Primary Care Breakfast Club Publishes in NEJM

We are happy to announce that the authors of Primary Care Breakfast Club published a perspective piece in the New England Journal of Medicine on September 6, 2012.  Our piece, titled "The Developing Vision of Primary Care", has received a lot of feedback from all sides.  If you are interested in continuing the conversation, feel free to leave a comment.

To read the piece, visit the following link: http://www.nejm.org/doi/full/10.1056/NEJMp1204487

We hope you enjoy and would love to hear your feedback!

Accountable Care Organizations: Par for the Course

Betty Jo was one of my favorite patients as a medical student. This 71 year old widow, with an obsessive zest for golf, was also one of my best teachers. It took this affable elderly woman to demonstrate the United States health system’s fragmentation before I truly understood the magnitude of the problem. She was a motivated patient who was lost in the shuffle between doctor visits. Miscommunication was the norm between my preceptor and Betty Jo’s other providers. She had 20 medications scribbled on an old piece of yellow legal paper, but nobody knew what she was actually taking, not even Betty Jo. I was embarrassed by her care which resulted in poor outcomes, deteriorating health, and multiple hospitalizations.

Like Betty Jo, over half of Medicare beneficiaries have five or more chronic diseases¹. Chronic illnesses require new and innovative ways to deliver care. A 10 minute appointment slot that culminates with a blood draw and limited free samples of necessary life-saving medications represents a failure of our pre-ACA system. Running from one doctor’s appointment to the next, getting each of her diseases treated individually is proving ineffective. The quality of care is poor, costs are exponentially rising, treatment regimens are uncoordinated, medical tests are redundant, hospitalizations and emergency room visits are frequent, and the patients are unhealthy and unsatisfied with their care.

For Betty Jo and the other 47 million Medicare enrollees, Title III of the Affordable Care Act (ACA) hopes to provide an answer². Title III establishes a shared savings program with organizations, known as Accountable Care Organizations (ACO), which will take responsibility for all aspects of Medicare patients’ care, including quality and cost. ACOs will bring together groups of doctors, other providers, and hospitals under one network³. ACOs that agree to manage all the health needs of at least 5,000 beneficiaries for no less than three years will roll out this spring ⁴.

The most exciting aspect of an ACO is that it will create an environment conducive to clinical innovations. ACOs will liberate providers from the chains of fee-for-service, and pay them in ways that promotes creativity and innovation in care delivery. Practices will finally step outside antiquated delivery models and start utilizing group visits, team based care, longer patient visits, and technology to maximally enhance patients’ health. Specifically, in a world where non-communicable diseases are the most salient health problem, this new model of care will integrate all components of the care delivery chain, improving health outcomes, and keeping patients, like Betty Jo, out of the hospital and on the golf course.

ACOs show promise and are being touted by some as the solution that will revolutionize health care delivery across the U.S., but I see three challenges ACOs must overcome to achieve effects of that magnitude: (1) primary care physician (PCP) shortage, (2) inaccuracy and inexperience assessing quality, and (3) inability to reach rural and other underserved populations.

The PCP shortage creates a barrier for successful implementation of ACOs. At the center of the ACO model are PCPs who are essential for providing access into the network, and then coordinating and integrating care with others in the medical neighborhood. Specialist providers are good at treating illness once the patient is already sick, but the goal of an ACO is to keep patients healthy and to reduce both specialty care and hospitalizations⁴. PCPs are specifically trained to provide comprehensive care focused on keeping the patient healthy. When prevention, health maintenance, and routine care fall short, they are experts at connecting patients with appropriate specialty care when needed. ACOs will ask more of PCPs, but with too few providers available, it will limit the capacity of ACOs⁵.

The second major challenge moving forward will be to determine what quality indicators are important and how these metrics are measured. As payment and shared savings are tied into quality control, it will be critical to ensure that the metrics accurately reflect the care being provided. A recent report from the Inspector General discusses how quality measures from electronic databases are often too blunt and are unable to provide useful information on targeted outcomes⁶. Quality measures must be able to tease out the direct effects that providers have on patient outcomes, but the science of measuring this will take time to fully mature. Lastly, many practices have limited or no previous experience with monitoring quality data⁷. For these practices, operating under new quality and cost incentives will feel like making their way in the dark.

