Patient centered care and the family physician’s brain

Paul Grundy is IBM’s Director of Healthcare, Technology and Strategic Initiatives for IBM’s Global Well Being Services and Health Benefits.

He has led the development of the Patient-Centered Primary Care Collaborative, which is leading the way to create a more efficient and responsive healthcare system. Before I go any further, let me be very clear by saying that his work is hugely important and I agree with 90% of what this organization is doing.

I heard him speak recently at the annual meeting of the North American Primary Care Research Group, which is the largest and most influential organization for primary care research. Others sitting at my table said they’d heard him before and that his presentation that day was typical of others they’d heard.

One oddity of his talk was that he showed a model of the Patient Centered Medical Home (PCMH) full of the usual boxes and arrows. It included phrases such as care coordination, electronic medical records, and disease management (I’m going off of memory here. I can’t find the slide online), but didn’t mention family physicians or primary care physicians.

After his talk I went to the mike and asked something like, “What is being done to reform the evaluation and management (E/M) billing system (the Medicare rules most insurers follow that determines how much documentation doctors must do to justify a charge) so that I can take care of 5 issues at one visit and be paid for dealing with all of them?” He gave a very political non-answer that went something like, “This isn’t the appropriate time to ask for something like that.” I was puzzled and wondered what about his background would cause my question to not connect better with him.

According to his bio (reading between the lines), the only time in his professional career he directly cared for patients was 1979-85 when he was a medical officer and flight surgeon in the Air Force. When the E/M system was mandated in 1995-7, he was the Medical Director for a non-profit medical system. I’m sure he’s financially savvy, but it doesn’t appear that he’s ever had to earn a living as a primary care physician off the current rules, which haven’t changed since 1997.

Because IBM is a tech company and because America is a technophilic society, it makes perfect sense that gadgets such as electronic medical records (EMRs) would appeal to Dr. Grundy and others. However, the evidence that primary care provides better health at a lower cost than multi-ologist care predates all the new gizmos. All the American studies listed in the Starfield analyses didn’t rely on EMRs to achieve their results. Quad Graphics, a large printing company in Wisconsin,  has 18 years of data showing its commitment to primary care has resulted in 30% lower costs than other large employers in its region over the entire time span.

The research on the effectiveness of EMRs is spotty at best. They don’t consistently improve quality, safety, or prevention. About the only care delivery factor they have been consistently shown to improve is they make handwriting errors on prescriptions go away.

I was dismayed that the inherent patient-centeredness of my question didn’t resonate. My question wasn’t just about my needs. When I talk to non-medical people they have the same frustration about their doctors’ visits. We live in a Wal-Mart culture not a go-to-the-market-every-day culture. Americans want to save  up a list of needs then go to the market and have them all met in one visit. There are studies documenting that Americans make fewer visits to primary care physicians than other countries. In Britain, the general rule is the consultation only lasts 10 minutes. If more issues need to be addressed, the patient is expected to make another visit. Most Americans would rather not make another trip.

The E/M rules are way too complicated, but in a nutshell, after I address two issues with my patient the rest of the visit I’m giving away my services. If you’ve ever visited a primary care physician for your migraines and high blood pressure, then was annoyed that he insisted you make another appointment to talk about a rash that just appeared, now you know why he did that. If he addressed the rash on the first day he was paid nothing; if he addressed the rash on a different day he was paid the full fee.

There are lots of other ways the national bigotry against family medicine, as reflected in the E/M rules, disincentivizes family physicians from taking complete care of their patients. I’ll cover more of that in a future post.

I have nothing against many of the other features the PCMH supporters push. I accept that colleagues such as diabetic educators and nurse case managers are an important part of a highly functioning healthcare team. Their work should be paid for as well.

What Dr. Grundy doesn’t seem to understand is that the most important component of any patient-centered solution to our healthcare system is a family physician’s brain. (Sorry general internists and pediatricians. The evidence for better outcomes at a lower cost is much stronger for family physicians/European GPs than your fields.) Family physicians bring to the patient encounter a unique set of skills and approaches to patient care that lead to efficient patient-centered care. An EMR by itself doesn’t add much. I want to be the comprehensive convenient family physician for my patients and I’d like to provide lots of services in one visit. My friends and neighbors tell me that’s what they want too.

Therefore it is much less important that reformers push electronic gadgets on my practice. It is much more important that I be paid for the work I do, which means blowing up the current E/M system.

I guess this means I’m not an IBMer.

Richard Young is a physician who blogs at American Health Scare.

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  • http://www.haelthecommunications.wordpress.com Steve Wilkins

    Richard,

    Nice post! Many of the PCMH pilots going on around the country do value the experience and knowledge that FPs bring to the table.

    Steve Wilkins

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    The 7 principles outlining the 2007 PCMH joint statement by AAFP, AAP, ACP and AOA, listed Personal Physician as the #1 principle and payment reform as #7.
    Both of those have somehow fallen off the cliff when NCQA designed its PCMH certification, and was also left out as other organizations began pushing for this type of change.
    Why? Because having a personal physician is way to expensive, and payment reform is way to hard.

