Ideal Medical Practices

Our approach to measuring health care quality is broken

I'm reading through the Massachusetts AG's report on Examination of Health Care Cost Trends.

The report points out many things that are obvious: 

• Payment changes absent substantive changes in care delivery will ultimately fail
• The logical route to improved (and lower cost) care is through care coordination, which is defined in the report as: "care that is managed across care settings, continuous over time, and patient-centered."
  
  • This is a near perfect match with the essential features of primary care:  access, person focused relationship over time, comprehensive services, and coordination of care.
• Current measures of quality do not appear to address the failings of the current system

From page 19 of the report:

"We also reviewed CMS, HEDIS, Mass-DAC, and ACES measures to understand how well providers in Massachusetts deliver care as compared to each other and, where national data is available, how they perform as compared to health care providers nationally. Our review shows that providers in Massachusetts deliver excellent care with little material variation in the quality of care delivered.18    For example, substantially all Massachusetts physician groups performed above the national average on HEDIS process measures. Other measures that we examined, such as CMS hospital process measures, show the same trend: little variation in the measured quality performance of providers, and high quality care from all providers. Based on our review of these measures, there are some differences in provider quality performance and room for improvement in certain areas of performance, but our review does not suggest that any provider performs consistently better or worse than any other."


I paraphrase:  "In spite of the facts that our current market fails to achieve meaningful goals and recognizing that considerable variation exists, our current approach to quality measurement fails to recognize meaningful variation and fails to provide any indication that our system is struggling."

If the current approach to measurement cannot identify variation when variation is known to exist, and if the current approach to quality measurement cannot identify system failure when the system is obviously failing, then the current approach to quality measurement is of very questionable value indeed.

High performing health care is founded on primary care.

Primary care has four cardinal features:
Access
Person-focused relationship over time
Comprehensive care
Care coordination

High performing health care results in better population health outcomes and reduced cost of care by avoiding potentially preventable events

Safran, Wasson and others have demonstrated that people can accurately report their experience with these cardinal features of primary care and both show us great variability between practices and strong indication of system failure:  Wasson tells us that only 35% of a national sample report that they experience the bulk of these positive attributes.

In addition to our national conversation and efforts to change payment, we must talk about the immense momentum behind a failed approach to quality measurement.  Patient experience with the core attributes of primary care appears to be a much more logical starting point.

Dreaming of the ideal practice - IMP article in Feb 10 Medical Economics

The February 10, 2011 edition of Medical Economics published an article about our work.

Here's a link to the article.

Funny title the journal editors chose.  I guess that given our current payment and policy environment the ideal is still just a dream, but the pressure to truly change cost and outcomes may help make that dream a reality.

 

Why is it so hard to get primary care practices to change?

There is a good deal of talk about support for primary care.  That support is demonstrated in AHRQ grants targeting interventions that support independent small and medium size practices, in a blizzard of Medical Home initiatives, and more.  There is also a good deal of concern that these initiatives may prove disappointing unless we can overcome the glacial pace of change in primary and fractional improvements observed.

What can we do to accelerate primary care transformation?  Hypotheses abound.  Some point to disappointingly incremental results of the Learning Collaborative model, others to the lack of aligned payment, still others to overly broad 'change package' that fail to promote fundamental changes. 

Many things have to go right if primary care is to make the transition. 

