Strengthening Primary Care With A New Professional Congress

Strengthening Primary Care With A New Professional Congress

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Three months ago a post argued that America’s primary care associations, societies and membership groups have splintered into narrowly-focused specialties. Individually and together, they have proved unable to resist decades of assault on primary care by other health care interests. The article concluded that primary care needs a new, more inclusive organization focused on accumulating and leveraging the power required to influence policy in favor of primary care.

The intention was to strengthen rather than displace the 6 different societies – The American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), the Society for General Internal Medicine (SGIM), the American Academy of Pediatrics (AAP), the American Osteopathic Association (AOA), the American Geriatrics Society (AGS) – that currently divide primary care’s physician membership and dilute its influence. Instead, a new organization would convene and galvanize primary care physicians in ways that enhance their power. It would also reach out and embrace other primary care groups – e.g., mid-level clinicians and primary care practice organizations – adding heft and resources, and reflecting the fact that primary care is increasingly a team-based endeavor.

We came to believe that a single organization would not be serviceable. Feedback on the article suggested that several entities were necessary to achieve a workable design.

So we propose here a new set of allied entities that, by convening clinical and non-clinical primary care stakeholders, will work to re-empower primary care’s role within the larger health care enterprise. In addition to aggregating and leveraging the strengths of existing primary care organizations, this new effort would collaborate with patients and health care purchasers to gather the influence required to effect positive change.

New Organizations

We envision four new organizations – an umbrella group and three professional entities – each independent and with its own governance structure. Membership in any organization would provide membership in the umbrella Congress. The names we have applied are suggestions only.

The Congress of Primary Care Professionals. This umbrella entity would bring all groups, including existing societies, together in a representative structure. The Congress would seek to galvanize and mobilize the power required to revitalize primary care, not only for primary care’s benefit but as a key remedy for America’s health care cost crisis. The effort must be about primary care, not a specific group within it.

The Section on Primary Care Physicians. Currently there is no physician organization that unites all primary care disciplines. Many physicians are adamant that they should have their own entity, and have expressed concern that physicians’ roles might be devalued inside a structure shared with mid-level practitioners.

The Section on Allied Primary Care Professionals. The accumulation of power requires inclusiveness. It makes sense to establish a separate section embracing nurse practitioners, registered nurses, respiratory therapists, radiation technologists, physical therapists and others participating in primary care.

The Section on Primary Care Organizations. A new society structure could mobilize influence by rolling up and leveraging the power of larger primary care practices. As one physician practice leader noted, “Market traction will come from organizations that facilitate more efficient and effective primary care.”

Where to Begin?

An undertaking like this begs several questions.

Will primary care physicians, other clinicians and organizations participate? We believe that primary care can be reinvigorated, but any campaign must first convince primary’s practitioners that a new effort is worthwhile.

Who can jumpstart this? Established primary care practices – particularly those that are sizable – have some resources and offer opportunities for collaboration and the development of a larger national campaign.

What’s in it for me? Why should I bother? Primary care practitioners have been diminished under old regimes that divide primary care by sub-specialty. Their other positive attributes notwithstanding, the standing societies have been unable to drive payment policy that meaningfully appreciates primary care’s measurable value. In turn, this failure has resulted in the diminishment of primary care’s current status and future prospects. A new effort would be dedicated to restoring an appreciation of primary care’s value in policy and the marketplace.

What will this Congress do (and not do)? We should emphasize that this effort does NOT aspire to assume most roles of existing societies (e.g., standards, continuing medical education). Instead, it will create structures that can more fully and fairly represent primary care’s interests. If the new primary care organizations focus on gathering strength that can create influence, then they must do several things.

– They must actively recruit members.

– They must develop approaches for easy, rapid communication with members (e.g., email bulletins, Webinars, semi-annual meetings). Taking advantage of more modern approaches like social media could streamline operations and costs as well as differentiate the new entity.

– They must analyze policy related to primary care.

– They must develop pragmatic alliances on policy advocacy with non-health care business.

– And they must drive advocacy that speaks for all primary care, and only for primary care.

Don’t existing primary care societies already do these things? Current primary care societies may respond that they already are engaged in these approaches. That said, despite their efforts, primary care as a whole is in desperate straits, and likely to remain so. Several societies maintain they can advocate for both primary care and sub-specialty interests. Comparatively low payment and stature has driven medical students away from this discipline. Most societies continue to participate in the AMA’s Relative Value Scale Update Committee (RUC), though its opaque and biased power structure has consistently undervalued primary care services. We believe a fresh approach is necessary.

