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What’s Behind Today’s Primary Care Crisis? You Don’t Know the Half of It

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By BOB WACHTER, MD

If you’ve ever been on a diet, you know that it really helps to keep a food log. Seeing your consumption chronicled in one place is illuminating – and often explains why those love handles aren’t melting away despite two hours on the treadmill each week.

In today’s issue of the New England Journal of Medicine, internist Rich Baron chronicles the work of his 5-person Philadelphia office practice during the 2008 calendar year. Rather than “Why am I not losing weight?”, Rich’s study aims to answer the question, “Why does my work day feel so bad?” The answer: an enormous amount of metaphorical snacking between meals.

In the NEJM study, Rich (who is a dear friend – we served together on the ABIM board for several years) found that each of the physicians in his practice conducted 18 patient visits per day (a total of 16,640 visits over the year for the practice). That’s not an unmanageable workload, you say. You’re right, but that was just the appetizer. On top of these visits, daily each physician also:

  • Made 24 telephone calls
  • Refilled 12 prescriptions (a vast underestimate of the daily refills, since a) the number reported in the study doesn’t count refills done during an office visit, and b) the study counted the act of refilling 10 meds for a single patient as one refill)
  • Wrote 17 e-mails to patients
  • Looked at 11 imaging reports, and
  • Reviewed 14 consultation reports.Continue reading…

A Backhanded Way to Make Policy

By PAUL LEVY


One of the arcane steps in government regulation of health care is the Physician Payment Rule. This is the manner in which CMS, the Medicare agency, annually allocates payment dollars among the various specialty services. The PPR effectively makes policy.

The construct for all of this is a zero-sum game. When CMS wants to raise fees for some specialties (e.g., primary care doctors), it is required to reduce the fees for others.Continue reading…

Commentology: Thoughts on the Death of Primary Care

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Anonymous

Vance Harris MD writes:

We are our own worst enemies, as we have allowed insurance companies and Medicare to set the value of our services. Clearly those values they impose have nothing to do with our contribution to the health of our patients or the cost savings we bring about.

Case in point:

How many dozens of chest pain patients have I seen in the last month who I didn’t order an EKG, get a consult, set up nuclear imaging or send for a cath? Only I have the advantage of knowing just how anxious most of these patients are and that they have had the same symptoms time and again over the last 20 years. After a pointed history and exam, I am more than willing to make the call that 27 hours of chest pain is most likely not angina in nature. When I take the responsibility on my shoulders I am saving the system tens of thousands of dollars. Most of these patients present to my office directly and are worked into a busy day pushing me even deeper into that mire of tardiness for which I will be chastised by at least 6 patients before the end of the day. Most of those who scold me are retired and have more free time in a day than I get in a month. My reward for working these people in and making a call that puts me at some risk is at most $75 if I count the less than $25 I get paid for being able to read an EKG without sending it off to be interpreted by a cardiologist. My incentive pay for saving thousands of dollars on each patient for 1-2 days in the hospital, stress treadmill and cardiologist referral is $75. Now there is motivation on a busy day to not send someone to the ER.

How many times has an anxious patient come in, almost demanding an endoscopy, who I examined, after taking a good history, and then decided to treat for 3-4 weeks before making the referral? Few of these patients are happy with me after the visit, no matter how many times I explain that it is reasonable to treat their reflux symptoms for several weeks before considering endoscopy. This delay in referral has lead to many a tense moment in the last 20 years. Cost savings to the system is again thousands of dollars each and every time I do this. I am willing to make the call and go with the treatment first before getting the scope. My reward is about $55 from Medicare and the Big Blues.

How many low back pain patients have come to the office in agony knowing that there has to be something serious to cause this kind of pain? Again a good history and a directed exam allows me to reassure the patient that there is nothing we need to operate on and that the risk of missing anything in this setting is low. This takes a lot of time to explain as I teach them why they don’t need, and better yet, why they don’t want to get an MRI at this point. If someone else ordered the MRI guess who gets to explain the significance of bulging disks and narrowed foramen to an alarmed patient? Setting realistic expectations on recovery and avoiding needless imaging that rarely helps, in the acute setting of a normal exam, saves the system thousands of dollars again. My reward is another $55 if I am lucky.

How many times does a good shoulder exam allow me not to order an MRI giving the patient time to heal and recover before imaging racks up another couple of thousand dollars followed by orthopedic referral for a shoulder that doesn’t need surgery? Another $55 will shower down on me at the end of the day when I send off the bill for that exam.

How many basal cell and squamous cell cancers have I discovered while examining some ones shoulder or abdomen or even a sore throat? How many of those was I stupid enough to remove the same day, only to find out that I would be paid for only one procedure and it would always be the least expensive of the two? How many appeals have been successful to Medicare when I performed the service and was denied payment?

How many diabetics do I struggle with, trying to get them to take better care of themselves? How many hours have I spent with teenage diabetics who will not check their blood sugars and forget half of their insulin doses? I have spent hundreds of hours dealing with them and their families trying to effect changes that will someday allow them to get their disease under control. I do this because the only Endocrinologist in the county will not see pediatric diabetics. I can’t say that I blame him as the time spent seems like a total waste. That is, until one day they open their eyes and want to take care of themselves. My reward for years of struggle and years of 30 minute visits trying to get them to take responsibility for their health is a few hundred dollars at best. The savings to society for my hard work and never give up attitude is in the tens of thousands of dollars.