    The problem I see is that when you construct an entire theory on certain assumptions, and then go ahead and arbitrarily remove two of them, chances are very good that the entire enterprise will collapse.
    I don’t know that what is being piloted and rolled out all over the country is the same thing that primary care associations originally suggested.

  • http://www.haelthecommunications.wordpress.com Steve Wilkins

    Margalit,

    Luckily there are large scale Medical Home pilots like that being conducted by BCBS of Michigan and Group Health to name a few, that have nothing to do with NCQA certification requirements. Have a person physician and payment reform are integral components of these programs.

    • pcp

      In the Group Health project, each physician had his patient panel reduced by 25%. That is, 25% of patients involuntarily lost their doc. One can assume that they were not included in surveys reporting increased patient satisfaction.

      In contrast, the original PCMH documents (Future of Family Medicine, et. al.) assumed that each physician would increase his/her panel by 25-50%. It was explicitly stated that the physician would spend LESS time with each patient.

      The point is that there are many PCMH models out there now, and they are all being co-opted by the insurers. The end-point has become “quality” (i.e., lower payments to providers).

      • http://www.healthscareonline.com Richard Young MD

        PCP,

        I must say I admire Group Health for putting their money where their mouth is by reducing panel sizes so the primary physicians hopefully won’t feel like their on the proverbial hamster wheel as much. The little I know of the details of this approach makes me think they’re putting too much emphasis on the prevention/wellness aspect of primary care and not enough financial support for encouraging family physicians to provide as much care for their complex patients as possible.

        What do you think?

        • pcp

          The Group Health results come from only one clinic. Patient panels were reduced by 25% and support staff by up to 75%, while physician salaries were maintained or even increased. One wonders if Group Health will maintain these standards as they rework their other clinics.

          In any case, this is a level of financial support that is unavailable to other primary care docs, even in the most generous of demonstration programs. And that’s why most of us are VERY tired of Group Health being held up as a model for the rest of us to emulate.

          The finances of the Medical Home are the elephant in the room that no one wants to discuss. Even practices in demo projects are crashing and burning, and the AAFP’s National Demonstration Project basically confirmed this (which is why the results have been shoved under the rug).

          All I know is that when I attempt to provide more comprehensive to complex patients (including those who work for IBM), I get the shaft.

    • http://www.healthscareonline.com Richard Young MD

      Margalit,

      I believe the NCQA certification requirements are severely lacking in their understanding of why family physicians deliver better population health at a lower cost. See my comments to Dr. Grundy where I expand on a few points.

      • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

        And I agree, Dr. Young. The problem I see is that the joint principles were written by primary care associations as a general concept on what a medical home should be, and those primary care organizations probably assumed that what they knew to be true about primary care is implied.
        When these principles were prematurely passed along to certifiers, the forest was lost from view due to the wealth of strange new trees planted around it.

        I think the primary care associations should have taken a more active role in specifying the details of this vision and particularly the means by which the implementation should be measured. But then again, it seems that medical associations in general have other things on their minds these days.

  • pcp

    I wrote Dr. Grundy and asked him why, when I provide to patients employed by IBM all the services of a PCMH, I get payed zero dollars and zero cents.

    I’m still waiting for a reply.

    • http://www.pcpcc.net paul grundy

      IF- you are a PCP in MN, VT, ME, CO, Az, TX, PA, MI , NC, RI and working with the state or healthcare plan you ar getting paid more already. If this is not happening in your state talk to plans, your Chapter, your state Medicaid leadership and ask why? IBM will play and pay more for PCMH level care and the value that brings where ever we an buy this level of care via our HC plans. If the plans will not or can not do this they will not have IBM’s business for long or for that matter many other large employers including the US office of personal management.

  • http://www.pcpcc.net paul grundy

    Dear Dr Richard Young, Good post and thank you so much for giving me feedback it is very valuable to me. I really do think the import issue is the healing relationship and the most important tool the physician comprehensivest brain.
    Here a few of my talks that are on line I would love to get some feedback from this forum on how I can improve them. What I say is from my heart but no question I could get it better .

    http://hosted.mediasite.com/mediasite/Viewer/?peid=cb0603cfc3e444af92fbc27610f2ee871d — my 2011 DOD talk starts at 8 mins (slide 17) but you will want to listen to Don Berwick at about 1 hour 12 mins (slide 85)

    http://hosted.mediasite.com/mediasite/Viewer/?peid=98001d020d3141e1b7e1ec2611b572e2 — here is my 2010 talk. Slide 2

    http://www.kff.org/ahr121310video.cfm

    But I also think it will be a very different brain – one with actionable information made avalible to it . Look the Automobile made the doctors legs very different in terms of communicating differently with their patients so too Data/actionable information tools like Watson will do to same for the brain. I do want the FP Physican with the right tools one that would allow them to do population management easy say or engage the patient better..

    What I say (or at least mean to say) is I want care that is comprehensive, integrated, coordinated, accessible and built on a personal healing relationship with their primary care physician.

    The care I want is that outline in the joint principles of the PCMH vs thec are I buy now which in large part is episodic, disintergrated, uncoordinated and inaccessible care.

    EMR’s well I think they are really primitive right now in fact very hard to use for most primary care docs just to inefficient hopeful that will improve in the near future.