Can primary care change health care? Not by itself. But primary care is the natural ally of health care purchasers, the one group with more size and influence than the rest of health care combined. Creating a unified primary care front is the first step in building an alliance that can reshape health care to be more reflective of broad primary care values and in the public interest.

Brian Klepper, PhD is an independent health care analyst and Chief Development Officer for WeCare TLC Onsite Clinics. His website, Replace the RUC, provides extensive background on the role that the AMA’s RVS Update Committee has had on America’s health care cost crisis.

This framework was developed with the participation and support of the following advisors:

William Bestermann, MD is an Internal Medicine Physician and Medical Director of Chronic Condition Management at the Holston Medical Group in Kingsport, TN.  Tom Emerick is a health care advisor to business, and the former VP of Global Benefits for Walmart.  Paul Fischer, MD is a Family Physician and Founder of the Center for Primary Care in Augusta, GA. He is the lead plaintiff in a lawsuit against HHS and CMS over their unaccountable relationship with the AMA’s RUC, in violation of the Federal Advisory Committee Act.  Tad Fisher is the former Executive Director of the Florida Academy of Family Physicians. He is now Executive Director of the Florida Physician Therapy Association.  Richard Glock, MD is a primary care internist and lead physician in the Internal Medical Group in Jacksonville, FL.  Paul Grundy, MD, MPH, FACOEM, FACPM is IBM’s Global Director of Healthcare Transformation and President of the Patient-Centered Primary Care Collaborative (PCPCC).  Jerry Miller, MD is a Family Physician and Founder of the Holston Medical Group in Kingsport, TN.  Patricia Salber MD, MBA is CEO of Health Tech Hatch. A former Internal Medicine physician at Kaiser Permanente, she later served as Medical Director for several large health plans.  Richard Young, MD is Associate Director of the Family Medicine Residency Program at John Peter Smith Health System. He has authored a book and blog, American Healthscare, and is in the initial class of CMS Innovation Advisors.

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48 Comments on "Strengthening Primary Care With A New Professional Congress"


Guest
Oct 4, 2012

pcb,

As I mentioned, our FT docs and NPs have caseloads of about 1,600, which affords a 20 minute standard office visit. We’re a lot less concerned about “productivity” and more concerned that our patients get good quality care in the clinic and downstream, throughout the continuum. Our employer clients know going in exactly what the investment in the clinicians is going to take, and they understand that they’re investing in the clinic to get the money back at a high multiple on reductions in health plan excesses.

All clinicians have every chart reviewed during their first 3 months of work with us, and then periodically after that. We have a team that does that across our clinics.

Guest
pcb
Oct 4, 2012

“Mid-levels have significant autonomy as pcb described, but all patients charts are reviewed with the team. Mid-levels who suspect that a patient has complex issues calls in the doc.”

Reviewing patient charts, especially “all patients” takes a lot of time, at least if it’s more than a worthless cursory review. Reviewed once a year? Reviewed for every visit or phone call or decision? Who decides what’s worthy of reviewing if it’s not everything?

Additionally, “Suspecting complex issues” is the difficult job we’re talking about. If you’re calling in the doc everytime something might be complex, what’s the benefit of the midlevel?

Brian, as you know, everyone’s busy, and the midlevels end up making a lot of autonomous decisions. If the MDs were really supervising thoroughly, they woudn’t be making enough money themselves , and the financial benefits of the arrangement dissolve. The dirty little secret those on the front lines know is the money doesn’t work if the doc has to back off on his/her productivity significantly to supervise/collaborate.

Guest
Oct 4, 2012

Margalit:

Total patient load of 1 MD/DO + 2 NPs is around 4,800.

I’d have to double check to make sure, but its probably a difference of $160K-$200K per year.

Guest

So that’s about $50 per patient per year, or less than $5 per month. I am just theoretically wondering if patients, or even employers, wouldn’t be willing to pay that for the assurance of having a “personal physician” as the PCMH principles originally intended…

Just thinking out loud here, Brian. May be a differentiator for a bunch of entrepreneurial docs getting together and offering a service like this… I can think of some really nice marketing messages… :-)

Guest

Brian,
I have a couple of questions. I’m not sure if you calculated the exact numbers, but a ballpark will do.
How many patients are one doc and two NPs carrying altogether?
How much are we saving, in dollars per visit or PMPY or PMPM, by having one doc and two NPs instead of 3 docs?

Guest
Oct 4, 2012

Southern Doc:

Well I’m certainly with you on that point! See my cover article in last month’s Medical Home News here (http://brianklepper.info/2012/09/11/demanding-more-from-medical-homes/).