I continue on in my 22nd year giving advice and services to 30 plus patients each and every day. Having me in the system has resulted in savings in the hundreds of thousands of dollars each and every year. My financial incentive to hang in there and work hard is the following. Twenty years ago I made about twice as much as I do now. This year I will make less as it seems even more of the claims are being reviewed while payment sits in someone else’s account drawing interest.

I have always served my fellowman out of a sense of love and compassion and for those reasons I went into medicine. I have been richly rewarded by my patients over the decades as they appreciate my judgment and skills. Isn’t it a shame that after all this time and with skills honed by decades of experience, I can barely afford to work as a physician? Taxes will be collected, no pass for the working physician, not like the Goldman Sacks guys and their buddies with the 9 billion in bonuses given last year after the 58 billion in funds we gave them.

My parting words next year will be good luck having PA’s provide the safety net with their 2 years of training. Good luck getting newly trained physicians to take over once they see my salary. Good luck having internists in your community with only 1% of medical students going into Internal Medicine. Good luck recruiting the primary care specialists when you are short 70,000 now and 1/3 plan on retirement within 3 years.

If there is any irony in this at all, it is that I will find myself in the same boat as I struggle to find a doctor to take care of me. Now that is ironic. Anyone know who is taking new patients in California?

Vance Harris, MD

Musings on Payment Reform

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By CHARLIE BAKER

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Charlie Baker is the president and CEO of Harvard Pilgrim, a nonprofit health plan that covers more than 1 million New Englanders. Charlie is a regular contributor to THCB, where he has authored posts on national health reform (See: “Is Massachussetts a Model for National Reform?”  and related issues facing the healthcare sector. (For example: “Shifting Costs From Public To Private Payers“). His posts also appear at his own blog, Let’s Talk Health Care.

This week Charlie confirmed a longstanding rumor, announcing that he will be giving up his position at Harvard Pilgrim at the end of July to run as a GOP candidate for governor of Massachusetts. You’ll find more about his campaign on his web site, CharlieForMA.com.

The Commonwealth of Massachusetts – along with a number of other states (including New Hampshire and Maine) and the federal government – is kicking around a number of ideas concerning payment reform.  The argument goes something like this – since the current health care system, led by the gigantic Medicare program, pays primarily on a fee for service basis.  This “do something” payment model encourages clinicians and hospitals to do “more” for patients than they might do otherwise, if they weren’t encouraged to “do something” to get paid.  Add to that the fact that fee for service – again led by Medicare – pays more for new technology than it does for existing technology, and less for primary care, and you have the primary ingredients in the recipe that’s driven our system to be technologically driven, volume driven, fragmented and very expensive.

In Massachusetts, the group that’s working on payment reform seems to think the solution to this problem is to move everyone away from fee for service and into something that’s being called, “global budgets.”  Put simply, global budgets are a new and improved form of capitation.  Let me be clear on this one – I’m actually a big fan of both.  I believed in capitation when I worked in state government, and I worked for a medical practice (Harvard Vanguard Medical Associates) before I came to Harvard Pilgrim that was built on global budgets.

And before I go any further, I would offer up the cover story in this month’s issue of Health Leaders Magazine – titled “Bundling By Decree” as a solid a representation of the pros and cons of this debate as it winds its way through the national discussion around health care and payment reform.  This article is primarily about bundling payments around episodes of care, but the issues it raises – in both directions – apply in either context.

With that said, I wonder about whether or not global budgets, at least in the short term, are the answer to our health care cost and quality problems.  For some provider organizations, global budgets work – but they work in large part because those particular clinicians believe in them, and want to practice in environments that are based on them (like Harvard Vanguard/Atrius HealthCare).  But that represents a fairly small slice of the practicing clinician community – I’m guessing 10-15 percent.  Maybe 20.  It’s also not clear to me that this issue, above all else, drives our cost/quality problem, since many other countries that spend a lot less than we do on health care and have solid clinical results use fee for service payment systems too.

As far as I can tell, those other countries that spend less than us on health care do two things differently than we do.  First, they spend less on each service than we do – sometimes a lot less.  They also have robust primary care systems.  This, in particular, is just the opposite of our approach.  Our payment policies – and as a result, our medical education system – have been disinvesting in primary care for years.

In the short term, I’m not sure global budgets solve this disinvestment problem.  First of all, it’s financial and operational whiplash for a system that’s been running on fee for service for years.  That, all by itself, will take some getting used to.  It’s also not clear that Medicare or Medicaid – which make up 50-60 of the payments to providers to begin with – would also adopt global budgets.  If they don’t, having private sector payors using global budgets and the public sector payors using fee for service is just about  the worst outcome I can think of for providers and their patients.  The mixed messages these two payment models would send about what matters and what’s important would be virtually undecipherable.

