Physicians

Can Health Plans Explain Why They Aren’t Re-Empowering Primary Care?

Mh_counseling

Sometimes a whisper is more powerful than a shout. Here’s a cartoon from Modern Medicine that shows a Medical Home counseling session between a primary care physician (PCP), a specialist and the health plan. The PCP looks forlorn, while the specialist and the insurer have their backs turned, fuming. It is perfectly true.

Along with changing the way we pay for all health care and creating far greater pricing and performance transparency, we need to turn around the primary care crisis if we hope to substantively improve quality and cost.

Over decades we allowed the combined actions of the AMA,
Medicare and the nation’s commercial health plans to marginalize
primary care
, so that now the typical cardiologist makes up to 4 times
more than a PCP, and only 7 percent of medical school graduates now
enter office-based primary care – not nearly enough to care for the aging boomer population that’s growing by leaps and bounds.

Worse, as the most recent Dartmouth Atlas report
made clear, the greatest concentration of "unwarranted variation" –
waste – is concentrated in the specialties and inpatient
arenas. This explosion in services and cost has largely resulted from tying the hands of America’s PCPs, preventing their involvement in downstream decision-making. Equally corrosive culprits have been a fee-for-service reimbursement system that financially incents specialists to conduct unnecessary procedures, and a lack of transparency that would allow us to more easily identify the excesses when they occur.

There’s hardly any question whether empowering primary care would dramatically improve the system. As Sepulveda, Bodenheimer and Grundy pointed out in a March Health Affairs article, literally dozens of studies show that more primary care in a community is associated with lower costs and better outcomes. More specialists lead to higher costs. In the US, the ratio of PCPs to specialists runs about 30/70, while in other developed countries its typically around 70/30. Their costs are generally about half ours and their outcomes better. Can anyone really argue with a straight face that empowering primary care is an iffy proposition, and that it demands more study before acting?

The entire premise of the Medical Home movement, seen most vividly through the efforts of the Patient Centered Primary Care Collaborative (PCPCC), is based, first, on empowering PCPs to do the things they were trained to do, and second, giving them the tools, programs and authority to optimize their roles. The PCPCC has been built around the power of Fortune firms and business health coalitions, each with considerable stroke, as well as several primary care associations. The health plans are at the table too, busily showing their support through pilot projects that test what happens when PCPs are paid a pittance more.

Even that is critically important, though, because the commercial health plans are the linchpins of change for this aspect of American health care. Unlike public health plans, who must adhere to policy that is dictated by the health care industry’s lobby, the commercials can respond to market forces. Health plans also are the only ones who can reach and transform the practices of the 250,000 or so community-based PCPs faltering under the lash of our current reimbursement paradigm. Their salvation is absolutely vital to re-establishing American health care’s stability and sustainability.

But so far as we’re aware, not one national health plan has yet decided to move beyond a pilot and unilaterally improve their medical management performance by paying PCPs significantly more. So far, there are no broad-based efforts to empower PCPs to have a say in what happens to their patients once they’re referred downstream to specialists. Nor are health plans systematically helping PCPs acquire the sophisticated patient management information technologies that can result in better outcomes at lower costs.

What are they waiting for? Why aren’t health plans making this obvious and straightforward adjustment to their medical management models? Skeptics might argue that, despite their protests that they’re in business to hold down costs, health plans make a percentage of total claims, so they certainly don’t want total claims to be less.

The plans might respond that they don’t want greater PCP involvement to antagonize the specialists, who they rely on. After all, its clear that, interference notwithstanding, collaborative decision making at the specialist level drives down specialty utilization and, with it, specialist incomes.

Or they might argue that they run enormous, complex operations, and big course changes are difficult and take time. Whatever.

Hence the inherent truth of the cartoon.

Still, there’s no question that we’re at a tipping point and that the time for action has come. Health plans have reported weaker enrollment figures, with reductions in the sales of even their much skinnier High Deductible Health Plans (HDHPs), as more employers and families are priced out of insurance. The coverage market is eroding as health costs continue to spiral upward, exacerbated by a credit crisis that is freezing liquidity. These economic trends are abetted, of course, by a primary care structure that is unable to exert control over the unbridled provision of specialty and inpatient services.

