides convincing support for effective primary care.  Rather than the typical US disease management approach - hiring third party disease management companies to work around the health system - the Germans worked through the patients' primary care physicians. 

They achieved impressive results: lower costs and fewer lives lost as well as a host of other improved process and outcome metrics (lower hospitalization, improved rates of eye and foot exam, etc).

According to the study team this "...physicians’ firsthand knowledge of, and personal relationships with, their patients to promote adherence to treatment goals and self-management..." is the essence of the intervention.

One of the things I find most compelling in this study is the evidence that patient experience is important and informative. Good outcomes follow when patients say they get care that eliminates waits and delays, has good communication, takes their personal issues into account, etc.  Our measurement paradigm is heavily skewed away from this essential source of information, a flaw we must correct.

"Enrolled patients were more likely to receive patient-centered, structured, and collaborative care; the largest differences were in the domains of follow-up and coordination, goal setting and tailoring, and problem solving and contextual scale. This contextual scale is from PACIC. It asks, for example, questions on how doctors or nurses consider patients’ cultural values in therapy planning and make sure that care plans are adapted to patients’ daily lives."

"While US Medicare invested in regional pilots that differ in their structure of care delivery and may use disease management vendors, German health plans decided on an approach with a heavy emphasis on quality assurance and the primary care physician as the program manager. The emphasis is on educating both the patient and the care provider. Characteristics of care considered desirable in a patient-centered medical home, such as coordination, integration, timeliness, efficiency, and effectiveness as well as the patient-centeredness of care, improved markedly."

 We can replicate this work in the US and because of how much more we pay for things here the savings potential is much larger.

To replicate this work we need:

• A payment model that supports the full scope of excellent primary care:  how about a case mix adjusted population based payment to primary care?
• A measurement model that accurately reflects 'firsthand knowledge and personal relationships': NCQA's PPC-PCMH doesn't go anywhere near this stuff.  How about HowsYourHealth.org or the Patient Assessment of Chronic Illness Care instrument?

(1) Stock SAK, Drabik A, Buscher G, et al.  German Diabetes Management Programs Improve Quality of Care and Curb Costs.  Health Affairs 29, 12(2010): 2197-2205

Small and solo practices can work together to prove and improve quality and participate in ACOs

The Ideal Medical Practices project used Dartmouth Professor John Wasson's HowsYourHealth.org tool to measure key attributes of primary care.  This broad denominator approach gave us meaningful data down to the level of individual clinician - a problem considered insurmountable by many of the current medical home projects.

The individual practices could compare their results against a large (200K+) database and even sort by burden of illness, indicators of socio-economic status, etc.  Practice participants were able to use an online curriculum to close any gaps they might find and collaborate in group learning through conference calls and listserv.

Contrary to those who think that solo and small practices are incapable of delivering high quality care, we found that:

• Solo and small practices would volunteer if engagement were made simple and the cost of engagement reduced to acceptable thresholds
• Meaningful outcome improvement was tied to active participation
• Individual clinician data were meaningful and actionable
• Data could be aggregated so that we could look at low-incidence issues of interest at the population level

We were in essence a practice-based research network with pooled data.  We could expand on this approach to understand the impact of our work on congestive heart failure or any other condition whose incidence can only be tracked for populations aggregated across many practices.

We could become an Accountable Care Organization able to demonstrate meaningful outcomes.

The necessary ingredients are:

• A large enough group of practices willing to work together on a common quality platform
• A payer willing to be flexible in the MEANS to the end. 

Our path to high quality primary care is different and we believe more compelling than the approaches gathering most of the press.  We are willing to be held to high standards but are not willing to pursue endless trivia that is tangential to high quality primary care.

To be specific: NCQA recognition is not the goal.  Meaningful use criteria are not the goal.  The goal is to improve population health, improve the experience of care, and in so doing achieve a lower cost per capita or a meaningful reduction in health care cost trends.

A group of practices serving a large enough population could be held accountable to the rate of 'preventables' (ED use, hospitalization, re-hospitalization), to total cost trends, etc.  A payer can use claims data as the overall assessment tool.   The group could use the HowsYourHealth tool as engine for individual practice accountability and improvement.

The outcomes are important.  Be flexible in the approach.  Allow inventive means.

 

P.S.  I'll be talking with Gregg Masters of ACO Watch today on blogtalk radio.  11A PST.

 

Listen to internet radio with ACOwatch on Blog Talk Radio

ACOs: boon or bust? Physician Practice Acquisitions on the Rise - like déjà-vu all over again.

In the 1990s when hospitals anticipated capitation, they binged on primary care practices.  Too many came out of that era with a whopping hangover.  Will ACOs merely replicate the worst of the 1990s?  Will hospitals gorge on and then disgorge primary care practices?