This makes me wonder if our short term approach shouldn’t focus instead on changing the message all payors send under the current fee for service system to providers by improving the way we pay for primary care.  No one thinks we can possibly deliver integrated, coordinated care if we don’t send some signals to the medical and medical education community that primary care matters.  If a young medical student can make $250 an hour in primary care – or $1,000 an hour in dermatology – or $2-3,000 an hour in cardiology or orthopedics – how hard do you think it is to get that person into primary care?  The answer is it’s wicked hard – and the declining number of students going into primary care coming out medical school for the past decade is proof positive of that.  We used to be 50/50 primary care / specialty care.  Now we’re 70/30, and some of the anecdotal information suggests that kids coming out of U.S. medical schools are now running 15/85 primary care/specialty care.

Think about it.  No one disputes the fact that primary care has a key role to play in care management and care coordination – especially as the Baby Boomers get older.  The state’s Payment Reform Commission says global budgets will take three to five years to implement – and expects that every doctor will be using an EMR as one of its requirments for success.  Will this approach really grab today’s medical students and practicing clinicians and say – ”HEY!  It’s time to invest in primary care!”  In the short term, I think we’re more likely to get more capacity, faster, into primary care by boosting, on a relative basis, the fees paid to primary care providers by the private plans, Medicare and Medicaid.

Over time, maybe everybody gets to global budgets, but in the meantime, I think we need to do more to support primary care.

Thomas Kuhn, Health Care Reform and Vascular Disease

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By WILLIAM BESTERMANN

The puzzle of improving care and reducing costs in American medicine and in vascular conditions (that is, diseases associated with blood vessel metabolism) in particular – these are responsible for 60 percent of all cost – has been in part due to the nature of medicine itself.  Physicians are at their core scientists. Our undergraduate degrees are in the scientific disciplines of biology, chemistry, physics. We have been educated in the culture of science and that is the environment in which we practice.

Thomas Kuhn’s The Structure of Scientific Revolutions perfectly describes a central problem in cardiovascular diseases.  A scientific community cannot practice without a set of core beliefs. These central constructs are, in Kuhn’s terms, the foundation of the “educational initiation that prepares and licenses the student for professional practice.” The student’s instruction is “rigorous and rigid,” with the purpose of ensuring that these beliefs are firmly fixed in the student’s mind.

Scientists go to great lengths to defend the idea that they know what the world is like. It should come as no surprise then that “normal science,” – that is, the framework to explain the world used by the scientists who lead the current paradigm – will often suppress novelties that undermine its foundations.

So research often is not about discovering the unknown, but rather “a strenuous and devoted attempt to force nature into the conceptual boxes supplied by professional education.” A generally-accepted paradigm, essential to effective scientific investigation, requires “some implicit body of intertwined theoretical and methodological belief that permits selection, evaluation and criticism.” That paradigm, in turn, forms the basis of a new profession or specialty, like Interventional Cardiology, and from this follows the establishment of journals, societies, and a special place in the medical academic structure.  The articles in those journals are intended for professional colleagues who share the the field’s knowledge and who are the only ones capable of fully understanding them.

A shift in the accepted scientific construct occurs when research aimed at further developing that formulation of the evidence runs into an anomaly — a fact that does not fit the paradigm and cannot be explained away. When anomalies pop up, they typically are not welcome and may be ignored. The current paradigm’s scientists may make little or no effort to formulate a new theory to explain the phenomenon. They are also likely to be intolerant of practitioners who try to do so.

All the same, the discovery of anomaly is the stimulus that leads to a new paradigm. The failure of  existing beliefs and rules is the necessary but insufficient platform for the development of new scientific and practice structure.

The leaders of an entrenched paradigm strongly resist alternate systems of science and practice. Only in  crisis can that resistance be overcome. No better example of this can be found than the current situation in the treatment of cardiovascular and arterial disease.

*****

The fixed blockage is the dominant paradigm today for both the science and practice of cardiovascular and arterial disease management. In other words, it is viewed as a plumbing problem. This paradigm has persisted because it made so much sense.

Angina is a historical diagnosis – particularly in a man.  Just talk to the patient and you can make the diagnosis. If a man walks and gets chest pain that is relieved by rest, he has angina. Almost all of those men have a blockage of 70% or greater.

If the cardiologist does a catheterization he will demonstrate the blockage.  If he opens the blockage with a stent the pain will go away.  But many men with angina go on to have heart attacks – it is high risk.  So it is no surprise that blockage became the dominant scientific paradigm. To this day, virtually the entirety of the science, practice, and financing are organized around this idea: Heart attacks are caused by a progressive blockage. If we open that blockage before it becomes complete, we will save the patient.

Now the anomaly. In 1988, WC Little and his colleagues at Wake Forest performed a study “to help determine if coronary angiography can predict the site of a future coronary occlusion.” If the plumbing model were correct and a progressive blockage of the artery caused myocardial infarction, the findings on coronary angiography should predict the site of heart attack. It did not.

Little and his colleagues studied 42 consecutive patient records of patients who had had coronary angiography before and up to a month after having a heart attack. In 19 of 29 (66%) patients, the artery that occluded subsequently had less than a 50% occlusion on the first angiogram. In 28 of 29 (97%) the stenosis (or narrowing of the vessel) was less than 70%, even though it takes a stenosis of 70% or greater to justify angioplasty with stenting.

