Health for life

Years ago, the Disease Management Care Blog had a pediatrician colleague who was widely admired for his diagnostic acumen, attention to treatment detail and personalized attention. As further testimony to his reputation, every physician wanted him to be their childrens doctor. The DMCB was one of those lucky docs. The luck ran out, however, when the DMCBs spouse quickly realized that she couldnt get any appointments and even if she did, the physicians clinic routinely ran two hours late.

Persons who read this New England Journal Perspective testimonial on the joy and frustrations of a primary care career should keep that physician in mind.   That reality contrasts with Dr. Finegolds fantasy world of dedicated physicians with limitless time where 1) the personal physician individually guides complex patients through a complex health care system and 2) the doctor patient relationship is fountainhead of professional satisfaction and patient well being. Thats why insurers should pay anything and policymakers should do everything they can to support this vision.

The DMCB sadly disagrees.

Primary care physicians are a precious resource. Theyre not only expensive, they are becoming more rare over time. As a result, use of their time and effort has to be restricted to circumstances when there is no one else who can deal with the paper work, make medication adjustments, work to increase treatment compliance, maximize the insurance benefit, deal with the social issues and provide psychological support. The DMCB thinks there are non-physician professionals who are better at these activities and do can do it far more cheaply. The solution is not more primary care physicians but more primary care physician support.

The DMCB physician colleagues may argue that the doctor-patient relationship is truly Holy Ground. Unfortunately, it is becoming increasingly apparent that there at too many patients and too few physicians to allow Dr. Finegolds indulgence of being so immersed in their patients lives. The degree of personalized involvement described in this article may be a luxury - like open access to brand drugs, the latest technologies, the priciest specialists or a few extra days in the hospital - that society can no longer afford.

Goin goin gone!

The Disease Management Care Blog recalls years ago when it was walking with some residents and students through a decommissioned wing of a hospital as a short-cut between patient floors.  Our footsteps echoed off the dreary beige tile while we chatted up the likelihood that we could get the next patient home this afternoon.  Then the  DMCB paused and took in the eerie fluorescent silence. "What you see around you," it mused, "is some valuable and unused capital."  The team then resumed the pace. Thats when the DMCB looked at the young docs and said "If we keep it up, theyll need to close another wing!" 

The fly in the ointment.  The monkey in the wrench.  The docs raised hand at a hospital board of trustees meeting.  Call it what you like, but sometimes our most cherished assumptions and best laid plans have a way of going all akimbo.  True to that tradition, curmudgeonly Dartmouth authors Stephen Rauh, Eric Wadsworth, William Weeks and James Weinstein examine the "illusion" of  expecting "lower costs" to come out the back end of a health system system after "quality" is put in the front end. 

The authors real focus is on hospitals and define "quality" as any intervention that reduces the utilization of health care services (versus other definitions). Despite the narrow view, the Disease Management Care Blog believes the article makes an important and yet obvious point: large and small health care organizations have rigid cost structures that cannot be flexed.  As a result, any increase in quality - such as reducing length of stay, admissions, readmissions or surgeries -  mostly results in additional dead space capacity, not bottom line savings.

Clinical improvement can reduce costs is in the general category of supplies and medications.  Unfortunately, those costs are at the margins.  Just because there are fewer readmissions wont mean all those expensive operating rooms. equipment, personnel costs and other administrative overhead will simply go away.  They dont.  Theyll be idle and cost just as much.

Some economists will argue that hospitals can take beds off line and furlough nurses.  Its also been pointed out that multiple health systems can regionally consolidate high-cost low-frequency services.
Unfortunately, the quarter to quarter business cycle facing the typical hospital administrator doesnt really accommodate that kind of wishful thinking.  The only way out is to find other revenue by either charging more or providing other services.

Despite many valiant attempts, the DMCB never managed to close another hospital wing.

Even the modest Disease Management Care Blog has to agree that its recent Patient Centered Primary Care Collaborative webinar on supporting care coordination within the medical home was a huge success.  Not only did it get to learn about the impressive work underway at North Shore-Long Island Jewish Health System, but the questions from a record 522 listeners helped the DMCB sharpen its focus.

Here’s one of the better questions that was emailed after the webinar was concluded:

What shared savings arrangements can happen on a small scale, for example a 4 doc office?

The (gently edited) DMCB reply:

None.

The month-to month variability in the insurance claims (think 95% confidence intervals) from a small practice makes it practically mathematically impossible to confidently compare an observed dollar amount to a target dollar amount. 