The last major impediment to successful implementation is that ACO models will be difficult to adopt in rural health clinics (RHCs) and Federal Qualified Health Centers (FQHCs). One out of five Medicare recipients lives in a rural area and in 12 states over 50% of the Medicare population is rural⁸. RHCs will not have sufficient startup capital or enough patients to justify bearing financial risk for their care. Even with the subsidies and tiered risk-bearing which was negotiated last October, it is feared that the financial incentives will not be enough unless the total potential savings is increased⁷. FQHCs serve 1.4 million Medicare beneficiaries and face a similar situation. It will require extra incentives for them to take responsibility for the outcomes of this inherently high risk population⁹.

Despite these challenges, ACOs show promise for delivering better health care to patients like Betty Jo. Betty Jo’s primary care provider will finally have the time and tools he needs to coordinate and integrate care effectively and ultimately keep her healthy and out of the hospital. This will encourage clinical innovations that are patient-centered, more efficient, and higher quality; all this will cost Betty Jo, as well as the overall health system, less¹⁰. Private insurers have already shown interest in negotiating ACO-like contracts, so non-Medicare patients will benefit as well¹¹. For Betty Jo, her future looks bright and her new biggest concern will the bogey she just got on the 18^th hole.

References:

1. Accountable Care Organizations: Improving Care Coordination for People with Medicare, Healthcare.gov; November 16, 2011

2. State Health Facts, “Total Number of Medicare Beneficiaries 2011,” Kaiser Family Foundation; February 2012

3. McDonough, J., Inside National Health Reform; University of California Press; New York 2011

4. Gold, J., “ACO is the hottest three letter word in health care,” Kaiser Health News; October 21, 2011

5. Centers for Medicare and Medicaid Services website; https://www.cms.gov/ACO/, accessed February 19, 2012

6. Levinson, D., “Adverse Events in Hospitals: Methods for Identifying Events,” Department of Health and Human Services; March 2010

7. Berwick, D., “Making Good on ACO’s Promise: The Final Rule for the Medicare’s Shared Savings Program,” The New England Journal of Medicine, 365:19; November 10, 2011

8. Kaiser Family Foundation, “Percent of Medicare Beneficiaries Residing in Rural Counties, by State, 2010,” February 2012

9. MedPac, “Federally Qualified Health Centers,” MedPac Report to Congress; June 2011

10. Merlis, M., “Accountable Care Organizations,” Health Affairs; July 27, 2010

11. Fisher, E., McClellan, M., and Safran, D., “Building the Path to Accountable Care,” New England Journal of Medicine; 365: 26, December 29, 2011

PBS Documentary: U.S. Health System: The Good News

PBS's recent documentary on communities in the United States that are providing high quality health care at a lower cost is inspiring and worth checking out. They highlight several communities across the nation, including Grand Junction, CO, Group Health in Seattle, and physician practices in Everett, WA. Communities are doing great things, but in isolation. This documentary shows us that we are capable of providing high quality care, efficiently and cost effectively. Hopefully, medical communities across the nation will adopt practice patterns that are similarly responsive the health needs of the population.

Check out the documentary here.

BWC

Ezekiel Predicts the End of Insurance Companies by 2020

Ezekiel Emanuel boldly proclaims that insurance companies will be extinct by 2020 in last week's New York Times article. He believes that Accountable Care Organizations (ACO) will push them out of the market. It will be interesting to follow his prediction over the next 8 years to see if he is correct.

Emanuel explains that ACOs will eventually bear all the financial risk for patient care when they are implemented which will eliminate the need for insurance companies. ACOs, which will be composed of groups of doctors, other providers, and hospitals, will work together to provide the full range of patient care. Eventually, he sees patients paying a flat rate directly to ACOs, who, in turn, will provide all services needed. The advantage of the ACO model is that it incentivizes providers to keep the patient healthy and focus on prevention, rather than provide care only at the point of illness. Additionally, it will integrate care for the patient, creating better collaboration between different providers.