All this would be academic if there weren’t a very visible alternative model that performs MUCH more efficiently. Employers with strength and foresight are actively moving around the health plans by establishing worksite clinics, effectively staff model primary care practices that are fully realized medical homes. In general, these enterprises pay PCPs far better than they make in private practices, giving them access to excellent tools, and letting them loose to provide the care they know how is appropriate. The results are dramatic. Clinic companies routinely report significant savings, both on group health costs and occupational health and productivity costs, which are corroborated by their clients.

If the reports from the big benefits firms are right, more than half of all jumbo Fortune firms will have put up worksite clinics by 2010. Because these clinics are scalable, the trend is now catching like wildfire with large and even midsized (down to about 250 employees) firms as well. Several clinic firms are also working to bundle commercial insurance products with clinics in ways that allow smaller businesses and individuals to come together, collaboratively using the clinics to enhance access and drive down cost.

But the core problem remains. We won’t have real change in the delivery of care until the health plans either voluntarily change their relationship with primary care, or are forced to do so. As the cartoon  suggests, they’re not inclined.

So here’s a sincere request. If you’re a reader of this blog associated with the health plan sector, how about provide us with a lucid explanation of your hesitancy to change. What EXACTLY are you waiting for? Tell us.

If you’re a primary care physician and you agree with us on this, then please send this post to your regional health plans and pointedly ask why they’re dragging their feet. Pass this along to business leaders you know as well, and ask them to contact their health plans too.

——–

Brian Klepper PhD is a healthcare market analyst. David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies.

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CardsharingsaglıkAlJane Jacobsdlgils Recent comment authors
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Cardsharing
Guest

It will no doubt include a reallocation of RVUs to primary care activities and away from some overused diagnostic testing procedures. Like MG mentioned, there are some powerful vested interests, but we’re past the point of allowing them to rule the day. Everyone is going to have to give a little. For instance, I think the technical component of ultrasound is overvalued and needs adjusted. I am shooting myself in the foot because my group gets a significant amount of revenue from ultrasound. However, it’s just something that must be done.

saglık
Guest

Along with changing the way we pay for all health care and creating far greater pricing and performance transparency, we need to turn around the primary care crisis if we hope to substantively improve quality and cost.

Al
Guest
Al

This is a great discussion. In particular the exchange between Deron S., Brad F., and MG regarding the RVU system is especially germaine. The RVU system, and particularly the RUC (AMA Relative Value Update Committee) is a root cause for the discrepancy between PCP and specialist pay. The RUC sets these values; CMS accepts almost all its recommendations. Of the 29 members of the RUC, only five currently represent primary care specialties. The vast majority of the representatives to the RUC are appointed by other surgical, procedural or subspecialties. As a result, the outcome of the RUC’s deliberations have usually… Read more »

Jane Jacobs
Guest

Another great discussion. Responding to the comments about medical education: The Mayo Clinic Health Policy Center is hosting a Medical Education Reform Symposium in April 2009. The purpose it to identify, discussion and come up with actionable steps to reform medical education to support health care reform in terms of coordination of care and creating value. There will be sessions on the overlap of health care reform and medical education reform, realigning the health care training system (at all levels) for coordinated patient-centered care, designing what a medical education system should look like, life-long learning in the health professions, and… Read more »

dlgils
Guest
dlgils

Is it possible to encourage or mandate the ACCGME, ABMS, AMA to increase the # of pcp/specialty slots per year to say a 50/1 ratio. Perhaps a moratorium on specialty slots for 5 years. This could curb the supply and demand problem and eventually lead to greater pcp emphasis and filling the needed gaps across our communities. In support of specialists this would increase their net-value to the industry as they could control their pricing power by volume limitation. In support of medical schools and specialty training programs, the programs get reverse incented for limiting specialty slots. Use this extra… Read more »

Jack
Guest
Jack

I’ve seen “inept know-nothing” primary care docs, but I’ve also seen plenty of inept, narrow-focused “chance to slash is a chance for cash” specialists, too.
I appreciate the help of a good cardiologist in a complex cardiac patient, but I don’t think a good cardiologist is 400% more valuable to the community than a good family doc or internist.