Little concluded

“Because it was difficult to predict the site of subsequent occlusion in our patients from the initial coronary angiogram, coronary bypass surgery or angioplasty appropriately directed only at the angiographically significant lesions initially present in almost all of our patients would not have been effective in preventing the majority of infarctions…instead effective therapy to prevent myocardial infarction may need to be directed at the entire coronary tree…”

And, in keeping with Kuhn’s description of the scientific revolution, the best arterial disease scientists quickly developed a new paradigm that provides a much better explanation of the mechanism of heart attack and other vascular events. Within 7 years of the first anomaly, Erling Falk, Prediman K Shah and Valentin Fuster, leading academic cardiologists, summarized four studies that came to the same conclusion as Little. Only 14% of heart attacks occur in an artery that was 70% blocked on the previous catheterization. Only 14% of heart attacks occurred in an artery with enough obstruction to cause angina and justify bypass surgery or stenting.  Falk and his colleagues described the new paradigm very simply:

“plaque disruption with superimposed thrombosis (obstructive clot) is the main cause of the acute coronary syndromes of unstable angina, myocardial infarction, and sudden death.”

Peter Libby is Chief of Cardiology at Boston’s Brigham and Women’s Hospital, one of Harvard’s teaching hospitals. One of the world’s foremost authorities on the science of heart attack and plaque rupture, he quite literally “wrote the book” on the topic. In the volume of Harrison’s Principles of Internal Medicine, the standard reference text for the discipline, that sits on my desk, Peter Libby wrote the chapter entitled The Pathogenesis of Atherosclerosis.

In 1995, the same year as the Falk article, Libby wrote a piece called “The Molecular Basis of the Acute Coronary Syndromes.”

“Bypass surgery or transluminal angioplasty (dilation of the artery and then, propping it open with stents) provide rational and often effective therapies for these fixed, high-grade stenoses (blockages).  However, these treatments do not address the non-stenotic but vulnerable plaque (which may rupture and suddenly block the artery with clot).  It is of interest in this regard that despite the well-accepted benefit of coronary bypass surgery on anginal symptoms, this treatment aimed at severe stenoses does not prevent myocardial infarction. To reduce the risk of acute myocardial infarction, one must stabilize lesions to prevent this disruptions, particularly the less stenotic plaque.”

In other words, heart attack is not caused by a gradual narrowing of the artery, but rather is the result of sudden cholesterol plaque rupture with subsequent clot formation, which blocks off the artery and cuts off blood flow.

Today, 14 years later, we can dramatically stabilize plaque and reduce plaque progression by smoking cessation and reduction of cholesterol, triglycerides, blood pressure, and blood glucose.  We can prevent clot formation with aspirin and other medications.

The scientific revolution in vascular disease is 20 years old and the new paradigm firmly in place and supported by the very best vascular scientists. Still, the practice paradigm persists as if the science never changed.

Just last year, I heard a brilliant talk by Valentin Fuster, one of the co-authors on the Falk article. Afterward I asked him what it would take to move the practice paradigm forward. He responded that it would take the time required to replace current practitioners wi
th the next generation.

Can we afford to wait for that?  Several years ago, I heard Dr Libby speak at a national meeting of the American Society of Hypertension. I later asked him, “Dr Libby, I read your article from 1995, saying that bypass and stenting do not prevent heart attack, do you still hold that view.”  He became very animated and enthusiastic and said he was convinced that the new science was valid and required action to move it forward.

The science has become irrefutable.  Yet the defenders of the old science still carry the day.  I fear that medical scientists will not move this forward and it will require changes in payment and support for research coming from outside the professional community to bring the latest science to patients.

We have to recognize the suppression of anomalies and new paradigms in medicine. Only then can we develop mechanisms that can bring the latest evidence-based science to patients.

Bill Bestermann is Medical Director, Integrated Health Services at Holston Medical Group in Kingsport, TN.

Following the Science To A New Era In Medicine

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By WILLIAM BESTERMANN, MD6a00d8341c909d53ef010536ee8138970b-pi

“The current care systems cannot do the job.  Trying harder will not work.  Changing systems of care will.”

Crossing the Quality Chasm, Institute of Medicine, 2001

Medical leadership in the United States has not yet come to grips with the level of structural and systemic change that will be required to produce the dramatic improvements in the management of chronic conditions that are required to reduce disability and mortality while reducing costs.

In this same space, I recently published an article called “The New Science of Vascular Disease.” The take-away message of that article is this: one of the most important products of our medical system is optimal medical therapy for vascular risk factors. As a system, we don’t even come close to achieving conservative goals for global risk management and the latest work from Dr. Steven Nissen tells us that plaque progresses more rapidly when the LDL cholesterol is over 70 and the systolic blood pressure is 120. Most providers are not even shooting at those targets.

The objective observer today could make a better case that medical rather than military intelligence was an oxymoron. The US military and medical systems share many common features. The scientific and industrial revolutions have changed both endeavors at a pace that can barely be digested. The tools that we use have improved dramatically and properly applied can achieve results that were unthinkable 100 years ago.

