Ideal Medical Practices

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.

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

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.

Does Good Primary Care Impact “Preventables”?

I had a chance to discuss the recent report from Dartmouth Institute for Health Policy and Clinical Practice: Regional and Racial Variation in Primary Care and the Quality of Care among Medicare Beneficiaries with Dr. Gordon Moore President, Ideal Medical Practices which is a nonprofit supporting those seeking to deliver ideal care. I thought his comments were quite insightful and worth sharing with this group. Read more: www.treoservices.net

Justice Dept. Sues Michigan Blue Cross Over Pricing Deals: not necessarily time to break out the party balloons

WASHINGTON (AP) — The Justice Department alleged Monday in a lawsuit that Michigan Blue Cross Blue Shield is discouraging competition by engaging in practices that raise hospital prices, conduct an assistant attorney general vowed to challenge anywhere else it is found in the United States.

via www.nytimes.com

Dispirited and exhausted physicians often assume that insurance companies are the source of all evil in health care.  While there are certainly examples of bad insurer behavior lending support to this assumption, reality is more complex.

I think it is fine and reasonable for the Department of Justice to check out 'most favored nation' clauses in contracts between insurers and hospitals - the idea certainly smells fishy and deserves investigation, but before practcies break out the party favors consider the forces at work in any given market.

The big actors on the health care delivery side are hospitals and hospital systems.  Doctor networks used to be the third big player but that force is significantly diminished as so many doctor practices are now owned by hospitals.

Like any human enterprise hospitals and hospital systems run the gamut from beneficent to malignant. Even well meaning hospitals struggle with the idea of supporting improved population health through more robust primary care - this concept is in direct oppostition to a business model that rewards hospitals every time someone gets really sick or hurt.

Imagine a hospital taking its slim profit margin and using it to fund the full scope of effective primary care. The resulting drop in emergency room utilization and hospitalization is a double-whammy to hospital finances, yet this is the core idea behind Accountable Care Organizations.

Some smart hospitals and systems see the writing on the wall.  Some will be early adopters and figure out that doing so will increase their primary care market share (doing well by doing good), others will fight it tooth and nail by metastasizing micro emergency rooms through communities and marketing 'centers of revenue excellence.'

Back to the DOJ move on Michigan BCBS.  If you hobble one side of negotiations in a market you hand the other side a huge advantage.  Given the nice work that Michigan BCBS has done to support effective primary care, it will be interested to see what hospitals do with their new leverage. 

How many will use this opportunity to pull back primary care resources that reduced unnecessary emergency room and hospital use and therefore hurt the hospital's bottom line?  This is where you might find some of the pull-back if a hospital or system chooses the low road:

• Increased volume-based productivity targets for primary care providers
• Reduced or eliminated population health functions
  • Health coaches providing outreach for patients who have gaps in health care
  • Staff to manage database used to help people keep on track with preventive needs and/or chronic conditions over time
  • Protected staff time used for quality improvement
  • Care coordination staff making sure patient care isn't dropped between the silos in which we work
• Stopping or pulling back on non-visit based care (email, phone, video, etc)

Of course even a beneficent hospital might be forced to engage in some of the behaviors listed above.  The sad thing is that payment policies dictate most of our behavior.  The current payment models reward volume not care or quality. BCBS of MI has been working to change that.  I hope with this change in the Michigan market that work can continue.

Putting the meaning back in 'meaningful use': lessons from the AAFP's National Demonstration Project

The evaluation of patient outcomes in the American Academy of Family Medicine's National Demonstration Project (a.k.a. 'TransforMED' project) is written up by Jaen et al in the Annals of Family Medicine supplement here.

This projected included a terrific evaluation team that really dug into a broad swath of data to understand the impact on patients.  They measured patient experience of care with the core attributes of primary care: access, relationship, care coordination & comprehensiveness of services, as well as a number of indicators of chronic disease management.

I want to point out a very common misconception in the office practice communities:  "Doing Open Access" is meaningless unless your patients report that their access has improved.  The industry standard of "number of days to third available appointment" with "future fill rates" are proxy measures.  They mean nothing if the patients in the practice report that their access has gotten no better.

After learning from the masters (Murray & Tantau) and implementing advanced access in my own practice, I have helped many achieve dramatic improvements in access and was one of the IHI faculty teaching this intervention to hundreds of practices from around the U.S.  There are a hundred ways to make the proxy data look good but accomplish nothing meaningful from a patient's perspective.

"We can see you today but you won't be able to see your regular PCP" is a fail because we trash one pillar of primary care to support another.

Making "Number of days to third available" go to zero by essentially cooking the schedule books is a fail.

Access success is not achieved when "sure we can see you today" is coupled with "But we run out of appointments by 11AM."

It is possible to truly improve access and to know with confidence that the improvement is real.  The way is to ask the patients in the practice to report on their experience with access.  Patients are the ultimate arbiter of access success/failure.  Populations of people who have good access are less likely to skip needed appointments, are more likely to follow up with their chronic condition follow-up appointments, are less likely to end up in the emergency room and are less likely to be hospitalized.