    To any and all welcome to give me feedback I find this so helpful thanks again for caring enough to take the time to write this – Bless your heart!! And thank the dear lord for the Family Practice Physicans Brains I just wish we had more of you and we could help expand those brains with the right easy to use tools.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    Well, if Dr. Grundy is willing to listen, here we go:

    I think the basic concept of patient centered medical home is a sound one, but the translation of it into an operational, measurable model is missing the mark.

    1) I don’t quite understand the emphasis on team care. No physician cares for his/her patients all by themselves today. Each person in a practice has a defined job, and in a well run practice each person touches the patient in many different ways, from the receptionist to the nurse to the NP (if there) to the physician and ultimately to the biller. But as you said in a slightly different context, there has to be a captain somewhere, and that captain must be the physician.
    What exactly is a “Primary Care Manager (PCM)” mentioned in the 2010 presentation?

    2) The joint principles mention the term “population” once as it pertains to payment and case mix. Why is a Patient-Centered construct, in need of population considerations? Where is that coming from and how does it square with the obvious variance between a single patient’s needs and population needs, and which one should prevail? Should a doctor concentrate on managing population indicators or should “Every patient be the only patient”?
    Here I must side with Dr. Berwick’s view (as published in Health Affairs in 2009).

    3) EHR and HIT, those are really not, or should not be, anything more than enablers for PCMH. I don’t understand why the focus on these tools is so pronounced, to the point of drowning the original concept. Dr. Blumenthal used to use an analogy of HIT as the circulatory system of medicine, which is fine (I love computers and HIT), but where is the heart in that system? Even with Watson coming up, we do still need a heart, don’t we?

    • pcp

      This, along with financial non-viability, is the major flaw in the PCMH: it’s primarily about management and administative processes, not about results.

      Primary care docs are drowning in administrative busy work. The PCMH raises that to an unsustainable level, and to what purpose?

  • http://www.healthscareonline.com Richard Young MD

    Dr. Grundy,

    Thank you for your open-mindedness, intellectual curiosity and honesty, and willingness to receive feedback on your important work. As I said in the original post, I agree with 90% of the points you make. If I were to include here everything I believe about what is wrong with American healthcare and what needs to change, I might overload the server. So in the interest of brevity I’ll just focus a few thoughts on the 10%. I watched all the videos in your post. they were very similar to your talk at NAPCRG, except I didn’t see the PCMH diagram you said you took to some gathering in Washington in these sets. (I also watched Dr. Berwick, and his talk sounded like his writing.)

    I believe the 7 Joint Principles of the PCMH are OK, but it’s the sub-bullets that are lacking. For example, if my patient calls me at night saying his asthma is acting up, should I coordinate care and send him to the ER, knowing that my EMR talks to the ER EMR and I can get the ER physician’s notes and test results the next morning. Or should I provide the care and tell my patient I’ll meet him at my office in 10 minutes. The PCMH model doesn’t answer this question. The cost results of the two alternatives are huge, particularly if the payer doesn’t respect the time and energy I took to keep my patient out of the ER, with its attendant ridiculous charges and over testing.

    If I have a mildly demented elderly patient who lost her husband last year and who just developed diabetes, should I push aggressive diabetes management including home health, diabetic educators, and case managers in an effort to lower her glycosylated hemoglobin below 7, or should I have a long talk with her and her family to present their options on how we approach this new issue? How strongly should I make the point that within reason her average daily sugar level won’t make a hill of beans of difference in the quality or length of her life. The existing PCMH model with its quality bean counters only allows for the aggressive treatment option.

    If I have a patient who sees a commercial on TV of a hospital gurney chasing a handsome and apparently fit man on a golf course and my patient requests the advertised drug, should I be patient-centered and please my patient by honoring his request so I score well on my next patient satisfaction score card? Or should I be system-centered and take lots of time to thoroughly explain why he doesn’t need this drug? If it takes me 10 minutes beyond a normal visit, will you pay me for that time?

    If I have a patient for whom I’ve addressed her knee pain and depression, but who mentions just as my hand touches the door knob that her feet are becoming numb, should I provide comprehensive care and conduct a thorough history and physical for this new symptom that will take me 10 to 20 minutes? Does your answer change if you realize that under the current E/M billing rules I will be paid nothing for the extra effort? Why shouldn’t I just send her to a neurologist if that action only takes me 1 minute? Or should I be non-patient-centered and tell her I don’t want to discuss this concern today–she has to make a new appointment (so I’ll actually be paid for my services, but of course I don’t tell her that).

    These are examples of the decisions family physicians make every day that are not recognized or respected by the payers, quality overlords, government agencies, or other physicians. None of the Joint Principles of the PCMH or the NCQA PCMH steps informs us what the right answers to these questions are. But how family physicians answer these questions are the real drivers of their cost-effective care. EMRs can’t answer these questions, only the family physicians with their unique set of beliefs, knowledge, and skills.

    Finally for feedback, when medical technology is spent on prevention, an ounce of prevention costs a ton of money (with rare exceptions such as prenatal care and the old childhood vaccines). In one of your talks you mentioned keeping 40–year-olds in IBM healthy, which you said is especially important as this group becomes IBM’s leaders of the future.