MG
Guest
MG

Deron S – The brutal truth is that specialists in this country have to adjust to the reality that they are overpaid. Granted everyone always thinks they are unpaid and under appreciated to some degree but I have found having this conversation with specialists is particularly difficult even when grounded in facts (e.g., a number of specialties in this country are among the highest average annual salary per capita in the US, salary difference between specialists in the US vs. specialists in other countries is greater than the salary difference between PCPs in the US vs. specialists in other countries).… Read more »

Deron S.
Guest

I’m more optimistic than most. I think Congress will take notice if there is a more coordinated and comprehensive push for some of these changes. If the right people can get around a table and develop a proposal that shows exactly WHY we need to focus on rebuilding the primary care delivery system, and HOW to do it, Congress will listen. It will no doubt include a reallocation of RVUs to primary care activities and away from some overused diagnostic testing procedures. Like MG mentioned, there are some powerful vested interests, but we’re past the point of allowing them to… Read more »

MG
Guest
MG

Really, really good comments. Yeah you can tweak how GME (graduate medical education) is funded and what residency programs receive or implement other solutions but when you get down to the heart of the matter, there are only two broad solutions to this problems: 1. Ultimately tear up and replace the RBRVS with something entirely new in the next several years. 2. Fundamentally change the process by which the RBRVS is set and calculated on an annual basis. Either one of these is going to require some type of serious action from Congress ultimately though and will all of the… Read more »

Peter
Guest
Peter

Why is the ability of a PCP to use their analytical and intuitive thinking to find the root cause of illness determined to be worth less in this health system? True diagnosis isn’t easy given all the contributing factors and that there is no two alike. I agree with docanon in his comparison of intellectual difficulty working OR and a surgeon doing his 500th stent placement and trying to justify reimbursement – although each has it’s degree of repetitive learning leading to routine. A surgeon looks like a savior because the process looks complicated (and it is) but the skills… Read more »

Brad F.
Guest
Brad F.

Deron The CPT bump was mostly smoke in mirrors. Because changes have to be budget neutral, they upped the RVU’s but rejiggered the multiplier against which it is multiplied. While some codes when up, in the end the equation robbed peter to pay paul. I am too tired to offer commentary on payments to surgeons/subspecialists. I am biased, truth is somewhere in the middle obvioulsy, but payment system is based on outmoded, Eisehower/Kennedy era paradigms on technology, how physicians should be compensated for its application. I am not a PCP, but boy, after seeing them in the office after 25… Read more »

Deron S.
Guest

The RVU system was recently tweaked to add quite a bit more value to E&M codes. Why aren’t PCPs talking about that? I agree that there’s still room for more tweaking, but if I’m not mistaken, the bread and butter CPT code of 99213 was increased by more than 12%. That had to produce a nice bump in compensation, as long as PCPs negotiated a corresponding increase with the non-Medicare payers if their fee schedules weren’t already tied to Medicare. It would be easier to justify further primary care increases if PCPs can offload some of the more routine work… Read more »

David C. Kibbe, MD MBA
Guest

“Guiding rational medical consumption…we’re 10% -30% lower cost, but can’t get paid more…a different physician-staffing mindset…defined population and meeting its needs…things don’t work if you do them for only a fraction of patients…first mover penalties…”
These great comments convince me that we certainly know what the problem is, and we know the barriers that stand in the way of its solution. There are so many good and skilled people who want a PCP-based health care system to emerge in this country. How do we push it through? DCK

rbar
Guest
rbar

docanon, I realize that – after not having been in an OR for 7 ys or so – I developed a romanticizing view of surgery, overestimating the average difficulty and stress involved. Some surgeries may be high stress and nerve wrecking, but most lap. choles and colonoscopies are quite comfortable routine. I still think that your suggestions of absolute pay equality are not realistic, but maybe I am too meek. That aside, the degree of difficulty, however, is a very rational way to estimate payment for a medical service (You seem to agree with that at least to some degree… Read more »

pcb
Guest
pcb

just a comment on reasonable PCP salaries. the overall yearly income may not need to change as much as everyone thinks. What needs to change is what it takes to make that number. Right now, many are burning out, running themselves ragged, working long hectic days, never feeling like they can give proper care, seeing too many patients daily. It’s the only way to maintain incomes. The result? Too many patients on their panel. Too much paperwork, too many phone calls, too much responsibility, etc. Overworked, underpaid, basically. Either pay more per visit (rvu changes) or pay a management fee… Read more »