When my son was studying at West Point, I learned that they spent what seemed an inordinate amount of time studying the American Civil War and I asked him “Why do you do that?” He said, “Generals get their soldiers killed by fighting the current war with tactics that were appropriate for the last conflict.” I have been haunted by that statement ever since. By any objective standard, the US military has done a much better job than our medical system of adjusting their structure and practice to the new technology that is available to them.

Translation is a major emphasis – perhaps the major emphasis – in all military education. All army enlisted and officers are trained as generalists and the infantry, the organization of generalists, is the “Queen of Battle.” All of the specialty arms in the army serve the infantry as the main focus of army operations. The leaders of the army are required to attend sophisticated schools at each stage of promotion in part to prepare them to incorporate new technology..All of this has developed out of that concern that the stakes are enormous and leaders get their soldiers killed by not translating new technology into practice.

Unteroffizier Paul Scheytt could not believe his eyes. During the week leading up to this moment, July 1, 1914, he and his troops had endured artillery barrages so vicious that the British high command was quite sure that all German forces in that section of trench had been annihilated. Indeed, he was just peering over the wall of his fortification after a final savage artillery bombardment, and there before him were thousands of British soldiers, so heavily laden with equipment that they could barely walk, moving deliberately toward his position. He and his fellow soldiers thought the British were insane. He was watching the beginning of the Somme offensive.

In that single day Scheytt and his fellow German troops would shoot down 60,000 young British men. These attacking troops had come at the Germans shoulder to shoulder and were annihilated in a murderous hail of fire from machine guns, repeating rifles, mortars, and breach-loading artillery.

How could such madness happen? The English generals did not change the tactics of the assault to take into account the tremendous changes in weapon technology. They did not translate new technology into practice. The British general Haig, who ordered the attack, was bright, well-trained and conscientious, but he caused thousands of young men to die because they were fighting with tactics appropriate 100 years before that day. The technical paradigm and science had changed, but the leaders had not adjusted structure and tactics to address those realities.

The British forces attacked across a broad front as western armies had done for thousands of years. Even as the American Civil War began, the broad frontal assault was still a reasonable strategy. The musket that was far and away the main weapon in use was only accurate at 40 yards. In the first battles of the Civil War, lining up in parade formation with the regimental colors leading the way and the band playing was completely appropriate. The armies would line up across a front two or three miles wide, march to within 40 yards of each other and fire by volley. There were casualties, but losses were reasonable and the tactics and technology were fairly well matched.

By 1863, when the battle of Gettysburg was fought, the dominant infantry weapon was no longer the musket but the rifle, which could reliably kill a man at 300 yards. When General Pickett led his infamous charge, his troops were crossing nearly a mile of open field and the Union defenders were protected by a stone wall. Pickett’s division had no chance and evaporated before it got anywhere close to the Union position.

The Union generals observed this slaughter first-hand, but in May of 1864, General Grant ordered one frontal assault after another against Confederates in trenches armed with rifles. None of these assaults had the remotest chance of success, and the Union Army of the Potomac suffered 60,000 casualties in that one month – a loss equal to the entire strength of the Army of Northern Virginia.

The paradigm had changed, the solution existed, but leaders of the Civil War and even of WWI did not change the tactics of the assault. Millions died as a result.

The solution to the changes in warfare really fairly simple. The method of attack had to change radically, and once that change was made, the impregnable defense paradigm changed to one in which the irresistible assault was the reality of the day. In a moment, we went from a world where the attack seldom succeeded, to a world where the well-designed and executed attack seldom failed.

Our tactics in dealing with chronic diseases lag the available technology to a similar extent and with similar casualties. Multiple major paradigm shifts have occurred in the new science of vascular disease. Heart attack is not a plumbing problem. It is not a problem of a progressive fixed blockage that can be fixed with a stent. Stents do not prevent myocardial infarction in stable patients.

Still, our system practically functions as if it is all about the blockage. Heart attacks are prevented by stopping smoking, diet, exercise, and a coordinated, integrated pharmaceutical protocol aimed at preventing plaque rupture by aggressively treating hypertension, high cholesterol and type 2 diabetes. Today, a carefully designed program of 6 four dollar prescriptions from WalMart can make an enormous difference. Multiple clinical trials have demonstrated the effectiveness of optimal medical therapy and that is clearly our challenge – to produce best medical treatment for risk factors consistently. Our current system of care has no more chance of success than the British attack at the Somme.

We require the same drastic reorganization required of the military after WWI. We are currently organized as if hypertension, type 2 diabetes, high cholesterol, high triglycerides and gout were separate conditions. They are not.

For the majority of patients, these conditions are part of the metabolic syndrome, a single condition that is the result of a diet rich in fat, sugar and processed carbohydrates, coupled with inactivity, resulting in increased abdominal weight. The metabolic syndrome and its later stages of pre-diabetes and diabetes are the leading cause of heart attack, stroke, and other serious vascular complications.