    Just to take one intervention that I’m sure is provided to these people, there is a debate in the mainstream literature now on whether primary prevention of high cholesterol with statins is effective at all. At best it’s a very expensive undertaking with no savings down the road to make up for the upfront costs of testing and treating. At best statins don’t save lives they extend them. On average in an otherwise healthy 40-year-old population, the average increased life expectancy is no more than a few days.

    Finally overall, I hope that me and my colleagues in the Residency Research Network of Texas can help bring some clarity to some of these PCMH issues. We interviewed 32 family physicians on the topic of cost-effective care last summer and submitted our findings to hopefully present at this year’s NAPCRG meeting. I hate to be a tease, but you know how prickly the academic world can be about prior publication. I’ll just say that we found many themes not covered in any statements of the Joint Principles of the PCMH. We hope our research findings can play a meaningful role in shaping the debate on the aspects of primary care the healthcare system should value most.

    Thanks for your leadership by going around the country and talking frankly about the exorbitant cost of American healthcare, and realizing that primary care is the most important foundation on which to build a better system. I applaud your efforts and hope my thoughts have helped in some small way.

  • Marc Gorayeb, MD

    Great discussion, Dr. Young. No one wants to address why your customers – your patients – don’t really value your services, and are encouraged not to value your services. EMR companies, Insurers, health care consultants, hospital administrators, pharmaceutical and medical device company executives, AMA, and government policy makers all have a vested interest in keeping patients from valuing physicians’ services. If people are smart enough to value the services of dentists, cosmetic surgeons, even accountants and lawyers, then they are smart enough to value the services of all physicians. You can’t/won’t value a service unless it costs you enough to make you stop, think and ask pointed questions. We all know what that means. None of the newly touted schemes of the government do that.

  • http://www.pcpcc.net paul grundy

    First point: IBM does not sell EMR’s- In fact we are in agreement that EMR’s are not the tool of choice for Primary Care Physicians who are trying to transform how they deliver care to become more patient centered. “I don’t understand why the focus on these tools is so pronounced, to the point of drowning the original concept.” Yes I would completely agree, the Primary care physician’s brain is the magic! Everything else- just tools- like a telephone is a tool – nothing magic about tools. Of all the HIT tools maybe the registry is the most important, and then a portal to allow better communication with your patients. Second point – payment innovation and reform are one of the PCMH guiding principles and currently what the CMMI, ACO and PCMH Pilots are trying to accomplish – better care deserves better pay.

    Back to tools and what they enable: Population management – as in managing the population in your practice so you can know who needs what and when- enables doctors to be proactive- to be sure care is delivered – this is how “accountable care” is delivered at the level of the healing relationship. True transformation happens when the PCP becomes a “Primary Care Manager (PCM)” or a primary care physician who does “well population” management, through the integration, coordination, and management of the whole population in his practice. For instance PCMH diabetes population management programs are producing significantly better outcomes and cost savings than are other disease management programs, including those for diabetes. In my opinion not to coordinate the care of a diabetic and to provide only episodes of care is unethical but done everyday. A single patient’s needs and the population needs of your practice – well they are the same thing. Your population is made up of single patients and all deserve to have you understand who they are and what they need –and they deserve a doctor who has the discipline to follow up and follow through, and for every one of their needs to be managed. The tools that enable this level of care are the tools our PCP’s need.

    Having the right team members is another important factor- -so for example moving the care coordinator out of the insurance plan office to the physician’s office and linking them right into the healing relationship with the physician. So, put the right tools and the right people right into the primary care physician’s office. Peter Anderson has done a lot of work on this – his Liberating the Family Physician is a book and instructions how the Physician can save 50% of his time in only 5 hours. http://www.familyteamcare.org As a buyer of care I want the care coordinated right in the practice and to be a connected/ part of the physicians practice and not delivered from a call center in Manila.

    Now there is a model of PCMH I call the Dr Joseph Scherger MD model that is much more physician oriented versus team care oriented and I think this model has a role to play as well. Joe’s just loves to practice this version of PCMH, and Peter’s “Family Team Care” approach is equally as satisfying for his team, look at them both and you decide what works for you – both are great models.

    • pcp

      “In my opinion not to coordinate the care of a diabetic and to provide only episodes of care is unethical but done everyday”

      Unethical is a very strong word to use here.

      I’ve asked the company that administers IBM health benefits in my area on multiple occasions to pay me for coordination of care, and they refuse.

      But I’m the one who is unethical?

      • pj

        Fully agree w/pcp.

        Paul refers to a “call center in Manila.”

        I doubt it would have ever come to that if our services were fairly valued to begin with.

        Is that not more due to the bean counters and buearacrats in the corporations than us lowly primary care docs?

        Again, what solution does Dr Grundy propose? I suspect he’ll just turf it to the RUC.

        • http://www.pcpcc.net paul grundy

          . PJ – Yes I agree with you — your services are not valued fairly at all nor are they paid for in a correct way and that is a huge part of the problem we have in the current broken system. See comment to PCP we need to help change that but it will take a social movement to do that – http://www.pcpcc.net please join in. See for you what solution is propose it is your solution that of organized primary care from the officers you elected. http://WWW.pcpcc.net.

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      Thank you for responding, Dr. Grundy.
      From your latest comment, I suspect we are in agreement on most substantive matters, and I have located some of Dr. Scherger’s writings and plan to read those.