I'm hoping we can avoid making the same mistakes.  There is great potential if we can work together and much misery if we continue our fragmented-silo approach.  There are some excellent examples of physicians, health plans, and hospitals working together. Let us learn from them and learn how to avoid the mistakes of the past.

We can't afford to put primary care through another round of what Kathy experienced (below).  If we want to build high-performing health care delivery we need good primary care.  Good primary care will be more likely when the primary care workforce is supported in their work and not forced into big-box treadmill care.  This will happen when the financing of health care aligns with improved outcomes and experience of care and not just doing more and more stuff for money.

Gordon

It may be hard to believe, but many experts believe the days of the independent family doctor, running a small, highly personal private practice, may be coming to an end. An estimated 2,910 physicians were involved in mergers or acquisitions last year - nearly double the number in the previous year - according to a new report from PricewaterhouseCoopers.  via www.midcapadvisors.com, October 22, 2010

To me this is like déjà-vu all over again.  The hospitals just want to make sure they are part of the equation.  So they are doing the same thing the did in the mid 90’s saying that solo and small practices can’t survive and our lives will be so much better if we let them handle this difficult job for our nonbusiness little brains.  I was part of a successful practice in the early 90’s; before capitation fees were ratcheted down to peanuts as well as everything else.  The hospital was buying up primary care practices or offering management contracts.  WE knew we didn’t want to be owned but the management contract sounded too good to turn down.  We were also expanding and needing to build out a new office, etc. 

It was a total failure.  None of the economies of scale they promised.  None of the taking away management issues so we could just practice medicine.  Staff were constantly being hired and leaving.  We still had management meetings and would be handed 100 page reports of detailed accounting saying “see more people”.  Billing dropped to poor performance.  Layers of management were added to our practice that we didn’t need and all these new fees assessed.  The build out probably cost twice as much as it should have and took months to make every decision.

I don’t see what is happening now as any different.  The hospitals know they need to create a new profit center.  They don’t want to be left out so they are trying to become the foundation.  They are running around pronouncing that this will be our only hope.  We don’t have to listen.  I don’t see it as being any more successful today than it was 15 years ago.  Just keep your fingers in your ears until they go away.

Kathy Saradarian, MD
Branchville, NJ
www.qualityfamilypractice.com

AMA supports small and solo practices in a letter to CMS administrator Berwick

Last week the AMA urged CMS to consider a number of issues that stand between solo/small practices and participation in Accountable Care Organizations.

It is an excellent letter and points out policy issues that systematically block small practice involvement in quality improvement and the kind of collaborative activity deemed necessary to achieve the outcomes we all want.

Create explicit safe harbors from antitrust enforcement and waivers of the Civil Monetary Penalty statute, the Anti-Kickback statute and the Ethics in Patient Referrals (Stark) statute so that small, independent physician practices can work with each other and collaborate with hospitals and other providers to deliver coordinated care for both Medicare beneficiaries and commercially-insured patients. Currently, all of these laws and associated guidelines favor hospital-based systems with employed physicians, yet the best way to preserve opportunities for appropriate competition in health care and choice for patients is to enable physicians to form ACOs in ways that enable them to continue practicing independently of hospitals and large health systems.

78% of primary care practices are small (fewer than 5 providers), and 62% are solo.*  The national strategy for improving health care delivery must include this significant part of the health care workforce.

Solo and small practices need a stronger voice in the process of improving health care delivery.  In addition to the excellent AMA recommendations let me make one or two additions:

• Increase representation of independent solo and small practice primary care practices at CMS meetings addressing delivery system redesign.
• In addition to the typical top-down approach, set aside part of the Center for Medicare and Medicaid Innovation funding to test bottom-up innovations with networks of primary care practices with emphasis on small and independent primary care practices.  Leadership for the CMMI and major positions in CMS are often culled from the ranks of large organizations, perpetuating the systematic big-system bias inherent in US health care. 

Big systems are not inherently bad but the systematic exclusion of small practices must stop.

 

*Hing E, Burt CW. Office-based medical practices: methods and estimates from the national ambulatory medical care survey. Adv Data 2007;12(383):1-15.

How to effectively reach out to solo and small medical practices which still make up 78 percent of practices in the US

According to The National Ambulatory Medical Care Survey (2007), 78% of primary care practices in the US have five or fewer providers and 62.9% of all medical practices are solo and account for 35.8% of all office visits.*

The number and percent of solo practices has been declining over time and some cheer this trend as there is some evidence that large organizations are more likely to have quality improvement infrastructure** and are better able to afford to participate in multi-day and expensive improvement seminars.