• We need an approach that invites the participation of all kinds of practices.  Participation costs (time away from patients, travel expense, etc) must be set very low if we are going to include the full spectrum of primary care practices including solo and rural.  The Ideal Medical Practices project demonstrated one path with group learning and practice coaching by conference calls plus online resources, all tied together with a simple measurement strategy addressing the fundamental changes required.  Group learning can break out of major urban centers and meet practices closer to home.  Regional learning can be complemented with conference call and online support.
• Assistance must address the heterogeneous nature of practices.  Coaching support, peer mentoring, and improvement pathways can be nuanced to address developmental stage, baseline capacity and infrastructure, variation in population needs.  Using a measurement system based on the fundamental features of high performing primary care can identify practices in need of further assistance.
• Launch projects in supportive environments:  Teaching transformative change without aligned payment is a waste of everybody's time.  At best we can prepare participants for a future when payment will support the work, but the full work of effective primary care is ruinous in our current payment environment.  Payment aligned with the work is necessary but not sufficient: the financial incentives must flow all the way to the front lines of work. If the aligned payment dissapears into health system general funds and has no impact on staffing and support of the work in the primary care office it is a wasted effort.
• Improve the signal to noise ratio of the measurement paradigm: Flying in the face of numerous studies we have adopted a measurement system holding primary care practices accountable for outcomes for which they are sometimes only fractionally responsible.  The primary care team is not responsible for the agriculture bill supporting terrible food choices, nor is it responsible for the epidemic of obesity and our society's willingness to restrict access to health care services based on socioeconomic status.  We play a role but often not the dominant role in a diabetic person's A1c level.  Why should we beat up practices with bad quality scores when the reason the A1c is because patients can no longer afford to take their meds because they've lost their jobs?  We can and should measure practice behaviors that predict good outcome: access, relationship over time, comprehensive services, care coordination (all easily and inexpensively measured through patient experience of care).

Primary care practices want to change.  Our professional ethics are aligned with the work of effective primary care.  Change happens when the forces are aligned with the desired results.

Primary-Care and Specialists Get Their Wires Crossed - and what to do about it

What we’ve got here is a failure to communicate.

via blogs.wsj.com

"Don't you guys talk?"  Well, to be perfectly honest..... not so much, and it costs us all:

• Primary care practices spend a significant part of staff time on tracking down information from emergency departments, hospitals, and specialists, filling out forms that - if approved - would make it possible for the practice to then call to try and arrange a scan, a consultation, etc.
• Specialists are sent the wrong patient for the wrong reasons with the wrong work-up or have no information at all and a patient who has no idea why they are there.
• Patients of course suffer the most. 

A colleague of mine surveyed a high-functioning group of individuals (readers of a reputable online news service). Some of these people reported that they were receiving care from their PCP and a specialist. 

Asked "Do you know who is in charge?", 25% said "No."  Those 25% were twice as likely to report having been hospitalized within the past year.

This striking correlation has a number of possible explanations.  One possible explanation is that we in the health care system are operating in silos and are put the people we serve at risk when we fail to communicate well across those silos.  This explanation has some face validity since poor communication and lack of coordination is a near-universal experience.

What can we do about this?

1. Require seamless communication across health information technology platforms.  The rules we have in place are either inadequate or inadequately enforced.  Right now we have lip service commitment to cross-platform communication but systems almost never communicate well and the cost of bridging the gaps is completely out of reach of the average practice.
2. Require insurers to pay for care coordination by primary care.  The evidence supporting good care coordination abounds yet practices receive only lip service - requests to do more without the means to do the work.  Primary care is the weakest part of our health care system because we have systematically starved it beyond its ability to perform the basic functions of primary care.  "Help" that stipulates "do this extra work and we'll consider maybe paying you in the future if you get those pigs to fly" is a non-starter.
3. Make 'patient experience of care coordination' a core quality metric.  We over-emphasize relative trivia while mostly ignoring the core functions of primary care.  This distracts the national conversation, the work of practice transformation, and new payment models with lower impact work while fundamental benefits to the public are ignored. We don't have to give up measuring 'the percent of diabetics who have had monofilament foot exams', but we should focus first on a core set of primary care measures addressing the core features of primary care:  access, relationship over time, comprehensive services, and care coordination.

Transforming our health care system so that we may achieve better outcomes at lower per capita costs will take monumental effort.  That effort should focus first on the most important aspects of our current failures - the ones that have the greatest possible benefit for the widest number of people.

Supporting primary care transformation does just that - but only if the transformation addresses the fundamental attributes of primary care.

Building a high performing medical neighborhood - better care, better outcomes

Rich Keller from Treo Solutions has an interesting post.  He's talking to health plans about why it might be in their best interest to support high performing local medical neighborhoods. 