    • http://www.healthscareonline.com Richard Young, MD

      Reading Dr. Anderson’s website reminds me of a local healthcare system that started installing EMRs in their clinics. This is one of those hospitals that started buying up primary care practices. The EMR was so inefficient the system then had to hire scribes to enter the information into the EMR as the family physician interviewed and examined the patient. The suits finally realized how much this was costing them, so they stopped installing EMRs in the remaining clinics.

      Another local system has used scribes for ER doctors for years. It sounds like Dr. Anderson is another example of an approach to seeing more patients per day that increases total revenue.

      However, his approach is still trying to make do with a payment system that does not pay family physicians for the complex cognitive work we do. His approach is no long-term solution.

      As for the claims of savings for diabetes management, I am reminded of the Medicare case management demonstration projects that showed it was hard to make up in downstream savings what was spent on case managers on the front end. I have no doubt that putting extra proactive work into diabetics with serious brittle underlying disease, or other psychosocial issues that make adherence to the treatment plan difficult, can save money. Indiscrimate proactive care on adherent patients with mild disease cannot save money in the short or long term.

      I love the idea of taking the care manager out of the insurance office and into the family physician’s office. I’d love to know how that service is paid for.

      On a related note, I thought the fact that none of the Medicare chronic disease management demonstration projects discussed in the February 11, 2009 JAMA article by Peikes, et al paid the family physician physician directly for the extra time and effort to manage the high utilizing patients, and was yet another example of the national bigotry against family medicine. Of course I assume that if the FP had such an opportunity, he or she would take the disease management revenue and direct his or her support staff to do a lot of the day-to-day communication and education. I also assume the family physician is the person in the best position to determine which patients would actually benefit from the extra attention. Perhaps some of the more recent demonstration projects will shed light on this question.

      You have said for years that IBM, other corporations, or the government should not pay for a dysfunctional healthcare system with its misaliged perverse incentives. Until the billing, coding, and payment reality changes for primary care, these PCMH approaches can only achieve so much. Otherwise, we’re only putting a fresh coat of paint on a house with a crumbling foundation.

      • http://www.doconomics.com Christopher Gregory

        Dr Young:

        Having read Dr Grundy’s views here and previously, and the responding comments in this running dialogue, the notion of the PCMH is clearly credible if (and that’s a big if) we achieve the efficiencies associated with horse-sense medicine characteristic of a delivery system that focuses on the most critical interface in health care, i.e., the interface between the patient and the comprehensivist ( a term I use) physician who sees the total patient. That requires an incredibly overlooked and grossly undervalued skillset and we have managed all along through the RUC and the E/M billing system to ignore and downplay the demonstrable efficiencies in the way primary care operates and how much it is costing us as legions of health care consumers wander aimlessly in the vast reaches of our jumbled health care system. Having worked with physicians for 30 plus years, I’ve heard stories from my doctors that are truly jarring, so I won’t tell any stories here about the horrors of misdirected, rudderless patient journeys through the provider-payer matrix. You have plenty of your own.

        We have a massive problem that all of these learned dialogues and all of the academic treatises seem to ignore, as the sand inexorably runs into the bottom of the hourglass. We have an aging population and we have a train wreck headed our way as 75 million Americans are due to board the Medicare train. So what do we contemplate politically? Find ways to cut? That is not the pat answer. The answer is to quit spending too much and avoid spending where spending has no demonstrable efficacy. Gee whiz, this ain’t rocket science folks. When a supply and demand problem is the 900 pound gorilla in the room, is cutting supply the answer and if so – what supply? Or is it focusing on the elements of demand, reducing the unnecessary drain on the system and increasing the best possible responses? Primary care medicine has time and time again demonstrated its cost-operational efficiencies, and that’s why the UK is taking on the crisis there by turning the wheel over to the general physician population. If our system is viewed as a spinning wheel, the lack of balance has the thing wobbling horribly and we are in need of a serious rebalancing.

        Using diabetes management as just one example, a couple of years ago, a study reported the difference between the cost of managing a Type 2 diabetic in Dallas and other cities in Texas. What was striking was the cost difference between Dallas and Fort Worth – just 35 miles away. In Dallas, the total management cost was reported as around $7,000 per year, while in Fort Worth it was around $1,600 per year. While subsequent feedback might have disputed the hard numbers (mostly out of Dallas), the simple fact remains that there is a difference, as there was with the other Texas cities surveyed. I happened to call one of my family medicine physician clients in Tarrant County (Fort Worth), and asked why he thought that was. His answer was straightforward – “influence”. In Dallas, diabetes care is much more under the influence of endocrinologists, who see patient more frequently, test more rigorously and treat more intensively than in Fort Worth – all the while referencing that Type 2 diabetics in Fort Worth are not suffering as the result of a different, less intense care regimen. So what else might explain the difference? Perhaps you can suggest, but from a conversation with one of my Dallas County family medicine doctor clients, there was a suggestion that when cases may present more difficult management issues, the family doctor may be financially disadvantaged in efforts to spend the additional adequate time addressing those issues, so the referral is made to the specialist.

