The Good and, Too Often, the Bad of Primary Care in the U.S.


Death by a thousand bureaucratic demands. That’s how many American physicians currently describe their jobs, with work days that often don’t end until long after their kids go to sleep, when they finally finish documenting their clinical interactions. You see, government regulators and insurance company bureaucrats have been imposing a growing number of quality measurements on doctors, who consequently have to spend hours each day tracking what they’ve done to and for their patients.
But physicians need to understand that the need for late-night documentations is partly their fault. Government payers and insurance companies are monitoring American physicians for a simple reason—too often, the medical care physicians provide is of substandard quality.
Consider findings from a study by David Levine and his colleagues at Harvard. They reported on how the quality of primary care evolved between 2002 and 2013. They found that primary care physicians do a great job in some tasks—90% success at offering cervical cancer screening, for example, all the way back to 2002; more than 90% success in avoiding unnecessary sleeping pills in elderly patients for most of the past decade. In addition, primary care physicians have improved their performance in some notable ways since 2002: the percent of people with heart failure receiving life-saving beta blockers has increased from less than half to almost two thirds in that time period; the number of people with coronary artery disease receiving cholesterol pills has also increased from half to almost two-thirds.
(To read the rest of this article, please visit Forbes.)

If We Cut Surgical Pay, Will Surgeons Cut into More People?


Knee replacements are booming. Between 2005 and 2015, the number of knee replacement procedures in the U.S. doubled, to more than one million. Experts think the figure might rise 6-fold more in the next couple decades, because of our aging population. Since many people receiving knee replacements are elderly, Medicare picks up most of the cost of such procedures. It shouldn’t be surprising, then, that the program is experimenting with ways to reduce the cost of each procedure.
The problem is – if healthcare providers make less money on each knee replacement they perform, they might start replacing more people’s knees than they should.
Does that sound crazy? Well consider what happened when Medicare began experimenting with a new way of paying for knee replacements – something called bundled payment. Under such reimbursement, Medicare pays one lump-sum for the total cost of a knee replacement – not just the cost of the operation but also the cost of post-operative x-rays, physical therapy, even time in nursing homes or rehab hospitals. Before bundled payment, providers received separate payments for each of these services. As a result, inefficient providers would take more x-rays than necessary, or keep patients in rehab hospitals longer than needed, and they would be rewarded for such inefficiency. Under bundled payment, providers cannot send separate bills to Medicare for hospital charges, physician fees, outpatient x-rays, and the like. Instead, they get a lump sum payment to cover all these expenses. Moreover, Medicare tracks all the knee-replacement costs for a given patient, over a 90 day period. If a patient incurs lower expenditures than expected, Medicare gives the providers part of these savings back as a reward. (Warning – this is a WAY oversimplified description of bundling.)
Early evidence suggests that bundled payments reduce the cost of knee replacements by an average of almost $1200 per patient. Save that much money on a couple million such procedures in a year, and we are looking at billions of dollars of savings. Moreover, research to date suggests that these savings don’t come at the expense of quality, at least as far as we can tell. (Quality measurement in healthcare is notoriously difficult.) For example, when knee replacements were paid for through bundled payments, there was no subsequent increase in readmission to the hospital or emergency room visits among patients whose procedures were reimbursed according to bundled payments. Same quality at a lower price – who could be against that?!
Well, caution is in order. Healthcare systems that enrolled in the bundled payment system might have saved money on each procedure, but they more than made up for that by increasing the number of procedures they performed – about three procedures more per hospital compared to hospitals not receiving bundled payments. This finding, indeed ALL these findings, are tremendously preliminary. Bundled payments are still in their infancy. Quality measurement still doesn’t capture everything we’d like it to.
(To read the rest of this article, please visit Forbes.)

The Key to Surviving Your Hospital Stay? Get Admitted During Inspection Season

A fascinating study from JAMA Internal Medicine shows that hospital mortality rates decline when hospitals are being inspected by The Joint Commission, a national accrediting agency. Here’s a picture showing the research findings:

Which raises the question – is there a way for hospitals to be vigilant even when they aren’t being inspected?

