This is the best of times and worst of times for solo and small medical practices

We're living in interesting times for primary care.  There is widespread recognition that effective primary care is the foundation of any high performing health system and there are a number of programs in the works to better support primary care (best of times).  Even though solo and small practices make up more than 60% of practices in the US there are continued calls to force them out of existence and numerous policies and initiatives aimed at helping primary care that threaten the survival of independent practices (worst of times).

I give you two anecdotes.

"Time to pack it in"

Well Folks the time has finally come upon us.... We have been pretty broke and just sort of attempting to ride out the insane wave of what was a perfect storm in our personal lives with family illness and being more than just a bit over whelmed with all of that, two kids, a crumbing school district, a crumbing healthcare system that wants us to work for peanuts if not even for free while constantly increasing its demands upon us for more BS busy work, reviews, prior auths, you all know the drill....

This has been a tough decade and many of my primary care colleagues in solo and small practices are wondering if 2011 is the year that will finally force them to close their practices.  They love their patients, love their profession, but are struggling to survive in a toxic health care payment and policy environment.

• There has been a steady increase in unfunded work of prior authorizations, permissions, restrictions on what they can do for their patients.
• Initiatives aimed at supporting primary care are biased in favor of large institutions that flex their negotiating muscle to land higher fees, a guaranteed place at every policy table.
• Measurement strategies built on assumptions that embrace burdensome peripheral detail while ignoring the foundation of high performing primary care.
• Payers unwilling or too afraid to shift funding to support effective primary care.  That funding is the missing ingredient in redesigning our delivery system to achieve better outcomes at lower cost.

"A glimmer of hope"

...I am also relatively certain 2011 will be my best year financially as I finish paying off the last of the practice debt, there is the meaningful use funds, and I believe as the economy gets better, patients will again find their way to my door. Aside from the economics, I look forward to launching my new website, adding a patient portal, pushing the envelope at the state level, and watching/helping  this movement of wonderful, heroic docs continue to grow and develop.
So tomorrow night I will toast both the fact my practice made it through another difficult year and the hope that this was the last difficult year I will have to make it through. I will also toast my fellow IMPs, whose continued words of wisdom and assistance have kept my practice efficient, my mind challenged and my heart optimistic. Thanks to one and all.
Have a wonderful, happy, healthy, safe and prosperous New Year.
John Brady MD  The Village Doctor Newport News VA

I'm hearing an increased level of interest in supporting solo and small practices in the US.  I've been reading an AHRQ RFP that is aimed directly at developing support for independent small practices.  The interest is real, the need is real.  2011 will tell us if the support is real.

Real support can be demonstrated by:

• Protecting independent practices from anti-trust allegations so that they may work together to improve quality.
• Provide cost effective technical assistance in a way that invites independent and small practice participation (e.g. by using techniques we found effective in the Ideal Medical Practices project).
• Use a measurement approach that provides meaningful data to individual clinicians on the core attributes of primary care while reducing the burden of measurement (e.g. the patient experience data set from HowsYourHealth.org).
• Reward participation, improvement and attainment in programs that lead to improved population health, experience of care, and in so doing bends the cost curve.
• Align the payment system with the work of effective primary care (e.g. care coordination payments, case or episode payments, partial capitation, almost anything that balances against the toxic nature of our RBRVS FFS pay-for-volume-regardless-of-quality system)

Primary care is stretched too thin to do this and prove the results before finances are shifted to support the work.  Real funding for real work is a non-negotiable starting point.  Medical literature supports both the improved quality and reduced total costs that come from doing this work well.  Practices of all sizes can and should be held accountable to performance standards on the core set of primary care functions.

Changes in payment means reducing payment elsewhere, so this will take guts, but give the dire nature of state budgets I suspect that 2011 and 2012 will provide the intestinal fortitude to at least pilot real innovation that truly supports excellent primary care in exchange for reduced per-capita cost trends.

Comments

[Hope Hetico RN MHA]

On Pay-for-Performance Initiatives

The concept of pay-for-performance (P4P) is an unproven trend, according to the Congressional Research Service, an arm of the Library of Congress. Initial studies suggested that pay-for-performance programs might change performance on quality measures that are used for the basis of bonus payments. Claims that P4P programs are cost saving in the long run are largely speculative, however, since determining whether a certain healthcare practice produces good results usually requires controlled studies rarely possible for a social policy.

A recent study published in the New England Journal of Medicine found that P4P accelerated quality improvements for some conditions in the short term. However, once targets were met, the rate of quality improvement slowed, and the quality of care actually declined for other conditions which were not incentivized. (N Engl J Med. 2009 Jul 23; 361(4):368-78). Research shows there is a fundamental problem with P4P programs: They have had little to no impact on quality.

Moreover, physician pay is contingent on them believing that goals are fair, measures appropriate, performance accurately tallied, and incentives worthwhile.

Dr. David Edward Marcinko
www.BusinessofMedicalPractice.com

[Robert]

"Real funding for real work is a non-negotiable starting point."

And that's exactly what the PCMH proponents don't realize. Asking family physicians to do more work and take on more administrative chores in the hope that someday, someone will pay you fairly for doing so is just a non-starter!