At the moment, 60% of insured citizens under age 65 in the U.S. are insured through their employer. In these cases, the financial risk falls on the employer, not the insurance company. This leaves the insurers there to help with processing claims and to provide negotiating power with hospitals and doctors. However, ACOs will charge a flat premium, which should reduce the amount of administrative work required to process and file insurance claims on a case by case basis. In situations where insurance companies take on financial risk for patients’ health – such as small businesses and individuals – they have enough market power to cherry pick healthy patients, charge high premiums, and deny patients’ claims. When ACOs start being implemented, insurance companies will be competing with ACOs for these patients. This will infuse better competition and should reduce the need for patients to hassle with insurance companies over coverage.

Emanuel also breaks down the difference between ACOs and HMOs in a very concise manner. First, ACOs and HMOs are similar such that patients are members of the organization and members pay a flat fee. In other words, payment is not done on a fee for service manner in either of these models of care. However, Emanuel emphasizes that ACOs will be local groups of providers, not large national corporations like many HMOs, so ACOs will be able to better respond to local patient needs. Also, ACOs will be financially incentivized to keep patients healthy rather than only getting paid to treat the sick. Lastly, he points to the advancements in electronic medical records as well as the science of care integration as improvements since the HMOs’ day.

Personally, I am not fully convinced that insurance companies will be extinct by 2020. It may be that I do not understand ACOs to the depth that Emanuel does. But, maybe in the end, ACOs will become large enough that they will just take over coverage responsibilities as well. Time will only tell.

BWC

Why Doesn't Pay-for-Performance Work?

Why doesn’t pay for performance work? It seems that by defining health outcomes and financially incentivizing physicians to meet those targets, we would see improved health. However, since the United Kingdom (UK) has implemented pay-for-performance incentives, the evidence that this change improves health status is negligible.

Researchers from the National Primary Care Research and Development Centre have been tracking health outcomes for asthma, diabetes, and coronary artery disease since implementing a pay-for-performance model in the UK. They found that health outcomes for asthma and diabetes improved, but only in the short run. In the long run, the rate of improvement leveled off. For heart disease, the results were even more disappointing as they did not even show improvement in the short run.

A study from the Department of Public Health Sciences, looking at intermediate outcomes of diabetes under pay-for-performance did not provide any better news. In fact, their results were not able to show a statistically significant difference in physicians’ ability to meet performance targets after rewarding physicians based off of performance.

The researchers also collected data from patients asking about perceptions of access to care, continuity of care, and the interpersonal aspects of care. The pay-for-performance method had no effect on any of these indicators either.

Performance based payment works in other fields, but for some reason it does not work in health care. This may point to the need to better define quality in health care, particularly in primary care. Maybe looking at HgA1c targets is fine on the individual level, but for population based diabetes control, this is not the answer? Perhaps, physicians are not incentivized by payment as much as economists would like us to believe? I am not sure what the problem is, but these results point us away from pay-for-performance as the silver bullet for improved quality in primary care.

BWC

References:

Stephen Campbell, et al, "Effects of Pay for Performance on the Quality of Primary Care in England," The New England Journal of Medicine 2009; 361: 368-78

Stephen Campbell, et al, "Quality of Primary Care in England with the Introduction of Pay for Performance," The New England Journal of Medicine 2007; 357: 181-190

Pooja Vaghela et al, "Population Intermediate Outcomes of Diabetes Under Pay-for-Performance Incentives in England from 2004-2008" Diabetes Care 2009; vol 32, no. 3

An Evening with Dr. Blumenthal

I just got home from a fascinating 3 hour talk with Dr. David Blumenthal. You can read more about him here, but he is basically one of the leaders in the quality field of health care and recently spent 2 years working in the Obama administration as the head of Health Information Technology (HIT). He came to speak to our US health policy class at the Harvard Kennedy School of Government and a smaller group of us had dinner with him afterwards. I wanted to share a couple things he spoke about that I found compelling.