        New systems are evolving, e.g., PCMH. ACO, etc. It’s acronym soup. But in all of this push to build a better mousetrap we do not recognize a fundamental set of forces that are operating. As a freemarket system on steroids, we are over-worrying, over-diagnosing, over-treating and over-prescribing – which all the while means we are feeding this dollar-guzzling system that will break the U.S. economy. As David Walker said once, health care is public enemy #1.

        • pj

          Right on.

          Hate to bash specialists, but I see so often how they justify their own existence or bow to perceived pressure by referring docs and the public.

          How do they do this? By doing more- more tests, more visits, more procedures.

          It seems absurd that the feds (CMS I believe) cannot consider the cost of a treatment when considering if they will pay for it or not.

  • http://www.healthecommunications.wordpress.com Steve Wilkins

    Dr. Grundy,

    Another important enabling factor which is generally overlooked amid the focus on Health IT support for primary care and PCMH is the quality of the “dialogue” between primary care physicians and patients during the medical interview. Almost 40% of patients are never asked the reason for their visit by their physicians, another 37% are asked but interrupted before they ca finish.

    50% of patients walk out of their visits not knowing what they were told yo do by their physician. Physicians spend <1 minute talking to patients about why they need and how to take new medications. And on and on.

    The point is that until physicians and patients do a better job talking with one another in measurably better ways all the rest seems to be just so much window dressing. I have made the point in my blog that '"lack of time" during the medical interview is not the real problem. The real problem is that physicians and patients simply do not know how to "communicate" with one another in a way that is tailored to both parties needs and beliefs. Any thoughts?

    Steve Wilkins
    http://www.healthecommunications.wordpress.com

    • http://www.doconomics.com Christopher Gregory

      Bullseye! In your comment – one hammer just hit one nail squarely on the head.

      I’ve read a comment of Dr. Young’s, in which he said that if he were the king of health care, he would replace the term “annual physical” with “annual conversation”.

      Just plain horse sense, isn’t it? One of my dear friends and a learned physician has repeatedly said that in all of medicine, the most valuable tools we have are the eyes, ears and hands of the skilled physician. What a shame that so much of medicine has gone off to “hi-tech-lo-touch”.

  • buzzkillersmith

    Don’t get hung up on the details, people. If this made any sense, you’d already understand it by now.
    The PCMH, like its close relations HMOs and ACOs, is not meant to solve real problems in medicine. It is meant to keep people like Dr. Grundy busy and employed and keep the rest of us confused enough that we can be fleeced by insurance companies and the government. Of course it will be a clinical failure. But that’s OK, because while it is failing its supporters can earn money telling us it is not failing or can earn money giving us bogus advice on how to keep it from failing. And once it fails, they can blame us. Also, as it fails, they can l come up with the next idea like BSIM (bogus solutions in medicine which can be implemented soon thereafter, with much fanfare from industry, version 2.0 EHRs (this time they’ll really work!) and non-practicing physicians touting their brilliance, of course.

  • Kaiser-FPMD

    I work for an “evil” HMO that so many here like to disparage. Over the last 6 years, I’ve seen Northern California KP transform into something pretty amazing. They’ve adopted a lot of what is recommended in the PCMH model without any “special” reimbursement from medicare. Premiums for private-pay have certainly gone up, but at no greater pace than the competition, and usually a fair bit cheaper than PPO and other fee-for-service plans.

    They’ve employed an Epic based EMR that’s made a significant difference in the efficiency and quality of the care that I can deliver, and has greatly improved communication between PCP’s, spcialists and patients. Email, same-day PCP and specialist appointments and imaging studies, in-room telephone specialist consults, roving physical therapy, telederm, care managers for many chronic illnesses including diabetes, HTN, asthma/COPD, warfarin therapy, etc. have made delivering care more convenient and timely. All of this has been achieved during one of the greatest down-turns in the economy in half a century, while remaining very profitable, and adding no net hours to my work day.

    I do see a few more pt’s per day (20 office appointments per day now compared to 18 when I first started, and 2-4 telephone appts per day) but the efficiencies generated by the system help make up for it. I’ve seen significant improvements in my pt panel with regards to all of the conventionally measured performance goals, including A1c’s, BP, lipid control, etc. Pretty much all of my patients are happier with these changes. Oh, and my salary has steadily gone up by about 6% per year since I started.

    The concepts of the PCHM work, as I can personally vouch for, given the right system. In a pre-paid system like Kaiser, the cost reductions easily pay for the capital cost of implimenting these changes (and those costs were pretty significant).

  • http://www.pcpcc.net paul grundy

    Richard Young, MD,
    I think you’re talking about the slide I showed in Seattle in Nov 2010 Today’s Care Vs Medical Home care this Slide comes from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma and it is the journey they are on to deliver care of greater value. That slide is here http://www.healthteamworks.org/medical-home/todayvspcc.html is this the one??

    So I thing this slide matchs the Joint principles of the PCMH pretty well and an example of how they are being but in action at the Univ of OK. As to the principles they are your not mine the principles are what your organizations put forward they are owned by you the membership of the AAFP, ACP, AAP, AOA. BTW they are the same concepts you put forward in the Future of Family Medicine (FFM) Project and for that matter very close to the principles laid down at the formation of the the precursor to the AAFP in 1947 and the Specialty of Family Med in 1969.

