Ideal Medical Practices

Breakthroughs in patient outcomes – helping people address lifestyle change and healthy behaviors

John emailed to say how happy he was for one of his patients with diabetes.

 

The anecdote:

 

“He rarely ever follows up with me and rarely ever gets his blood work done (I always have to beg his wife to get him in), and his last 4 HGBA1Cs were 14.9, 12.7, 10.6, and 12.0 (in Dec 2011). Yesterday, his HGBA1C was 7.5! He is walking 30 minutes a day and is writing down everything he eats. He is down 8 pounds from the beginning of the year and feels great.” - John

 

John’s setting:

 

John has a solo independent family medicine practice and uses an electronic health record.  John’s intervention was to hire a part-time nurse wellness coordinator and house her in his office.  This RN enjoys the interaction with patients and the ability to use a greater range of nursing skills and training than is typical in most practices.  The intervention starts with four one-hour long sessions, either one-on-one or with family, and then graduates to follow up phone calls.

 

John’s revenue comes exclusively from insurance payments (no membership or extra fees charged to his patients).  He pays the RN for 16 hours per week of work, yet his practice receives no extra payments, bonus, or incentive dollars for the wellness coordination work or the improved outcomes. John worries that charging patients for this additional support will discourage participation by those who most need the help, so he is reluctant to charge a fee for these services.

 

The evidence base for the intervention:

 

• Changing health behavior has the greatest potential…for reducing morbidity and mortality and for improving quality of life across diverse populations…50% of mortality is from 10 leading causes of death linked to lifestyle changes such as tobacco use, poor diet, inactivity, alcohol and drug use, and sexual behavior[i]
• Randomized trials of simple coaching demonstrate lasting impact on patient outcomes.[ii]
• This coaching can be replicated and used by primary care practices to help patients improve outcomes.[iii]

 

Comments:

 

This collaborative physician/nurse coaching model is likely to help other patients in the practice.  Efforts like this tend to improve overall clinical outcomes, the experience of care, and the total cost of care.

 

High performing health systems are founded on good primary care.  Good primary care leads to better outcomes and lower total costs of care.  Good primary care includes much work that is not part of the current funding stream.  This lack of adequate primary care funding hamstrings effective primary care and is one of the root causes of the cost/quality we face today.

 

One solution may be the aggregation of small practices into larger health systems.  This solution is receiving almost all the attention of those interested in improving health care, but some evidence points out that this aggregation adds to the overall costs of health care without necessarily improving outcomes.[iv]

 

Would it not be interesting to support networks of primary care practices like John’s to:

• Reduce the threshold of adoption of techniques that improve outcomes
• Achieve economies of scale in population health management across solo and small practices
• Provide a sufficient attributed patient population for accurate tracking of outcomes (real outcomes like hospitalization rates, ER visit rates, not a bevvy of bioclinical intermediate measures that often have little to do with what really matters[v])

 

Health plans should by all rights be very interested in this approach but seem to spend all their time negotiating with hospital-centric ACO types that must by their nature struggle with goring their cash cow to achieve “shared savings.”  A primary care virtual ACO has no such conflict of interest.

 

I’m not suggesting anyone drop the hospital-centric ACO work, but where is the action on the primary care virtual network model?

---

[i] Evelyn P Whitlock et al., “Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-based Approach,” American Journal of Preventive Medicine 22, no. 4 (May 2002): 267–284.

[ii] Tim A Ahles et al., “A Controlled Trial of Methods for Managing Pain in Primary Care Patients with or Without Co-occurring Psychosocial Problems,” Annals of Family Medicine 4, no. 4 (August 2006): 341–350.

[iii] John H Wasson et al., “Clinical Microsystems, Part 2. Learning from Micro Practices About Providing Patients the Care They Want and Need,” Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources 34, no. 8 (August 2008): 445–452.

[iv] Gardiner Harris, “More Doctors Taking Salaried Jobs - NYTimes.com”, n.d., http://www.nytimes.com/2010/03/26/health/policy/26docs.html?pagewanted=all.

[v] David B. Reuben and Mary E. Tinetti, “Goal-Oriented Patient Care — An Alternative Health Outcomes Paradigm,” New England Journal of Medicine 366, no. 9 (March 2012): 777–779.

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

Some States Find Burdens in Health Law: some practices are ready to help

“The federal government has to account for states’ inability to sustain our current programs, much less expand,” said Kim Belshé, secretary of California’s Health and Human Services Agency.

via www.nytimes.com

I'm privileged to know PCPs from all over the country who are ready to give their all to their patients.