I've worked as a solo physician and in a big group.  No matter the setting, I always worked as part of a larger team - coordinating the care of those whose needs exceeded the comprehensive services our practice had to offer.  Our teamlet (RN and I) preferred to work with wider team members who: communicated clearly and in a timely manner, provided a clear and convincing rationale for doing procedures that might put our patients at risk, provided timely access.

The relationship we had with the wider team was fostered in part by our willingness to provide good information, do the right work-up in advance, and generally to refer the right type of cases. We did not have this type of relationship with all the specialists and other providers in our community; some we preferred to avoid, others were just less well known. This group of better-known specialists is the 'medical neighborhood.'  We built these relationships over time and solidified them through trust built on repeated good experience.

I can site for my patients published examples of the benefits to patients of good collaborative care between PCP and specialist, examples of benefits when there is good communication and choice of specialists who don't consider my patient referral as license to use every device and procedure likely to generate revenue.*

If I want to build an Accountable Care Organization to better care for a population of people, I would only consider doing so with my team, my neighborhood, the group with whom I have built trust over the years.  When patients ask to be referred outside my trusted group I am willing to do so, but I explain the risks and benefits of working with specialists I do not know: the care might be terrific or they might be exposed to unnecessary testing and procedures that put them at risk of unnecessary complications and harm.

*Zastrow RJ, Quadracci L.  Engaging Quad/Graphics Employees in the Improvement of Their Health and Healthcare Journal of Ambulatory Care Management, 2006 29(3), 227-231

Fuhrmans, V.  Radical Surgery -- One Cure for High Health Costs: In-House Clinics at Companies Wisconsin Firm Saves Money By Hiring Its Own Doctors
Patients Get More Time, The Wall Street Journal, Feb 11, 2005

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.

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

Building the foundation for great primary care is not rocket science

Primary care is the foundation of high performing health systems, and when more people have better access to good primary care, those people are more likely to achieve good health outcomes, less likely to end up in the hospital or emergency room, and health care costs are lower.  So it seems that policy makers are keen on the idea of supporting primary care.  Yay.

Good primary care has four cardinal features:  good access to care, a relationship over time, comprehensive services, and care coordination.  This makes primary care different from the rest of health care.  Doing a good job on these cardinal features results in the good outcomes listed above.  Doing poorly on these translates to worse outcomes and increased costs.

So how can we get some more of that good old primary care?

The solution is pretty simple.  If you ask Rob Reid MD who with colleagues published the paper on the Group Health Cooperative PCMH work @ their Factoria practice, you'll find out that some simple interventions lead to profound results:

• Reduce the panel size and stop fee-for-service productivity incentives to help the practice unit get off the hamster wheel
• Add some incremental staff to support the extra work of care coordination, outreach to patients, etc
• Provide a small amount of training on process improvement
• Let the professionalism of the staff drive the work

This work can be replicated in practices large and small across the U.S.  All it takes is a little bit of breathing room.  Group Health has breathing room because it has its own insurance product and can call its own shots.  GH is not beholden to hospitals looking to keep beds & emergency rooms filled.  Finally, they chose to support excellence in primary care.  The early results in publication look good.  I expect continued and improved excellence and outcomes.

The part I like best about the GH Factoria experiment is the degree to which they replicate the work of the Ideal Medical Practices project in which volunteer practices got off the hamster wheel by reducing their own overhead and panel size.  From a huge integrated system to solo independent practices.  There's a lesson here.

"Knowing all of your patients" = breakthrough for Geisinger says more @ the US baseline than improvement

"The patient-centered medical home allows you to do primary care the way you would want to do it," said Graf. "From our perspective, it is really the way we do business now. It is about knowing who all of the patients in your entire populations are, where they are, what is going on with them and then being proactive about managing them."

via article from www.aafp.org

Let me start by saying that I respect and admire Geisinger and their immense efforts to roll out quality throughout their entire organization, but I am dismayed.

I am dismayed not by what Geisinger is doing but why it is necessary to do this work and why it deserves mention not only by communication engines of the AAFP but the President of the United States.  What is so special about 'knowing who all of the patients in your entire population?"  This is supposed to be the case in every primary care practice and is in fact a fundamental attribute of primary care.