    As to Kaiser thanks for the note Kaiser-FPMD my employees are increasingly more happy with the care they get from their doctors at Kaiser. You guys are learning how to get smaller project to my employees as their Dr by name vs my doctor is Kaiser. They love the email engagement just love it. In one of the locations where we have a large number of IBMers under KP we are seeing 1/3 less need to do cardiac interventions because your managing their hypertension, aspirin cholesterol etc really managing it. I visited with some of my employees a PCMH in KP Riverside and Portland Oregon very cool!!

    • http://www.healthscareonline.com Richard Young MD

      Dr. Grundy,

      This is not the slide I referred to. The one I mentioned in the original post was not in any of your talks you gave the links to in this thread. No worries. It must have been for temporary use and not part of your standard presentation.

      Richard Young

      • http://www.pcpcc.net paul grundy

        Dr young I will be happy to send you the whole deck from that talk let me know where. Again thanks for your comments and feedback very helpful I do think your spot on.

        • http://www.healthscareonline.com Richard Young MD

          My blog-associated email is american@healthscareonline.com, which I assume is what you’re asking for. If not, email me at that address and I can provide other contact information.

          Thanks

  • http://www.pcpcc.net paul grundy

    Well a lot of work has been done in a few short years to change the covenant between Physician providers of comprehensive care in how we pay. http://www.pcpcc.net/guide/payment-rate-brief Where family physicians have stood up/demand change both of themselves and of the payers it is happen and I would say fast!!. Some states lets say CT not so much but from what I see in the ground in direct response to a lack of organized effort on the part of the Docs where this is not happing. Thomas Bodenheimer, M.D. said in this landmark article in the N Engl J Med 2006; 355:861-864August 31, 2006 http://www.nejm.org/doi/full/10.1056/NEJMp068155 “ A covenant is needed between those who pay for health care and those who deliver primary care: primary care must promise to improve itself, and in return, payers must invest in primary care.”

    At IBM we have instructed our healthcare plans to offer PCMH level care and to pay for that wherever it has emerged. IBM is are now paying more for this level of care to docs serving about 1/3 of our population and would be happy to do for all. We love PCMH level of care and it is adding great value to both our patients and the Family Pysician. BUT, it has to be via a healthcare plan now because that is how it is structure — we can not (surely you understand) pay an individual practice with a staff of three people facing the buy of our healthcare for all of IBM and neither can most compaines. The exception to that is corporate concierge PCMH where a company hires on site or near site care this is also happening like Perdue Chicken.

    Now for tough love -you have to stand up, have some courage, stop whining, organize in all your chapters around the convent change in the Joint Principles of the PCMH. For example In central NY 157 of your FP collogues told the plans and us employers they would no longer sell uncoordinated episodic dis-integrated care it was unethical immoral and all are on a journey to PCMH level care. BTW it has stabilized the manpower situation as well and the docs are happier much happier. Also, sorry to say if you do not transform your practices they are going to be worth nothing in 5 years honest. If this transformation is not happening in your state now call your AAFP chapter and get organized. to Quote Jerry Garcis — “Somebody has to do something, and it’s just incredibly pathetic that it has to be us.”

    • http://www.healthscareonline.com Richard Young MD

      Dr. Grundy,

      Thanks for loving us toughly. I agree that it’s time for family physicians nationwide to say, “I’m mad as hell and I’m not going to take it any more!” Leaving RUC should be the first step of that journey.

      However, for America to ever have healthcare that is somewhere in the same time zone as the Europeans in terms of cost-effective delivery, the PCMH principles aren’t nearly enough. They are too broad and don’t drill down the details necessary to change the American medical culture substantially.

      You never addressed my earlier comments about the three scenarios where family physicians provide services that currently are not paid for and make reasonable decisions that violate standard quality measures. Would any of these plans you enjoy touting pay for these services or recognize family physicians for appropriate exceptions to standard quality measures?

    • pj

      “we can not (surely you understand) pay an individual practice with a staff of three people facing the buy of our healthcare for al of IBM”

      “facing the buy of our healthcare”.. what????

  • http://www.pcpcc.net paul grundy

    The United States Office of Personnel Management (OPM) is the largest book of business for Blue Cross Blue Shield about $40 Billion a year 9.6 million lives the good news they are looking at your Joint Principles of the PCMH and saying yes this is what we want to buy !! The letter that went out to all the healthcare plan said between now and Jan 1st 2014 healthcare plans change the covenant between you and the Primary care physician so this is what you deliver. And by the way here is what the OPM is tell the healthcare plans what they want. And guess who they are going to need to talk to make this happen.

     24-7 clinician phone response
     Provide open scheduling.
     Provide care management and coordination by specially-trained team members.
     Use an EHR with decision support and registry.
     Use CPOE for all orders, test tracking, and follow-up.
     Medication reconciliation for every visit.
     Prescription drug decision support.
     Implement e-prescribing.
     Pre-visit planning and after-visit follow-up for care management.
     Offer patient self-management support.
     Provide a visit summary to the patient following each visit.
     Maintain a summary-of-care record for patient transitions.
     Email consultations.
     Telephone consultations.
     The development of care plans.
     Performance outcome measures.