There are methods that can be applied to diminish the variability (such as censoring “excess” claims and using “risk adjustment”) but, at the end of a fiscal year, a lack of documented savings could be the result of either a) poor care coordination or b) an “underpowered” or mathematically suspect claims analysis.  The skeptical insurer will say it was the former and the screwed docs will say it was the latter.  When that happens, docs lose.

This is an example of the “law of large numbers” and why the shared risk arrangements in Medicare ACOs have to be based on a minimum of “5000” persons. By having that many observations, the variability is blunted and measures of central tendency hold up in an actuarial basis.

And then there are the two policy implications.  First of all, shared risk contract involving a relatively small practice is perilously close to the bad old days of capitation and HMOs, vs. the approach of spreading accountability across a large system that is armed with all the requisite care coordination resources  A four person group can’t match that.  Secondly, the insurers have little interest in putting together a payment system that could financially cripple a four person clinical practice, especially if its primary care.

The DMCB will examine accountable-like arrangements for a small group practice in a future post.

Dr. Smith* was well known among the hospitals medical directors. Thanks to his superb training and busy clinical practice, this busy physician was convinced, thank you very much, that he had all the knowledge necessary to manage his patient population.

Summary quality reports, feedback and best practice advice he did not need.  He also loved pointing out that he wasnt being adequately reimbursed to deal with administrative hassles, many national Clinical Guidelines were based on faulty research, his patients were not "average," and his duty to his patients was to "first do no harm."  He believed in patient education but resented administrators meddling.

The medical directors werent about to use a "stick" and "de"credential Dr. Smith and kick him out of the network. The "carrot" financial P4P incentives they offered for quality measures were modest and comprised a only a small percentage of the physicians income.  They. Were. Stuck.

Enter the Affordable Care Acts Patient Centered Outcomes Research Institute (PCORI). Writing in the latest issue of Health Affairs, RAND researchers Justin Timble, Eric Schneider, Kristin Van Busum and Steven Fox reassure frustrated medical directors everywhere that PCORI will come to their rescue by ushering in a new dawn of clinical trial research.  The studies will be so good that Dr. Smith will change his passive-aggressive ways.

Dr. Timble et al point out that the reluctance of physicians like Dr. Smith to change their clinical practice is not surprising.  Payment mechanisms incent questionable treatments, much of the published medical science is riddled with ambiguities, even expert scientists succumb to a host of biases when they interpret study results and doctors are more interested in avoiding the risky downsides versus the upside benefit of new medical advances.  Last but not least, clinic-based electronic record decision support never fails to disappoint.

Fortunately, says these RAND authors, the PCORI is on it. Its sponsored research will transparently solicit stakeholder input and investigate all meaningful outcomes, including side effects.  When this high octane knowledge is combined with a dollop of rigorous guideline development, more gigabytes of information tech decision support and the luster of Obamacares payment reforms, uncooperative Dr. Smith will be transformed into compliant Dr. Smith.

Sounds good, but the DMCB doubts that sprinkling PCORI pixie dust on docs is the cure to what ails the health care system. In its estimation, the RAND authors and the editors of Health Affairs are only telling half the story.

The DMCB to the rescue.

Despite the authors enthusiasm, PCORIs well-meaning stakeholders will have to make real-world compromises on study scope, data collection and completeness. Their research methods and findings will never be completely immunized against healthy skepticism.  And while RAND scientists and the readers of Health Affairs are professionally invested in PCORI, how well it competes for the attention of practicing docs like Dr. Smith remains to be seen.

Financial carrots and sticks can be used to change physician behavior, but Dr. Smith will ultimately stay in the drivers seat thanks to a) a looming physician shortage and b) the prospect that total physician reimbursement will go down, leaving no room for incentives. While integrated delivery systems, accountable care organizations and physician-hospital alliances may (or maybe not) wring some dollars out of PCORI-based efficiency and quality studies, it remains to be seen how these big capital-intense organizations will share any precious leftover dollars with their docs.

The population health management (PHM) service community has a better answer.

While high quality research conducted under the supervision of an expert professional class has its place, they know its ultimately up to the informed patient to make decision.  A considerable body of research, much of which would pass PCORI muster, has shown that shared decision making using a personal physicians advice is remarkably adept at reconciling imperfect research with patient values and preferences.  This, in turn, increases quality and reduces unnecessary costs.

The DMCB has seen countless physicians like Dr. Smith welcome the help of team-based nurses who can help his patients. He may call it "education," but theyre engaging patients in science based decision-making and taking a lot of work off of Dr. Smiths hands.