“Changing systems of care” is not just something for the worker bees. From top to bottom our system functions as if the science of the last 20 years never happened. Even our major academic centers are still organized as if these are unrelated conditions. Most medical schools have hypertension clinics, lipid clinics, and diabetes clinics. The professionals who man these clinics organize meetings sponsored by the American Society of Hypertension, the National Lipid Association, and the American Diabetes Association respectively. Then, when these anachronistic systems fail to produce optimal medical therapy and these patients experience a plaque rupture in a coronary artery and a resultant heart attack, the patient is referred to a cardiologist. When they develop a clot in a neck artery, they see a neurologist and when they develop gout we send them to a rheumatologist.

The whole arrangement is an anachronism based on decades-old science. Until we address these fundamental realities and make the adjustments in our systems of care demanded by new technical developments, optimal medical therapy will remain an elusive dream. Until we seriously attack these structural issues, we cannot produce patient centered care.

And so, the obvious question becomes: “What changes in structure and practice would be the medical equivalent of a mechanized infantry division in the management of cardio-metabolic conditions?” The best answer today would come from a combination of “Crossing the Quality Chasm” from the Institute of Medicine (IOM) and the Advanced Medical Home from the American College of Physicians (ACP).

The IOM recommended that focused programs be developed for 15 priority conditions that included diabetes, high cholesterol, hypertension, ischemic heart disease, and stroke. Peripheral arterial disease and congestive heart failure are strongly related conditions and the whole could be managed by internal medicine and family practice providers with a special interest in these conditions. A special focused effort to address all of these conditions in a coordinated integrated way could be housed in a cardio-metabolic center of excellence within a larger practice.

That cardio-metabolic center-of-excellence team would assure that the IOM system for producing optimal medical therapy was consistently implemented along four key principles:

  • Organize evidence-based care protocols consistent with best practices
  • Organize major prevention programs to target key health risk behaviors associated with the onset or progression of these conditions.
  • Develop the information infrastructure to support the provision of care and measurement of care processes and outcomes.
  • Align the incentives inherent in payment and accountability processes with the goal of quality improvement.

The ACP document on the advanced medical home describes a number of models:

“In the advanced medical home model, patients will have a personal physician working with a team of health care professionals in a practice that is organized according to the principles of the advanced medical home. For most patients, the personal physician would most appropriately be a primary care physician, but it could be a specialist or sub-specialist for patients requiring ongoing care for certain conditions, e. g. severe asthma, complex diabetes, complicated cardiovascular disease, rheumatologic disorders and malignancies…Principal care, that is, the predominant source of care for a patient based on his or her needs could be provided by a primary care physician or a medical specialist..”

This is a great new opportunity for primary care to rise out of the ashes, to produce a very high value product and to be paid fairly for it. Current systems and practice do not  produce optimal medical therapy consistently. The cardio-metabolic centers of excellence proposed here would be manned by generalists assembled in a kind of medical special operations unit, bringing together just the right mix of assets to accomplish the reliable production of optimal medical therapy for large numbers of patients. The expectation would be that the providers would train and retrain to continually improve their practices as the science and technology continue to change.

We could train generalists to become part of special teams that change with the science and technology. They would not practice primary care in the usual sense; they would not attempt to be everything to everyone. They would be the ideal principal physicians for patients with vascular risk factors and a history of vascular events. Half the population dies of these conditions and they produce nearly half the cost of care. Effectively addressing this single collection of chronic conditions offers the most impact for the cost and effort of any that I have seen proposed.

Over the last two years, our group has run a cardio-metabolic center of excellence. In providing coordinated integrated care for these conditions we have been able to show dramatic results in patients referred by the 140 clinicians in our larger practice. The entire practice has a quality culture and good outcomes. Even so, these patients have realized average reductions in the LDL of 60, A1c of 1.8, triglycerides of 200, BP of 11/9 and weight loss that averaged 9 pounds.

Good relationships and high provider satisfaction come as we attain good referral volumes from a doctor. Patient satisfaction and persistence with the program is very high. Still, most physicians in the group do not yet refer to the program.

Medical leadership has not begun to produce the level of structural change to adapt to new technology. We are in a time that will precipitate great change. Following the science, we can restructure medicine in ways that will improve lives and save enormous dollars.

William Bestermann, MD, is a Preventive Cardiologist and Medical Director for Integrative Services at the Holston Medical Group in Kingsport, TN.

Will CIGNA Remake The Health Plan Marketplace?

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By BRIAN KLEPPER

ALP_H_BK_0010America’s health plans are floundering. If their job has been to provide the nation’s mainstream families
with access to affordable care (let’s leave quality out of it for the moment), they have failed miserably, though they were very profitable along the way, at least until Q1 2008. In 2008, the Milliman Medical Index – an estimate of the total cost for health coverage premium and out-of-pocket costs for a family of four – was $15,609. Now it is almost certainly above $17,000, more than the total income of more than one-third of American households.

To many health plan execs, these are simply market dynamics that must be accommodated through new product and service designs. I just attended a health plan conference where the overarching themes were the transition away from group to individual coverage, and the use of incentives and touch points like texting, email, and ergonomic Web interfaces to cultivate member competency, loyalty and retention.

There are important steps forward but, to me, the discussion tiptoed
around the more glaring problem – costs this high have exhausted many
purchasers’ ability to pay, and are rapidly shrinking health plans’ commercial market and profitability.