    Now you could see this as a really opportunity to have a conversation with the healthcare plans to work with them to have the resources to do this level of care and change they way your seen and paid, In some state this is happening already Maryland, Minnesota, Michigan, Vermont are good examples (not perfect mind you but progress) In these states we see the comprehensivest working with the state leadership their chapters, their healthcare plans and real change happening. We are also seeing primary care practice leading in this Palmetto Primary care in SC a great example but hundreds more..

    Other option whine feel sorry but you yourselves have said as a specialty society that unless your specialty family med moves in this direction your out of business in the Future of Family Medicine. A charge was developed for the FFM Project: “Develop a strategy to transform and renew the specialty of family practice to meet the needs of people and society in a changing environment.” .

    Now you have large buyers on your side saying we agree we do want to pay you for the value you contribute we do agree with your principles. But can you deliver it will not just happen it will take risk and a lot of courage on your part for sure. For the first time in history, we have both the knowledge and the to force together substantial change. We are at a unique time in the history. In five or ten years, we might well look back with amazement at the pace of the changes that are currently taking place. The route is clear: We know what to do. We know how to make the system better. The crucial question is whether we have the courage to take on this difficult solution. But are strength lies in the fact that the primary care physicians want to help us take this on a wholesale transformation at the Micro primary care practice level in exchange for payment reform at the Macro level.

  • http://www.healthscareonline.com Richard Young MD

    How much does IBM pay for each of these services?

    How does a family physician who reconciles medications at every visit bill for the extra time it takes to do that over the traditional visit the E/M fees are based on?

    Does IBM pay for decision support, since the evidence in the literature is that it makes a miniscule difference in the quality of care?

    How does IBM pay family physicians (through the ERISA-protected insurance company administrator of course) for Pre-visit planning and after-visit follow-up for care management?

    Is the family physician on 24/7 call/access duty paid for being on call by IBM? If yes, but the on-call physician just tells everyone who calls to go to the ER, does he still get paid by IBM?

    Does IBM pay for the development of care plans? How is that billed, as a time fee or a number of issues addressed fee?

    I’m just thinking, if IBM has already worked out how to pay family physicians for all these services in a way that an insurance company computer can capture and report back to IBM, let’s just use the IBM model. No reason for the AAFP to re-invent the wheel.

  • http://www.pcpcc.net paul grundy

    Where ever we can buy care that has CDS, 24/7 cover, pre visit planning, email with the physician and better relationship based care more use of the Family practice physicians brain we have paid for that. We have been one of the companies willing to help pay for process change.
    We would agree with you and think the CDS out there is very primitive and adds little value now BUT we think it will get much more robust and have seen this is some places already.
    IBM is trying to work via a system change build broad base coalition in DC to drive transformation change the system. We feel as the 4th largest corporate buyer of care we should not only make the system better for our employees and families but for our mothers our community.
    Others large employers increasingly are taking a different route they are opting out and building corporate concierge PCMH asking you to work for them vs buying care from you. http://www.newsleader.com/article/20110423/NEWS01/104230323/1002/On-site-clinics-help-employers-workers-keep-down-costs
    We think this kind of care (lets call it Perdue chicken) care adds lots of value to the employees and families but does it fragment care? http://www.perdue.com/company/news/press_releases/press_release_detail.html?id=1159 Just so you know this kind of care is really growing it is up from 10% of the care to over 23%. What would it mean for your Area if the school boards, the county government, the fire department and the three businesses over 1,000 employees opted out set up their own box primary care box?? This is happening all over the USA right now. http://www.thetowntalk.com/article/20110422/NEWS01/104220326
    In Grand Junction Colorado the primary care doc are working with the buyers the healthcare plan to change the whole system. This might be a good model to follow Tom http://www.nejm.org/doi/full/10.1056/NEJMp1008450, So what is Grand Junction’s secret? Tom said “These features could be replicated in other markets—though generally not without political battles,”
    Leadership by primary care community. The Rocky Mountain Health Plans and the Mesa County Physicians Independent Practice Association (MCPIPA) is controlled primarily by family physicians.
    A payment system involving risk sharing by physicians. MCPIPA and the Rocky Mountain Health Plan (which has 60 percent market share) withhold 15 percent of fees from physicians—and put that in a risk pool. If costs are held low, physicians receive withheld payments. Cost profiles of each physician are also made available to all physicians to help spur “self-correction” of high specialist costs.
    Equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients. Rocky Mountain Health Plans pays physicians who treat Medicaid patients the same amount they’d receive for treating other patients.
    Regionalization of services into an orderly system of primary, secondary, and tertiary care. There is only one tertiary care hospital in Grand Junction and its surrounding areas. Smaller hospitals do not offer expensive interventional services.
    Limits on the supply of expensive resources. Cardiologists and other specialists are limited in Grand Junction because there is only one hospital that offers interventional services. And the tertiary care hospital has kept bed and expensive equipment at reasonable levels.
    Payment of primary care physicians for hospital visits. Rocky Mountain Health Plans has agreed to this policy—even after hospitalists began assuming care for inpatients.
    Robust end-of-life care. Compared to national averages, Grand Junction’s population spends 74 percent more days in hospice and 40 percent fewer days in the hospital during the last six months of life.

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