Watch Out Hospitals: Medicare’s Planning to Punish You if You Misbehave

It used to be that hospitals billed Medicare for the services they provided, and Medicare – I know this is crazy! – simply paid the bills.
Those days are rapidly receding into history. Soon, a significant chunk of hospital revenue will be at risk, under a series of Medicare pay-for-performance programs. The idea behind P4P (as the cool kids call it) is simple. Third party payers, like insurance companies or the Medicare program, will monitor the quality of care offered by health care providers like hospitals. High quality providers will receive more money than low quality ones, thereby giving providers an incentive to improve the quality of care they provide.
Medicare has created several P4P programs which, unless they are halted by the Trump administration, are slowly coming into effect. By 2017, as I will show in a bit, these programs could put a sixth of Medicare payment at risk.
What are these programs?
One is the Hospital Value-Based Purchasing Program or (and you have to give Medicare folks kudos for their marketing prowess) VBP. Under VBP, Medicare monitors a bunch of quality measures, like the rate of hospital acquired infections, the number of patients falling while in the hospital, and even the risk adjusted mortality of hospitalized patients. Medicare scores each hospital based on how well it performs compared to other hospitals, and compared to its previous performance. This score determines part of a reward or punishment at the end of the year. By 2017, 2% of Medicare hospital payments will be redistributed according to VBP results, with money transferred from low to high performing hospitals.
Medicare has created another acronymically-challenged program, HRRP, which stands for Hospital Readmissions Reduction Program. The program measures how often patients with diagnoses like heart attacks, congestive heart failure, and pneumonia are readmitted to hospitals after an initial stay. The program will financially penalize hospitals that have excessive readmission rates.
Finally, under its HAC program (not named after the sound made by someone with bronchitis), Medicare is tracking how well hospitals reduce the rate of Hospital Acquired Conditions, like catheter-related bacterial infections. Some of these measures overlap with the VBP measures, amounting to a double counting. That’s a problem I’ll talk about in a minute.
(To read the rest of this article, please visit Forbes.)

Hugs, Tweets, and Physician Reimbursement — A Problem for Pay-For-Performance

According to recent research, a hug a day could keep the doctor away. According to another study, twitter can predict the chance that people will experience heart attacks. A normal blogger would look at these two findings and tell a story about the relationship between stress and health. I’m not normal. I looked at these two studies and came to a different conclusion – that we need to change the way we reimburse physicians.
Want to know how I arrived at that view? Let’s start with a quick look at the two studies.
A research team headed by Sheldon Cohen from the University of Pittsburgh exposed volunteers to Rhinovirus particles and monitored them for signs and symptoms of illness, going as far as weighing their nasal mucus. (Isn’t research fun!) Consistent with previous research, they found that people under psychological stress were more likely to become sick, unless they reported having strong social support in their lives. You see, stress creates a neurohumoral cascade, a series of physiologic reactions in the body that impair the immune system. But social support can buffer the immune system.
Even more interestingly, Cohen discovered that hugs – the likelihood that a volunteer was hugged each day – further buffered people’s immune systems, reducing colds even after accounting for the other kinds of social support people received. Hugs are good medicine!
What does this hugging study have to do with physician pay?
In the old days, health care reimbursement was based primarily on the volume of services medical providers provided. Perform one procedure and receive payment; ten procedures and receive ten payments. Perform one annual exam and you’ll be paid for one annual exam, well… you get it. More recently, payers have tried to shift from such fee-for-service payments to pay-for-performance methods. Two doctors might charge Medicare for conducting annual exams on their patients, but if measures show that one does a better job of making sure her patients receive appropriate preventive measures, she will receive higher payments than the other physician. In this case, Medicare would be relying on process measures of care to adjust payments. In other cases, pay-for-performance is based upon outcome measures. For example, cardiac surgeons might receive different levels of pay at the end of the year depending on the survival rates of their patients who undergo specific procedures, after accounting for the severity of patients’ underlying illnesses before the procedure. It’s these outcome-based pay-for-performance measures that are threatened by hugs and tweets.
(To read the rest of this article, please visit Forbes.)