My argument here is that, despite all efforts to stop it, a health care market is emerging. Value – measurably driving down cost while improving quality – will take precedence, particularly among employers and, even possibly, health plans, and so the ability to perform will become much more prized than it has been.

Or at least that’s my story and I’m sticking to it.

Guest
Oct 4, 2012

This strikes me as a bogeyman discussion.

First, in a proper medical home – not the pretenders that have bought NCQA level 3 credentiallng but don’t do anything differently – a lot of patient data – med/surg claims, Rx claims, DM/UM data, HRA and biometric data – is constantly tracked and analyzed so we already have a good idea of which patients have risk when they walk in the first time. Those indications are validated or refined as patients are seen by the staff. Traditional practices typically don’t have anything comparable.

All our practices are led by physicians, meaning that we begin with a doc, then add up to two NPs before adding another doc. Mid-levels have significant autonomy as pcb described, but all patients charts are reviewed with the team. Mid-levels who suspect that a patient has complex issues calls in the doc.

It is not a perfect system. It appears to be far better, though, than what we can see in conventional primary care practices. The docs who come to work with us strongly agree.

Guest
southern doc
Oct 4, 2012

But it’s not a bogeyman.

The only medical home that the AAFP acknowledges is the NCQA PCMH, and they are trying to make sure that that’s the only one insurers will pay for. Read the articles on the Transformed site: it’s very openly about complex patients turn right and see a doctor, simple patients turn left and see some member of the team, continuity of care be damned.

But now that the members of the PCPCC have realized that the NCQA PCMH is just a glorified triage station and CAN be run by an NP or PA, the AAFP has really got its panties in a wad, as we recently saw.

Why does it make me think of Frankenstein’s monster?

Guest
pcb
Oct 4, 2012

Re: mid-levels.

I see a disconnect between their role in theory vs. what ofthen happens in the real world.

“Supervision” or “collaboration” is often minimal, if at all. The supervision/collaborating physician is seeing their own full load of patients, if even on site. Literally hundreds of day to day treatment and diagnosis decisons are made without any supervision or collaboration, and the decision when something needs to be discussed is entirely up to the mid-level. This is why many NPs and PAs are advocates for independent practices that wouldn’t require any supervision. They’re pretty much practicing independently already.

One of the hardest skills (arguably the most important skill) in primary care is recognizing when something isn’t routine or treatable with an algorithm, i.e. looking for the needle in the haystack of common, self limited conditions. If MDs aren’t doing the hands-on front-line care, then we’re leaving the needle finding to those who aren’t trained to do it as well.
Additionally, developing long lasting relationships with patients, interacting with them in person, following them over time, and establishing a therapeutic relationship is one of the biggest reasons MDs choose primary care in the first place. Most don’t want to track population data and provide managerial oversight to NPs and PAs.

Guest

Brian,
It’s difficult to make politically correct statements when it comes to the non-physician scope of practice conundrum. I believe these folks are a vital part of health care delivery, as they always have been and most likely always will be.

However, I also find the statements that doctors should be there to only deal with complex situations a bit disconcerting, because in addition to extensive education, expertise is built by day-in and day-out practice (this is true for everything, not just medicine). One is properly equipped to become an expert upon completing various graduate programs, but the road to expertise is just beginning at that point.
If we don’t allow doctors to actively practice, and instead place them in overseer of analytics positions, much of that education will be squandered and I don’t know where the expertise to step in at the right time will come from.

BTW, a similar thing occurred with software engineering, which based on Mr. Friedman’s misguided book(s), and capital’s interests to cut costs, allowed “drudge” work to be outsourced in the hopes that US engineers will become the architects and master designers overseeing armies of cheap programming labor. It didn’t work out quite that way.

Americans see doctors less than people in most developed countries, and the numbers keep dropping. I don’t know what the deal is with the obsession of replacing doctors with either mid-level providers or machines or phones. There is not much money for the public to save with these tactics and there is plenty for us to lose, and frankly, I don’t think the need for entrepreneurs or corporations to make money by replacing doctors constitutes an overriding public interest.
As I said above, there is really full alignment of interests between physicians and people/patients, we just need to quit worrying about other “stakeholders” who are in this solely for the cash.

Guest
southern doc
Oct 4, 2012

“If we don’t allow doctors to actively practice, and instead place them in overseer of analytics positions, much of that education will be squandered”

That’s exactly what the PCMH gurus are proposing. But who would go through the rigors of med school and residency to do that kind of work?