But killing off solo and small practices might make sense only if solo and small practices are incapable of delivering the kind of high quality care our country needs.  To cut off such a large part of our primary care workforce we ought to have iron clad evidence.  So far the evidence is far from iron clad and there is some evidence that solo and small practices are quite capable of delivering high quality care.***

The Rittenhouse study** demonstrates the circular logic used (not by Rittenhouse) to bash solo and small practices.  Defining quality in ways biased to favor very large organizations will lead one to the conclusion that large organizations are able to demonstrate quality.

A lot of medical practice quality improvement is currently delivered in large venues where as many as 200 participants learn new content and process improvement from experts in two day meetings, several times per year.  These meetings can be costly to run and it is very difficult for solo and small practices to close up shop to participate in two day meetings.

The NCQA defines quality as being able to spend many tens of hours filling out forms and taking screen shots to prove the capability of health information technology.  A large organization can do this once for all providers, solo practices have to do this for themselves at a monstrously larger cost per MD per submission. [If it costs a hypothetical $2500 in time and fees to submit, a 100 MD group spends $25/MD, a solo doc spends $2500/MD.] So the deck is stacked against solo and small practices.

We must explode the myth that solo and small practices are unable or unwilling to participate in quality improvement and reporting.  The Ideal Medical Practices project work predominantly with solo and small practices and easily recruited more than 100 volunteers.  Solo and small practices participated in the AAFP's TransforMED project.

At issue is the mode of practice engagement.  The Ideal Medical Practices project recruited via online listservs, provided online content and supported improvement work through conference calls.  Participants did not have to leave their practices and had no costs other than getting on the calls.

Organizers of medical home or ACO demonstrations, other organization interested in supporting improved health care delivery, improved outcomes, and reduced unnecessary costs could do the following:

• Set threshold for participation to include all practices, not just large groups and organizations.
  • Require for instance that solo practices make up 62% of practices in improvement projects.
• Use quality improvement processes that work as well with solo and small practices as with large groups.
  • A significant amount (if not all) technical assistance can be provided through conference calls thus minimizing the opportunity costs to the practices as well as the cost of practice support.
  • Provide online resources and tool sets.
• Make measurement and reporting less onerous and more accessible. 
  
  • Use quality data sets that always have sufficient denominators at the individual provider level.
  • Use reasonable proxies for quality that can be measured through aggregate patient experience of care, thus minimizing the practice burden of measurement.

This is a choice.  We can't afford to write off this much of our primary care workforce. The IMP project demonstrated one path of inclusion.  This can be done. 

 

* Hing E, Burt CW. Office-based medical practices: methods and estimates from the national ambulatory medical care survey. Adv Data 2007;12(383):1-15.

** Rittenhouse D, Casalino L, et al.  Measuring The Medical Home Infrastructure In Large Medical Groups Health Affairs 27, no.5 (2008): 1246–1258; 10.1377/hlthaff.27.5.1246

***Moore LG, Wasson JH.  The Ideal Medical Practice Model: Maximizing Efficiency, Quality, and the Doctor-Patient Relationship.  Family Practice Management September 2007 pp. 20-24.

Simple rules drive the complex behavior of high performing primary care

Something is missing in the conversations of quality measurement and improvement of primary care.  There is no question we have a lot of opportunity to improve primary care and solid agreement that good primary care is the foundation of high performing health systems.

The conversations around quality and primary care fall into a trap and once in that trap never seem to escape.  The trap is the mistake of making part of a system work well at the expense of the overall system performance. 

We see this all the time in practice.  We see health care delivery improving efficiency and flow (a.k.a. 'throughput' = number of patients treated per day/hour/minute) without attending to quality and experience of care.  We find practices improving access by trashing continuity of care.  We see primary care practices put all their improvement energies into one or two diseases and exhausting themselves while leaving the overwhelming majority of patients they serve with the same old care.

Primary care is fundamentally different from the rest of the health care delivery system.  More primary care leads to improved outcomes and lower overall costs.  More specialty or hospital care leads to increased costs and worse outcomes.

The national paradigm for primary care quality right now is based on detailed tactical aspects of work in practices:

• Add a diabetes educator
• Screen diabetics for depression
• Implement ePrescribing
• etc

These are all nice but effective primary care is more than a bucket of tactical improvements.  Moreover, focus on the tactical detail may distract us from attending to the overall system.  Any one of the interventions listed above may lead to improvement for some patients but a practice could do all of this and more and still fail to provide a solid foundation of primary care.  This approach perpetuates the general lack of understanding of the value of primary care.

If we want to achieve overall population health improvements, improve the experience of care and in so doing reduce per capita cost trends,  we must understand primary care as an effective system for population health care management.

Complex systems are driven by simple rules.  The simple rules driving primary care are:
- Be the first point of access
- Develop relationships over time
- Provide comprehensive services
- Coordinate care

Understanding, measuring, and working with these simple rules helps drive the complex and nuanced work of primary care improvement.  Focus on the overall system and support innovation as teams explore the right parts for their local environment.