Why The Government Tried To Fix Primary Care And Failed

Americans spend more per-capita on medical care than just about any other country and, yet, they often have little to show for it. Americans have worse access to care than people in other countries, and are often less likely to receive primary care services, like preventive therapies and screening tests. Determined to address these problems, Medicare leaders have been testing out new models of primary care, hoping to find win-win situations – reimbursement schemes that improve quality while maintaining or lowering the cost of care.
So far, many of those efforts have failed.
Near the end of 2012, Medicare began giving extra money to almost 500 primary care practices across the US, money the practices used to try to improve the care they offered to their patients. The goal of this Comprehensive Primary Care Initiative was to prod primary care practices to make it easier for patients to: contact providers quickly; coordinate care with other specialists; provide care management to patients with complex chronic illnesses; and better engage with patients and their care givers. The extra Medicare payments were decent sized, almost $60,000 per physician per year. The practices could use this money to hire extra nurse practitioners, or to reimburse those who were working odd hours to give patients more access to care, or other efforts.
Medicare not only gave practices these upfront payments, but also offered to give practices extra money if they reduced overall spending for their Medicare population, an incentive known as shared savings.I am a primary care physician and for around 20 years I worked in VA medical centers, a system that, during my time there, did a great job of coordinating care between primary care physicians and sub-specialists, and of offering care management for patients with complex illnesses.
When I practiced in the VA, I often worked closely with pharmacists and nurse practitioners, for example, to address the need of patients with uncontrolled diabetes. So I am very excited that Medicare is trying to invest in and test ways of improving primary care.
Medicare administrators hoped that better primary care would lead to lower costs. Coordinating care with specialists, for example, should reduce unnecessary testing. Better care management should reduce the need for hospital care.
(To read the rest of the article, please visit Forbes.)

Your Physician Can't See You Yet – She's Busy Filling Out Paperwork!

Left to our own devices, most of us physicians try our best to provide high quality care to our patients. But almost none of us provide perfect care to all of our patients all of the time. In fact, many of us get so caught up in our busy clinic schedules we occasionally forget to, say, order mammograms for women overdue for such tests, or we don’t get around to weaning our aging patients from unnecessary and potentially harmful medications.
Because the quality of American medical care is often uneven, third-party payers – insurance companies and government programs like Medicare – increasingly measure clinician performance and reward or punish physicians who provide particularly high or low quality of care.
The result of all this quality measurement: gazillions of hours of clinic time spent documenting care rather than providing it.
According to one study, in fact, clinic staff spend more than 15 hours per week dealing with quality measures for every physician in the practice. In other words, a six-physician clinic group can expect 90 hours of staff time spent documenting quality performance. And it’s not just the staff that are left to do such documentation. Physicians spend precious time in such activities, too. The same study estimates that physicians spend almost 3 hours per week documenting the quality of their care. Here’s a picture of that finding:

Your Physician Can't See You Yet -- She's Busy Filling Out Paperwork 1
Is it any wonder why so many American physicians report being burned out by their jobs?
To read the rest of this article, please visit Forbes.

Are Device Manufacturers Playing Bait-And-Switch with the FDA?