Patient experience of care with access is hard wired to meaningful outcomes as noted above.

Our industry has lost sight of the meaning of our work when we credit ourselves with success for things that have no meaningful impact on the lives and health of those we serve.

The AAFP's NDP/TransforMED project has demonstrated that their high cost/low relative value approach is not a path likely to lead our nation to the kind of robust primary care we need so that we can become a high performing health system.  At this point any large purchaser of health care or agency that funds improvement & innovation ought to be surveying the field for other paths, ones lined up with meaningful improvements in patient experience of care measures linked to important outcomes.

Small practices cannot let false assumptions drive quality measurement - we can 'do' quality and do it well

Although the federal government and other health care stakeholders have expressed interest in moving the nation's health care system toward a value-based system that relies on measuring the quality of health care delivered against the dollars spent to provide that care, new research suggests that this may not work well for primary care practices.

via www.aafp.org

If we accept the notion that the only way to measure quality is with biometrics (e.g. HbA1c) then we're stuck with a statistical problem: no PCP has enough data to be statistically meaningful.

If we accept that assumption then we go down the path of presuming to force solo and small practices to either wither & die or become part of big Virtually Integrated Health Systems.  I posted yesterday to give folks a heads-up on why such VIHSs may not be the right way to go given their very strong interest in continuing the status quo ("Don't slaughter my cash cow!").

If we accept that assumption then we can easily accept all the studies that link practice size to 'quality.' 

Those studies are a neat trick: 

"Hey, let's define 'quality' as something that only works in large organizations."

"Gee look Bob, it appears that only large organizations are able to measure and report on quality."

"Small practices must not care about quality.  They are bad people.  Let's force them to become large organizations or go out of business."

Health care measurement is stuck in a geo-centric paradigm. 

"The celestial bodies revolve around the earth.  Their movements are very strange, but once we accept that the earth is the center of the universe we can compound theories that explain these strange movements."

I for one am tired of torturing nature like that.  We know from the work of Dana Safran @ Tufts, John Wasson @ Dartmouth and others that we can use patient reported outcome measures to identify how well a practice and even an individual PCP performs.  With PROMs we have very large denominators and are not stuck trying to explain the bizarre motions of the celestial bodies.

I know the orthodoxy of quality measurement will send robed inquisitors, so if you don't hear from me for more than a week please send a rescue party.

Real patient-centered care: where more spending results in net savings

Four primary care sites in the United States constitute “medical home runs” because their patients incur 15–20 percent less (risk-adjusted) total health care spending per year than patients treated by regional peers, without evidence of reduced quality.  Milstein & Gilbertson Health Affairs article

An interesting article and worth reading.  Of particular note is what the practices do that results in the equal-or-better-outcomes and the lower-net-cost:

(1) an exceptional form of individualized caring tailored to preventing ED use and unplanned hospitalization for chronic illness
(2) efficient service provision
(3) careful selection of, and coordination with, medical specialists

Note the intersection between these observed qualities and the attributes of effective primary care:

1. "I can get care when and how I need it" - access
   
2. "I have a PCP/nurse who know me as a person" - relationship
   
3. "My PCP takes care of the bulk of my health care needs" - comprehensiveness
   
4. "My PCP coordinates any care I need in the health system" - care coordination
   

(adapted from Barbara Starfield's/IOM/WHO definition of primary care).

Milstein & Gilbertson call these "exceptional caring characteristics:"

1. we will take enough time during office visits to fully understand your illness and self-management capability and fine-tune your treatment plan
2. between office visits, we will directly provide or mobilize the help you need to succeed in implementing your self-management plan, with special emphasis on medication management
3. we will respond promptly 24/7 when you ask for urgent help between visits
4. we will link you with a small group of carefully selected specialists with whom we actively coordinate
5. we care personally about protecting you from health crises.

Also notable is the lack of correlation between Milstein & Gilbertson's qualities and the tens upon tens of arcane electronic minutia demanded by the NCQA for "medical home" recognition (180+ metrics).

The Ideal Medical Practices project demonstrated that even independent solo and small practices were willing and able to deliver truly patient-centered care if:

1. They were provided a teaching vehicle at reasonable opportunity cost (conference calls & webinar versus time away from patients and travel to meetings)
2. They had real time feedback on their own patient data
3. The results were actionable - they could understand them and do something to make them better
   

Is technology the answer (as implied by the 97% emphasis on technology in the current recognition system for medical homes)?

However, all four sites had achieved their distinguished results without the benefit of such IT. This suggests that recovering the first 15 percent of the 35 percent estimated waste in U.S. health care spending may not hinge on use of health IT or the larger organizational scale required for nuanced, IT-enabled continuous reengineering of clinical processes.

In their conclusions:

The signal to public policymakers is that to attain more health with less health care spending, health plan enrollment must be tilted toward those plans that vigorously reward PCPs and physician groups that excel in low total annual per capita health care spending and clinical outcomes.