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Five Recommendations for an ONC Head Who Understands Health IT Innovation

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By David C. Kibbe, Brian Klepper and John Moore. Kibbe

Now that the legislative language of the HITECH Act — the $20 billion health IT allocation within the economic stimulus package — has been set, it’s time to identify a National Coordinator (NC) for Health IT who can capably lead that office. As many now realize, the language of the Bill can be ambiguous, requiring wise regulatory interpretation and execution to ensure that the money is spent well and that desired outcomes are achieved. Among other tasks, the NC will influence appointments to the new Health Information Technology (HIT) Policy and Standards Committees, refine the Electronic Health Record (EHR) technology certification process, and oversee how information exchange grants and provider incentive payments will be handled.

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The New Science of Vascular Disease

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By William H. Bestermann M.D.

BesterrmannVascular
disease and the conditions that produce arterial problems consume
roughly one- third to one-half of the $2 trillion annual spend in
American health care. The science and systems exist today to dramatically improve the quality and cost related to cardio-metabolic
conditions but almost nothing has been done to implement these new
tools since the Institute of Medicine (IOM) published “Crossing
the Quality Chasm” in 2001.

The most glaring
example of the failure of medical and political leadership in these
matters can be found in the treatment of chronic conditions, which
consume 70 percent of our health care dollars. “Crossing the
Quality Chasm” was a stinging indictment of American medicine,
describing a system that is in need of fundamental change, with many
professionals and patients concerned that the care delivered is not
the care that we need. The report described a system that harms too
frequently and routinely fails to deliver its potential benefits.

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Five “Shovel-Ready” Health Care Reforms

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By Brian Klepper & David C. Kibbe

Microsoft Health Vault’s leader Peter Neupert has a wonderful blog post that makes two important points really well. One message is that health care reform is about the outcomes, not the technology. We should think expansively about which technologies to invest in, based on the results we want to get.

The other message is the economic stimulus package is different than the reform effort. It is moving at hyper-speed through Congress, and it may be difficult for staffers and other advisors to sort through and incorporate what may seem like opposing Health IT views against a backdrop of traditional ideology and extremely forceful special interest lobbying.

Even so, there’s consistency among the health care professionals who worry about these issues all the time. Peter unexpectedly discovered that the messages of his fellow panelists from the Health Leadership Council, the National Quality Forum, the Permanente Federation and the General Accounting Office were remarkably in sync with his own testimony to the Senate Health, Education, Labor and Pensions Committee.

Congress is about to make some big moves in health care that will require immense resource expenditures but, depending on what we pay for, may or may not bear the fruits we hope for. They should move carefully. Not all health care reform has to be labyrinthine. Not all ideas must require huge cost or take years to come to fruition and gain market traction. There are relatively simple actions that are available now, and that the Obama Health Team could tackle to effect tremendously positive, immediate impacts on the system.

Of course, right now the Health IT industry is focused on the promise of a huge stimulus windfall that would be dedicated to their products. But the opportunities we describe below follow principles that have broad support among students of the health care crisis. Two would change the way we pay for health care services, tying payments to documented results. Three are based on how we pull together and make use of the data that can drive clinical and financial decisions, and they overlap, though not perfectly, in their potential. Still, if any system adjustments can be passed through policy initiatives that focus on what’s best for the common rather than the special interests, these should be among the most straightforward.

Payment
Re-Empower Primary Care
There is general agreement that primary care is in crisis, the result of years of abuse and neglect by the medical establishment and by CMS. In simple terms, the primary care/specialist ratio in the US is 30/70. In all other developed nations, its about 70/30. And our costs are roughly double theirs.

We should allow primary care physicians to do the jobs they were trained for, changing their roles from “gatekeepers” to “patient advocates and guides.” We should immediately start financially rewarding them for collaborating with specialists to manage patients throughout the full continuum of care. Keep in mind that, as the Dartmouth Atlas and other studies have made clear, most health care waste is concentrated in the sub-specialties and in inpatient settings, incentivized by a fee-for-service reimbursement system that rewards more procedures, independent of their utility.  One very thoughtful approach to invigorating primary care has been advanced by Norbert Goldfield MD and colleagues.

Of course, truly re-empowering primary care will require more than just paying primary care physicians more. Higher reimbursements will help them afford to spend more time with each patient, yes, but PCPs also need help acquiring tools that can help them better manage those patients. And they need the authority to work collaboratively with specialists. Challenging, but certainly doable and important!

Changing America’s current imbalance between primary and specialty care should drive significant downstream waste from the system, dramatically improving quality and reducing cost.

Increase the Incentives For Programs That Tie Payment To Outcomes
Projects like the CMS/Premier Hospital Quality Incentive Demonstration (HQID), in which 250 participating hospitals got 1-2 percent bonuses for achieving quality improvements, have clearly demonstrated that incentives work. The hospitals that pursued the incentives made greater strides in quality improvements than their peers who did not work toward the incentives.

But we need to make the financial incentives large enough to drive real paradigmatic change. Too many programs offer incentives that are trivial in the minds of providers. Does it make sense for physicians in small, busy practices to rework their office flows to try to meet the challenges associated with hitting targets in exchange for a 1 or 2 percent financial bump, tied to a fraction of their patient population?