Their individual efforts to eliminate the barriers to access, to engage in highly personal individually attuned care that their patients need results in dramatic cost savings (see the example of Dr. M in Maine for instance - these are MaineCare (Medicaid) recipients).

These are the savings States and patients crave: savings from doing the right thing and delivering great care and improving the experience of care.

All the States have to do is to fully fund the work of effective primary care - shift ~ 5% of the health care cost wedge over to primary care and the total costs drop by 20-30% according to studies done in commercially insured populations. The potential savings in covering disadvantaged populations is larger given their propensity to use the emergency department when primary care access is poor (just ask Massachusetts).

So, States - you ready to work with practices to get the results you and your taxpayers want? Step up to the plate. You have to do two things:

1. Fund the full scope of work of effective primary care.  Small independent practices have demonstrated ability to do this work.  Large institutional players might one day be able to perform at this level but tend to make very gradual/incremental change.
2. Stop or drastically reduce the amount of administrative trivia that adds so much cost to practices and diverts staff time from needed patient care.

Don't pretend you're doing this just 'cause you have some Patient-Centered Medical Home project going - most don't come anywhere near to clearing the two aforementioned hurdles and most just tweak the status quo.

So, States:  we know how to be accountable for high performing primary care.  We have demonstrated this work in pilot studies.  It gets better results and lowers cost beyond the limp and timid PCMH projects.  We're ready to get to work.  Are you?

Scary survey results: 64% of MDs base decisions on payer rules instead of what patients need

From Athena Health's Physician Sentiment Survey

Let me state right from the start that I understand why these docs responded this way.  Every day we are hounded by insurance rules and policies that attempt to shape what we do.  In theory this seems like a good idea and many of the policies are easily defensible on paper.  The problem is that in aggregate this approach to managing health care costs has created an impossible situation. 

We are spending hours and hours responding to insurance clerks and less and less time focusing on what our patients need - we just don't have the hours in the day necessary to do all of our work well.

The overwhelming bulk of this work falls to primary care - the most under-resourced part of health care.  Think about the global stupidity of this approach:

• If primary care works well it results in overall better health outcomes and reduces the cost of health care.
• Primary care works less well when it receives only about half the resources it needs to do the work.
• Primary care works less well when in addition to the inadequate funding it is the dumping ground for the overwhelming majority of prior authorizations, formulary adjustments, discussions with Pharmacy Benefit Companies, discussions with disease management companies, and all the other interventions brought to bear by payers in a desperate attempt to control costs.

These policies emasculates primary care leading to:

• The primary care shortage because it is an unattractive career choice
• Increase primary care office overhead as we hire more and more staff to play the game of 'mother-may-I' with insurance clerks
• Increased hamster-wheel care as we pay for the overhead
• More practices going under or selling out to become part of the institutional care machines

The sum total of these things gives us exactly the situation we have today:

• The woefully inadequate population health outcomes we see in the US
• The extremely high per capital health costs we suffer in the US
• The near universal experience of patient experiencing waits and delays, impersonal and rushed care in ever more institutional settings

Is it any wonder that we're seeing a rising tide of PCPs choosing to work for their patients and no longer follow insurance company rules that force them into professional, personal and ethical penury?

Here's one doc of many describing his motivation to stop working for the insurance industry and start working for his patients.

More middle-income Texans go without health insurance | News for Dallas, Texas | Dallas Morning News | Latest News

Nationwide, the total number of uninsured middle-income people increased more than 2 million since 2000, to 12.9 million in 2008.

via www.dallasnews.com

One of the interesting moves on the health delivery system side are practices creating transparency around their pricing, differentiating themselves on services, communication & price.

Take a look at Bruce Feldman MD in NYC, Megan Lewis MD in Durango CO,  CarePractice in San Francisco,  all transparent in pricing.

More and more practices are putting their financial houses in order through the low overhead models of the Ideal Medical Practices group and are thus able to offer a compelling patient experience and transparent pricing.  Compare this to your typical practice with not so compelling patient experience and pricing obscurity to beat the band.

Leaving aside for the moment the fact that we can leave tens of millions of our fellow citizens without health insurance while spending twice more per person than the average developed countries of the world...  We at least see some practices stepping up and trying to help.

One reason business runs into a brick wall when trying to change the health care game

I've been in it so long I forget how difficult it is for people outside the industry to understand the financial drivers in health care.