Cost
Dr. Blumenthal answered one question about cost containment, which has been a hot topic in the national debate of late and something I've been reading quite a lot about. His answer was not novel nor complicated but brought my attention back to the reality of our health care system. 5% of the patients account for 50% of the costs. Atul Gawande wrote about this in his The Hotspotters article in January and countless others have shed light on this as well. Blumenthal's answer was simple: "Go where the money is." He spoke about better coordinating care, keeping these patients with multiple chronic diseases out of the ER and hospital, and actively pursuing them to better manage their care. Call them at home everyday, visit them in person, lay out their 15 or 20 medications for them, and fill in every gap where their care is dropped.

My reflection is this: If we are serious about reducing health care costs, and there is no doubt that we now are, we must work tirelessly to first find these patients in our health care system, even if they are not our own. We must proactively engage them in the medical system so that we are not caught reactively responding in extremely inefficient ways. We must think system-wide about the ways in which we currently fail to fill the gaps and bring all of the sometimes dozen providers for these patients into the discussion. And we must find innovative ways to engage the patients and their communities to embrace healthier attitudes and behaviors the are community driven.

Health Information Technology
We couldn't spend three hours with Dr. Blumenthal without talking about health IT, something he spent the last two years of his life on in Washington. Here are some of his reflections:

-Health IT is rapidly expanding across the country and has doubled in the last 2 years
-Competition and decentralization of HIT is good because it is driving innovation in the field. There are now over 1300 different private companies providing HIT and the innovation they are creating will have enormous positive impacts decades into the future. Quelling that force now in favor of a more unified system is the wrong thing to do.
-That being said, cross-talk is an important part of the future of our electronic medical records (EMR). Patients need to be able to take their records with them when changing locations and health systems. The government has put in place standards that are being adopted by the private HIT enterprise. Providers will also have to achieve some standard of meaningful use in the coming years to earn the substantial savings available through the stimulus bill that passed in early 2009. It is up to providers to put pressure on the health IT companies they work with to comply with these standards
-Privacy isn't nearly as big an issue as people say it is. Technology has been developed. Barriers to the sharing of information is primarily systems and politically generated.
-He doesn't have much sympathy for small practice physicians who are complaining about the cost of switching to EMR. The previously mentioned stimulus bill has provisions that will more than pay for their implementation, provisions that amount to $100 of tax revenue per American citizen to make this happen. He says this indicates that the public prioritizes it and it is high time providers do too.
-He is very optimistic that HIT will continue to grow, and it is necessary, but not sufficient, to attending to many of the problems in our health care system.

Quality
Dr. Blumenthal is a national leader in the quality movement in health care. He spoke at length about this during our structured lecture with him. Quality essentially was put on the map in the late 1990's after the Institute of Medicine's report in 1999 called "To Err is Human." This was followed in 2001 by another report from the IOM that Blumenthal described as a seminal document called "Crossing the Quality Chasm." Prior to these reports, quality was not on the policy map as much of an issue.

Quality is something that I admit I don't think about much. I tend to be of the mindset that our health care system is pretty darn good, but I often compare it to other places I've been in the world that have far worse health systems but also shoddy electricity. This fails to ask the important question, "How can we do better?" If I truly reflect on my medical training, I'm appalled at much of what goes on in the hospital and even in the outpatient setting. Care is so fragmented that providers are often very under-informed about the stage of care delivery a given patient is in or a recent change in treatment plan proposed by a different physician or service. The bottom line is that lots of bad things happen all the time with even more near-misses to make even the most inexperienced clinician worried.

This is what Dr. Blumenthal has been trying to remedy. So while I often push quality issues to the back of my mind, they are an area we can drastically improve on. We will save money if we keep people's blood pressures and hemoglobin a1c's under better control and don't order unnecessary costly imaging studies. We will save lives if we prevent infections in the hospital by washing our hands. And we will make much better clinical decisions if we have electronic records that remind us when we are doing something outside best practices. I think we can do a lot better to improve quality and I am excited that through better care coordination and the smart use of HIT we can work to accomplish so much more than simply containing costs. After all, our primary goal is helping patients get and stay healthy.

JK-R