As I've written in the past, primary care is different from the rest of the health delivery system because:

• It is the first point of contact: yet the reality is that most Americans must wade through intolerable waits and delay due to practices policies regarding panel size and productivity, and to slog through barriers erected by public policy (our national shame of letting personal income dictate access to care).
• Has relationships over time: yet we fracture and dishonor relationship through our 'next available' scheduling protocols (another consequence of practice policies regarding panel size and productivity), and by growing practices beyond any human ability to "know all of my patients."
• We offer comprehensive services: yet our productivity/throughput standards make it nearly impossible to address the full scope of our patient's needs so we miss opportunities to address meaningful issues and/or push our patients off to specialists for care we might have delivered well if we had the time.
• We coordinate the care our patients need from the rest of the health system: but because this work generates no revenue it is pushed to the side.

Geisinger makes headlines by doing incredibly basic work but the root cause of the problems remain unaddressed.  The root cause is way we pay for health care.  We pay for piecework. 

The more 'visits' or 'encounters' we produce, the more money we get.  Because we work under strictly regulated price caps we respond (as any economist will predict) by increasing the number of visits.  Increasing regulatory and policy burdens (such as endless reporting of trivia to an increasing crowd of public and private agencies demanding data) add to our cost of business.  With fixed price caps we respond again (as any economist will predict) by increasing the number of visits.

Ron Paulus MD, EVP for clinical operations "pointed out that the PCMH has been in the medical literature since the 1960s, but the concept has not "really taken off" because insurers and other entities are reluctant to pay for it."

Why might insurers be reluctant to pay?

• The US spends more per person on health care than any other developed nation in the world and has worse population health results to show for it. Let us all agree that spending even more is dead on arrival until we have exhausted our efforts to spend it more wisely.
• Shifting funds to support excellent primary care comes at the expense of hospitals and high end specialty interventions.  Since hospital systems are fierce and powerful negotiators any significant shift to support primary care could launch an all out war.
• Insurers have deep investments in their own disease/case management (even though we have yet to see significant improvements despite years of these investments).  Shifting these dollars to effective primary care would call into question these fiercely defended programs.

Geisinger deserves headlines not so much for doing the incredibly mundane work of "knowing your patients" - this is one of the foundational attributes of primary care. Geisinger deserves headlines because it is WILLING to do this work when the net effect reduces income to their own hospital.

Hospital systems willing to look to the future and risk the life of their own cash cow are rare. I for one applaud and encourage their efforts.

I would like to point out that "knowing all of your patients" is a fundamental attribute of practices ascribing to the Ideal Medical Practices model.  By reducing their own overhead these practices have eliminated the waits and delays, gotten off the hamster wheel and spend more time working for their patients.  The work is deeply rewarding to their patients, deeply satisfying to the practice, but to once more quote Paulus:

"...the concept has not "really taken off" because insurers and other entities are reluctant to pay for it."

I'm waiting for the headline: "Insurer fully funds effective primary care and is able to reduce premiums by 25%"

Being valued for the work we do - a positive story from the front lines of primary care

I wanted to share this with fellow IMPs [Ideal Medical Practices] to thank you for making a different
 to people:



I went to visit a patient at a hospital I haven't been at since I stopped
 doing OB a year after my second daughter was born (so 11 or 12 years)....I
 didn't see anyone knew. I was lost looking for things in an unfamiliar
 chart and wandering around the huge remodel.

A cool thing happened though. 
The nurse taking care of my patient saw me coming down the hall with a 
stethoscope around my neck and yelled out, "You must be the doctor from
Irvine who does house calls; we so wanted to meet you."

I had faxed in the summary sheet from Amazing Charts as the patient was on 
his way.

My patient's wife said all the specialists, nurses and the social
worker were so impressed at how much information was and easy it was to 
read. It was nothing that we don't all do everyday, but I sometimes forget 
that much of the medical world is too rushed to do even things that seem pretty basic and straight-forward.



It was nice to be welcomed as an IMP (even though they don't know that 
term).



Sharon McCoy George MD


Renaissance Family Medicine

10 McClintock Court; Irvine, CA