They tell us that the NPs/PAs should see the “simple” patients and the docs the “complex” ones. What they don’t tell us is who assigns the patients to those categories: is it the high school grad receptionist? the patient themselves? Are simple patients ever allowed to become complex, or are they stuck with that label until death do us part? One thing I’ve learned in my career is that I never know if a visit will be simple or complex until I’m alone with the patient behind a closed door.

It’s another one of those gimmicky ideas that sounds good until you actually start to think about what it means. The real reason they’re pushing it is that the finances of the PCMH are so bad that the doc has to have a team of mid-levels to even have a chance of breaking even.

Guest
pcb
Oct 4, 2012

“They tell us that the NPs/PAs should see the “simple” patients and the docs the “complex” ones. What they don’t tell us is who assigns the patients to those categories: is it the high school grad receptionist? the patient themselves? Are simple patients ever allowed to become complex, or are they stuck with that label until death do us part? One thing I’ve learned in my career is that I never know if a visit will be simple or complex until I’m alone with the patient behind a closed door.”

This is worth repeating because it’s rarely articulated this clearly.

Guest
Oct 4, 2012

One more thought. My previous comment is NOT meant to demean the care that NPs and PAs deliver. Mid-levels play an increasingly important role in a primary care system gutted by the politics of money and influence. But it is critical that we avoid the last logical step of suggesting that they are “just as good as but cheaper than docs.” They aren’t.

Guest
Oct 4, 2012

Margalit,

A quick note. The fact that PAs and NPs are less expensive than physicians and that certain organizations – including FQHCs, convenience care clinics and many worksite clinic vendors – use them to advantage does not mean that, as I noted earlier, they can spot or manage complexity when it presents. This is a market-based choice, of course, but one that clearly has quality ramifications that are, to my mind, corrosive, filled with moral hazard and inexcusable. It is bad medicine, not necessarily when the mid-levels are doing routine care, but when they miss a sign or symptom that is suggestive of something more serious, which is inevitable.

I should acknowledge that this same thing also happens with physicians, but their significantly more in-depth training is a buffer against poor decisions, and presumably improves the odds of a better outcome. That’s why we have doctors in the first place.

Guest
Gerard
Oct 5, 2012

“It is bad medicine, not necessarily when the mid-levels are doing routine care, but when they miss a sign or symptom that is suggestive of something more serious, which is inevitable.”

If there was so much bad medicine being practiced by midlevels, don’t you think the trial lawyers figured that out by now? Patients can pretty reliably be stratified by complexity and severity and referred to the appropriate clinician. If you think this can’t be done by well trained and experienced midlevels then you have missed the boat. That issue has already been settled.

Guest
Oct 3, 2012

pcb,

I most assuredly do NOT think that physicians and nurse practitioners are interchangeable. There’s a wealth of literature suggesting that NPs can often provide routine care as, or even sometimes more, effectively than MDs, but by definition they typically cannot identify or manage complexity nearly as well. To be crass about it, those cases are where the money is. To me, any other strategy is penny wise but dollar foolish.

Please note that I wrote a strong response to the AAFP’s most recent exercise in poor judgment – http://thehealthcareblog.com/blog/2012/09/20/the-business-case-for-nurse-practitioners/ – when they recently went out of their way to point out that NPs shouldn’t lead practices, as though anyone needed to say so. (To my mind, family medicine doesn’t have so many allies that it should take liberties poke one of them in the eye.)

So no. I don’t think the handwriting is on the wall. I do believe that competent NPs can do a lot of primary care work, but they are not physicians and will never be.

Margalit, I’m not saying that physicians need to be kept down, and I’m completely comfortable offering incentives for hitting quality targets. That said, I don’t think any of us benefit from the continuation of a cottage industry where everyone makes up their own rules as they go along. I’m a believer in science, evidence and performance. That applies where my loved one’s are concerned, and to everyone else as well.

To your point about mass produced vs. handmade, medicine is, alas, still a handmade science and art, even at the level of care that my Elaine is getting, with the best genomic science currently available.

Until we can break through that bar, I’d suggest that we need to trust professionals who can think through problems at the molecular level. We need to change the system to give them an advantage, and the smart money is on the long term play toward appropriateness, and away from excess.

Guest

Brian,
Since this post started with advocacy for primary care, and evolved into a debate on fee-for-service, I think there is a fine point here that southern doc was trying to make which often gets lost in the shuffle:

Primary care physicians derive negligible financial benefits from “more” services, except “more” primary care E&M services, which are both relatively inexpensive and, as I’m sure you’d agree, serve as a deterrent to other more expensive services.