Are Device Manufacturers Playing Bait and Switch with the FDA Charlie Brown
The problem with the FDA is that if often requires so much proof of safety and effectiveness that the time it takes to bring a new product to market can grow by 3, 4, or even more years. FDA delays into the time that companies have to exclusively produce and sell their products.
In recognition of this problem, the FDA sometimes grants marketing approval to innovative new devices through a Pre-Market Approval Pathway, or PMA. Under this pathway, companies are allowed to bring their products to market more quickly – with less than optimal evidence on safety and effectiveness – as long as they promise to continue collecting such data through post-market surveillance.
According to a study in JAMA, device manufacturers often fail to keep up their side of this bargain.
In the study, Vinay Rathi and colleagues looked at all 28 new high risk devices receiving PMA approval in 2010 and 2011. They found that FDA approval was often based on scant data – studies of less than 300 patients with no blinding and limited follow-up. (With blinding, clinicians measuring patient outcomes do so unaware of which patients have received which interventions. Without blinding, such outcome measures can be biased by clinicians’ expectations.)
Given the small number of patients studied prior to market approval, it is that much more important that manufacturers continue to collect data once their products come to market. Unfortunately, most devices are not well studied once on the market. According to authors of the JAMA study: “Most devices have been or will be evaluated through only a few studies, which often focus on surrogate markers of disease in small numbers of patients followed up over short periods of time.” In fact, almost half of post-market studies are funded without support from the manufacturer.
Why are manufacturers being so lax in conducting post-market research?
(To read the rest of this article, please visit Forbes.)

Have Reimbursement Rules Taken the Joy Out of Being A Physician?

Photo Credit: The New York Times
Photo Credit: The New York Times

She came to the urgent care center with a sprained ankle. The primary care provider gave her excellent care, expertly applying evidence-based evaluation guidelines to her situation, and, thereby, avoiding unnecessary x-rays. By all measures, the provider’s care was excellent, but the interaction still ended up reducing his salary. You see, that patient’s only medical interaction that year was for this ankle sprain, and the provider was therefore held accountable for all of her primary care needs. Since she had not received a mammogram that year, or received a diabetes screening, he incurred an end-of-the-year penalty for failing to meet these quality standards.
Is it any wonder that many providers – primary care physicians, physician assistants, and even many beleaguered specialists – are increasingly dissatisfied with their jobs? What is happening to medical practice and what can we do to bring the joy back to being a healthcare provider?
I am early into a one-year quest to connect with leading thinkers from inside and outside medical care, so I can better understand why many clinicians are miserable in their careers, and much more importantly, what can be done to help them thrive at work even though an increasing number of outside parties are looking over their shoulder, assessing the quality of the care they provide .
These increasingly burdensome rules and regulations are making it hard to enjoy medical practice these days. Several decades ago, physicians largely practiced as autonomous professionals, governed by standards developed by their professional peers. Physicians underwent intense and prolonged training to develop the knowledge and skills to know how best to help patients with their problems. And the world generally stood back and accepted, on faith, that most physicians would provide excellent care to most of their patients. (To read the rest of this article, please visit Forbes.)

Could Pay-For-Performance Lead To Overuse Of Antibiotics?

Not long ago, the Joint Commission (a healthcare quality organization) established that patients with pneumonia should receive antibiotics within four hours of diagnosis. Timely diagnosis and treatment can be the difference between life and death in patients with this illness. In fact, some people believe this kind of quality measure should play a large role in how we pay for medical care. After all, doctors should not be paid solely on the basis of how much care they provide, but also based on the quality of that care. All else equal, a physician who treats pneumonia efficiently should be rewarded more handsomely than one who takes a fortnight to make a diagnosis.
Only one problem with this seemingly sensible view. Experts believe this four-hours-to-treat requirement leads to an over diagnosis of pneumonia and, consequently, to an overuse of antibiotics. How we measure healthcare quality, and how we factor such measures into physician reimbursement, can have surprising effects on how physicians diagnose and treat patients.
Consider another life-threatening illness – sepsis, a syndrome of widespread inflammation and, at its most extreme, multi-organ failure caused by infection. Sepsis typically requires not only high power antibiotics but also intensive care from multiple specialists. A recent article in the New England Journal of Medicine suggests we may be experiencing an over diagnosis of this syndrome, because hospitals often receive higher reimbursement for patients with sepsis than for ones with milder infections. In other words, it pays not to miss sepsis diagnoses. (Visit Forbes to read more and leave comments.)