Now that there’s no question that incentives work, we could easily give these programs teeth by raising the incentive antes to 15 or 20 percent, while also demanding commensurate levels of savings. And we should go in, understanding that the goal is to drive out unnecessary care, and create expectations that,  by managing better upfront, the total spend will be lower.

Data
Establish a National All-Payers Database
Data sets, including those comprised of health care claims, must be large to generate credibly useful information.

But health care is financed through many different payer streams and by many players within each stream.  Nearly all treat their data as proprietary, and information remains fragmented. So, for example, physicians rarely receive useful information on their complete pool of diabetic patients: instead, they get small slices of data from each payer, each analyzed using a different proprietary methodology. Or, we fail to accumulate adequate sample sizes to identify which treatments, interventions, drugs, devices, health plans, physicians or facility services provide the best value.

But merging those data across payers and making the aggregated set freely available would create the basis to identify true evidence-based best clinical and administrative results. Based on hundreds of millions or billions of records, we might be able to credibly identify which professionals, services or approaches most consistently produce the best results within value parameters. The data set would always be building, providing an always slightly-new base for answering our most difficult questions. Together with the analytical tools that are also becoming stronger and more refined, the potential is vast.

Of course, health plans, always politically formidable, might fight tooth and nail to maintain the competitive advantage they believe is inherent in their data. But health care is a special enterprise, with objectives that are ultimately rooted in the common interest, so they have no real excuse to refuse this. And health plans, like the rest of us, would gain access to much larger data sets that can be mined to advantage.

There also are precedents here. Several states have already begun to establish all-payer databases. At a June 2008 meeting, a presentation on Maine’s experience highlighted 3 fundamental, telling principles that are challenges to any effort.

1. Nobody wants to pay to develop and manage the database.
2. Nobody wants to contribute their data to the database.
3. Everyone wants the aggregated data that develops in the database.

The solution: make it a national effort, paid for by CMS, and with mandatory participation, user fees, and open access to the data.

Create Uniform Nationally Accessible Disease Registries
Many physicians have come to appreciate the value of disease registries. Registries allow clinicians to count all active patients with distinct conditions, e.g. hypertension or diabetes. They can track characteristics within a patient subset, e.g. diabetic patients on a particular medicine. They can monitor and stratify patient status and progress within each group, and generate reminders and alerts to assure guideline level care. And they can identify trends in performance and, with relative ease, get a sense of what works and what doesn’t.

Even so, many registries are still in silos, meaning that the sample sizes remain small and that the parameters that define the registries’ characteristics often vary between implementations.

What we need are freely available, Web-based registries with easy data entry and easy querying capabilities. The impact on our management of patients with chronic illness, who consume 70 percent of our health resources, would almost certainly be powerfully positive.

Release Medicare’s Physician Data
Nearly a year and a half ago, the consumer advocacy organization Consumer Checkbook sued the US. Department of Health and Human Services (HHS) for the Medicare physician data in four states and DC. HHS argued that physicians have a right to privacy, even though, in the case of Medicare and Medicaid, they are vendors taking public dollars, and even though hospitals do not enjoy the same protection from scrutiny. In August 2007, the court held with Checkbook, and on the AMA’s “advice,” HHS promptly appealed, locking up the data for the duration of the Bush Administration.

The large commercial health plans have traditionally considered their claims data proprietary and so have not made their data sets publicly available. Self-funded health plans, administered by Third Party Administrators (TPAs), develop sizable data sets but have resisted collaborating, and have also not expressed an interest in making their data available.

So for those outside the health plan community, there are few, if any, data sources with sample sizes large enough to accurately evaluate and profile physician performance. This is significant, since studies have shown that there can be profound differences, 6x-8x, in resource consumption (i.e., cost) between the least and most expensive physician (within a specialty and market) to obtain the identical outcome.

In other words, not all doctors perform equally. While more patients are paying out-of-pocket for a larger portion of care, there is still virtually no credible information to guide their physician choices.

The American people could quickly learn which physicians within a specialty and a market consistently get the best outcomes at the lowest costs if Medicare physician data were made publicly available. Releasing these data would also put pressure on physicians everywhere to understand their own numbers, and to improve if their performance values are lacking.  We see this as beneficial to the great majority of physicians who seek excellence in their work.

Smoothing the Way
American health care is a vast enterprise in which millions of professionals and hundreds of thousands of organizations vie for an ever larger portion of what has historically been an always growing resource pool. The chaos and dysfunction that has developed in health care is largely due to two system characteristics. One is the fee-for-service reimbursement system that has rewarded more rather than the right care. The other is a lack of transparency that prevents us from knowing and understanding performance, even when that performance is dangerous: what works and what does not, which approaches are high and low value, who does a good job and who does not.

The five action steps outlined above would allow us to better identify the problems and opportunities in our health system, as well as the strongest solutions to drive decision-making. Then they would leverage that information to create strong incentives for the right care, organically changing the dynamics of care and reimbursement and, to the degree possible, smoothing the transition required to heal the way we supply, deliver and finance care in America.