In the case of primary care, more and more thorough, is actually better, so why do we need to put these guys on a salary?
From all the experiments out there, it seems to me that docs with significantly smaller panels, are able to provide much better and more efficient care.
Any way you slice and dice this, and assuming that the take-home pay is not widely variable, it translates into paying more for each visit. If you are concerned that physicians will churn through 5 minutes visits even if you paid double (and I don’t think this will happen), then by all means, have CMS and all other insurers, set the fees by time spent instead of by documentation generated.

As to infrastructure and analytics and risk management, you need those things if you deal with populations. If you deal with a few hundred patients, as most concierge docs do (and as all docs should do if they were paid appropriately), the need for fancy tools is less obvious, since you go to the hospital when the patient goes and you actually talk to the specialists and patients themselves as needed.

I guess it’s the difference between hand-made and mass produced. I think in health care most folks are more comfortable with hand-made at this point. And to just close the loop on the primary care advocacy piece, I think most docs don’t believe that what they offer can be, or should be, mass produced at the current state of scientific development.

Guest
pcb
Oct 3, 2012

Brian,

You mention MDs and NPs working as your “clinicians” in your model. Do they do different things? Are they, for the most part, interchangeable for you? Do they each manage their own 1600 patient loads?

If so, I’m wondering what you think the role of the MD will be over time.

Because if NPs/PAs are doing most of the same work as the MDs, and easier to churn out and cheaper to employ, then we can all read the writing on the wall. If this is the case, I’m not sure about the long term MD role in this “primary care congressional congress”.

Guest
Gerard
Oct 3, 2012

pcb,

Please see my above comment about midlevels. PA’s and NP’s are not the same.

PA’s are a creation of the AMA and they are lisenced only to practice medicine under the supervision of an MD or DO. They are trained solely to be extenders, as such, they are not in direct competition with doctors. In fact, they help increase doctors efficiency and profitability by handling the more routine aspects of patient care. NP’s can practice independently, bill independently, and soon all their programs are transitioning to doctorate degrees.

Guest
Oct 3, 2012

Gerard, I do not agree with your interpretation of PA services. The scope of practice of NPs and PAs, their ability to work independently and bill are equivalent in most states. CMS narrowly differentiates that PAs must be under “the general supervision” (though not necessarily on site) of a physician, while a NP must work “in collaboration” with a physician.

Guest
Gerard
Oct 5, 2012

I suppose it varies by state. I’m in a very PA friendly state and I don’t usually work with NP’s so I wasn’t very familiar with their scope of practice.

I found a good breakdown of the laws:

Chart of PA regulations by state: http://bit.ly/QLhfRY

Chart of NP regulations by state: http://bit.ly/Ww3EyQ

Guest

Actually PAs can and do lead FQHCs and RHCs on their own.

Guest
Gerard
Oct 5, 2012

True, PA’s can own or become partners of a practice in some states, but the laws are such that MD’s & DO’s have the final word on any and all medical decisions. PA practice laws must be upheld, of course, and these do vary by state.

You can read about PA owned practices here:

http://bit.ly/T63Kcd

Guest
southern doc
Oct 3, 2012

Thanks for the reply. Enjoyed the discussion.

Guest
Oct 3, 2012

Southern Doc,

I’m not saying that at all. I’m all for docs being entrepreneurial, but I’m not for anyone, including me, doing so in a way that unnecessarily drives up cost without significantly improving quality. If you’ll look at our business, which as I mentioned is completely outside FFS, you’ll see that I practice what I preach.

Being successful in this next generation of health care requires significant investments in analytics, clinical decision support, wellness/prevention/disease management programming, and a host of other business and clinical tools. So far, I’ve seen few organizations that are willing to put all that together.

I disagree with Margalit that our agenda is to do anything else but provide the highest quality care while reducing overall cost. Our business model is predicated on the fact that health care utilization and unit pricing has become egregious, and that excess constitutes a market vacuum that is an opportunity for exploitation. We will win through economies of scale, not by being excessive.

That said, Margalit’s comment is a precise description of the prevailing paradigm throughout health care, in every sector.

The day I met the couple that would become my partners, we were walking down the sidewalk to get a sandwich. Lynn, the husband, turned to me and said, “When an employer sits at the table with all his health care relationships – the broker, health plan, hospital, doctor, drug and device firm – everyone int the room wants it to cost more and they’re all positioned to make that happen.”

That was a true statement, and it became the impetus for what we do.

To my mind, my willingness to speak so openly about that is straightforward evidence that I believe that you, Southern Doc, or anyone else are welcome to come down the same path. Just don’t think its going to be as easy as providing excessive services under FFS.