In response to HHS’s plan to begin using innovative payment models, Stephen Schimpff asks if actual health care providers will design these models or if the plan just represents more government regulation.
By Stephen C. Schimpff, M.D.
MARCH 5, 2015 – The Department of Health and Human Services recently announced that Medicare will reduce fee-for-service payments in favor of paying for value, which means improved quality at a reduced cost. They say, “Our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018. Alternative payment models include accountable care organizations (ACOs) and bundled-payment arrangements under which health care providers are accountable for the quality and cost of the care they deliver to patients.” This sounds like a logical step in the right direction. After all, many policymakers believe that the fee-for-service reimbursement method increases costs by encouraging more visits and more procedures. But unless HHS looks to health care providers themselves to identify these innovative, alternative payment models, I believe this will be just one more dictum from a centralized bureaucracy that will further stifle innovation and deepen the shortage of primary care physicians. Let me explain.
The current fee-for-service system pays too little for routine visits to primary care physicians. Given increases in office overhead yet stagnant reimbursements, the primary care physician tries to “make it up with volume.” In the last few decades a typical primary care physician has doubled the number of patients seen per day yet has the same income, inflation adjusted. More patients mean shorter visits; shorter visits mean less listening; less listening means less “relationship” and less trust. It means frustrated doctors and unsatisfied patients.
Medicare has developed innumerable rules and regulations that primary care physicians (and other doctors) must comply with or face audits and/or a reduction of payments. These have substantially increased the primary care physician’s workload without adding to patient care quality. Indeed, it takes time away from the patient and leads to a lower rather than higher quality of care.
Here are some examples:
The potential value of the electronic medical record (EMR) cannot be discounted, but most primary care physicians find that they must add an hour or more a day to comply with the Medicare rules for “meaningful use.”
There are standard, well-accepted quality measures such as levels of Hemoglobin A1c or blood pressure control. Quality measures sound appropriate, but do they really matter the most when treating older patients? The HA1c or blood pressure measurements may be low, resulting in a positive with Medicare, but if the patient wakes up with a blood glucose of 70 and feels groggy, that’s hardly quality. If the blood pressure is low it counts as a plus but, if the patient has resultant syncope, falls, breaks a hip and is hospitalized, that does not count as bad quality. Something is perverse here.
(Dr Andy Lazris, a primary care geriatrician, has written a compelling op-ed on this topic.)
Patients are clear that they most care about quality time with the physician — time to develop a relationship, be heard and build trust. They want easy access with short waits, a cheerful receptionist and a sense that they are the true customer of the doctor. That’s impossible if the doctor has only 15 minutes per patient.
Primary care physicians are a vanishing breed. Many are retiring early, others are selling their practices to local hospitals, and few are entering primary care practice from residency. It is a real crisis. Medicare’s new approach may inadvertently hasten the shortage.
It’s time for primary care physicians to stand together and demand accountability from Medicare. Primary Care Progress is a step in the right direction, as is the developing Primary Care Action Committee. Medicare should look to the primary care physician community to develop innovative approaches – not the other way around as it has always been. Heretical, perhaps, but it makes sense that real innovation that works will come from the people on the front lines, not from the well-meaning but distant bureaucrats in Washington.
One innovative payment model suggested by primary care physicians and designed to eliminate the 15-minute visit in favor of as much time as truly needed, would be to let Medicare pay primary care physicians a set amount per month or year for all primary care for each patient, a form of direct primary care or retainer-based primary care. This amount would allow primary care physicians to have a limited practice size of about 500 to 600 and therefore to see a reasonable number of patients per day, perhaps 10-12, and give the patients comprehensive, expanded primary care in the context of a close relationship built on trust. Called direct primary care, membership, or retainer, the effect is greater quality and reduced costs. Data from Qliance, a Seattle-based group that allots about 600 patients per physician, is striking. Primary care visits and time per visit have doubled, which costs more than typical primary care. But ER visits are down 14 percent, inpatient days are down 60 percent, specialist visits are down 14 percent, advanced radiology visits are down 29 percent and the total costs per patient, after subtracting the costs of Qliance primary care, are down 20 percent. Doctors and patients are satisfied, not frustrated.
Another innovative approach has been taken with a Medicare Advantage plan. Called Erickson Advantage, it is available to residents of the 18 Erickson retirement communities. The primary care physicians are salaried and each has no more than 400 patients – compared with the usual 2,500 of typical primary care physicians. Visits are the same or next day for a minimum of 30 minutes or longer as needed since prevention is paramount. Hospital admissions are down, ER visits are down and returns to the hospital have been cut by more than half. Quality is up, doctor and patient satisfaction is up and total costs are down. The data is in – more time with the patient means better quality and less cost.
I have written here before that Medicare has inadvertently created the crisis in primary care that exists today, but it can also be the savior of primary care. This will require a new approach by Medicare – a change that looks to primary care physicians to initiate innovations that work for the benefit of all.
Stephen C. Schimpff, M.D., is senior advisor to Sage Growth Partners, a retired internist, professor of medicine and public policy and former CEO of the University of Maryland Medical Center. He is the author of The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You.