Let's take the case of Brave Employer.  Tired of costs that keep going up in spite of Health Plan promises regarding medical management, Brave Employer's trust of Health Plan pitches has waned.

Brave Employer has learned from his buddy Paul Grundy MD at IBM that primary care if done well will reduce hospitalization rates, reduce emergency room use, and all while improving outcomes and making patients happier.

Brave Employer thinks "Where can I get me some of that good primary care?  Oh, I bet Vertically Integrated Hospital System has some!  I get the idea of vertical integration and in business it's a good thing (so it must be good in health care too!)."

Brave Employer reaches out to Vertically Integrated Hospital System (VIHS) with its primary care practices, specialists, outpatient departments and hospital beds, XRay machines, MRI machines, etc. 

VIHS is totally jazzed and takes the deal.  Their margin goes up a bit but after a few years there's no real bend in the cost or quality curves and everything is still pretty much the same.

What gives?

You need to understand that and health savings have to come out of the health delivery system.  The good news is that we in the U.S. are incredibly bloated with unnecessary testing, preventable hospitalization, avoidable emergency room utilization.  When we do a good job at primary care we end up with fewer people in the hospitals, fewer emergency room visits etc.  People are healthier, people are happier with their experience in health care, and costs are much lower.

But wait! VIHS has empty hospital beds!  Each unnecessary hospitalization lost the hospital tens of thousands of dollars!

Oh no!  VIHS CFO is pulling his hair out!  Every person who had easy access to their PCP instead of going to emergency cost the hospital a $4000-$9000 claim!

Fewer unnecessary MRIs?  Avoiding unnecessary CT scans?  No way!!!  VIHS makes great margin on those things, to say nothing of their Centers of (revenue) Excellence.

VIHS wins if the status quo is maintained.  VIHS loses if primary care does a really good job. 

In the 1990s VIHS saw the other hospital systems buying up primary care practices and got into the game too: "We need them as a funnel - gotta keep our beds and operating rooms full.  So what if we lose money on primary care - we make it up 8:1 in the hospital and on ancillaries!"

Just about the only beef I have with Elliot Fisher from Dartmouth (brilliant guy and love his work - he, Jack Wennberg and team have published scads documenting what I'm describing here) is that he says 'accountable care organizations' should be formed around HOSPITALS!    AAAAH!  They're the ones who are most likely to try & shut down any attempt to beef up primary care!

So what is Brave Employer to do?

1:  Stop expecting hospital systems to gore their own ox. 

2:  Work with independent primary care practices & practice networks that are not tied to a system that has no interest in changing the game.

The game is afoot.  There have been nice pilot projects demonstrating how practices can delivery great primary care.  Now we see early forays into developing clinically integrated primary care networks that can be real game-changes: high quality, better outcomes, costs go down.  No mixed incentives.

Colleagues: you can come together legally if you are 'clinically integrated.'  This is not so hard.  We did that as part of our IMP project - using Wasson's HowsYourHealth.org tool we had a common data set, we learned on conference calls how to improve outcomes and even though it was a grant funded study we were clinically integrated.  It's not as hard as some make it sound.  You can do this.

Let the renaissance of primary care begin

I'm hoping I'll be able to fall asleep tonight.  I just came from a meeting with colleagues in NYC.  I met with Moitri, Soma, Sofia, Bruce, Matt, Sean, Michele, Carrie.

These independent primary care practices want to come together to delivery and demonstrate exemplary primary care.  We know we can do it.  We talked about how we can use a common data platform to measure the quality of care we deliver based not on the "chase a thousand points of detail" but rather on key indicators of how our practices perform as systems of care for our patients.

We have confidence (based on previously published data as well as personal experience doing this work) that we will be able to demonstrate care delivery that anticipates vastly superior outcomes (avoiding unnecessary hospital admission or emergency room use, helping people improve their lifestyle, work on wellness as well as chronic disease management).

We know that there are self funded employers desperate to offer a better health care experience to their employees and yearning for better outcomes that reduce their costs, and we know how to talk with them.

I'm done playing mother-may-I medicine. 
I'm done begging clerks to approve needed treatments for patients.

I'm done playing quality Twister trying to prove my worth against a silly quality paradigm that is so blatantly biased to reward big institutional practices and punish small ones.
I'm done begging for pennies on the dollars I need to fund the full scope of my work.

I'm totally jazzed that this group of solo and small practices is willing to come together around doing the right thing for their patients, willing to hold themselves to the highest standards of care, to measure and report and if need be to work hard to improve.

I'll blog more as we get this thing going.