Mayo Clinic Principles of Health Care reform

I had an interesting experience this week when my friend, retired pathologist Dr. Bob Gibb, asked me to sit in with him on a group telephone call among alumni physicians trained at the Mayo Clinic. It seems that Mayo has decided to try and play a "convener role" in our national discussion of health policy, and this phone conference was part of an effort to spread their message and get the word out about what they believe is central to true health care reform. They have also developed a web site for the Mayo Health Policy Center.

On the call I learned that Mayo has 4 cornerstone principles that they believe must be included for meanigful reform:

• Creating Value - do we actually improve health in a measurable way?
• Coordinated Care - Mayo is an example of working together and not in silos
  
• Payment Reform - provide incentives to coordinate care, improve outcomes and enhance patient decision making
• Health Insurance for All- essential in order to share risk, and improve the health of entire populations.

Although they have nailed 4 needed elements, I would add two more principles that I believe are also essential for us here in the United States:

• Choice - people want a choice of doctors, plans and hospitals when possible
  
• Access -the Massachusetts experience makes it clear that "insurance for all" is a hollow accomplishment without enough primary care doctors to provide access to care!

During the call, there was a discussion of the thought behind the Mayo cornerstones which noted that they support the personal medical home as a way of achieving the principles, they do not believe that simply expanding Medicare is rational, since it does not address value, coordination and payment reform, and they do support some pilot projects to sort out the various ideas of how to manage the needed change.

Steven Pearlstein noted in a recent Washington Post article, "If we really want to fix America's overpriced and under-performing health-care system, what really matters is changing the ways doctors practice medicine, individually and collectively. Everything else -- mandate or no mandate, the tax treatment of health benefits, whether there's a "public plan" to compete against private health insurers -- is just tinkering at the margin." I could not agree more. In order to get there, however, we will need to pay physicians differently to coordinate care, and measure results. For this reason, payment reform is the most critical first step. Indeed, the results we are seeing today are just what our payment system is designed to produce! The American College of Physicians (ACP) 2006 report actually predicts the imminent collapse of primary care in the United States, due to the inadequate and dysfunctional payment policies of the government and other third party payers.

We have an historic opportunity to change course. Thanks to the Mayo Clinic for weighing in!

How Does The Patient-Centered Medical Home Transform Health Care Delivery?

Can Patient-Centered Medical Homes Transform Health Care Delivery? The answer is clearly yes, and that is a point I have tried to emphasize, but I often get asked by those less familiar with the subject, how does this really make a difference?

The basic idea in a nutshell is that in order to be effective and add value, health reform must deliver a new delivery system built on a solid foundation of primary care. There are two barriers to this happening:

• We are losing primary care providers, and very few new doctors are in the pipeline to replace them
• The way primary care doctors are paid is inadequate and dysfunctional, so that they are not paid for the work that patients truly need and want them to do.

The medical home is an approach to primary care organized around the relationship between the patient and their personal physician. It is is primary care that is "accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.” It has now been endorsed by important, independent health care think tanks, such as the Commonwealth Fund.

In 2007, four primary care specialty societies, representing more than 300,000 primary care specialists, issued a joint description of the Principles of the Patient-Centered Medical Home:

• A personal physician;
• A whole-person orientation;
• Safe and high-quality care (e.g., evidence-based medicine, appropriate use of health information technology);
• Enhanced access to care; (e.g., phone visits, secure web visits, group visits with appropriate use of health information technology);
• payment that recognizes the added value provided to patients and insurers who have a patient-centered medical home.

Today, few Americans say they have a source of care with these features, but I am proud to say that my medical group, Family Care Network, has made wonderful progress to become a full fledged Patient-Centered Medical Home for our patients. We now know what works. There is no excuse to delay. If we do not move forward in this effort, we will continue to reap the whirlwind of spiraling costs and plummeting value. Primary Care will disappear. Now is the time.

The need has never been greater

My grandfather was a physician in general practice at the beginning of the last century, before the Flexner Report revolutionized medical training and brought medical education into the scientific age. His office was in the bottom of the family home. My grandmother would open the door, folks would come in, and the agenda was whatever was on the mind of the person who came. There was no phone interuption (there were no phones!), record keeping was easy (20 years on one 3 by 5 card), and most modern therapies had not yet been invented.

Today, many physicians in primary care continue to practice in the same basic style as my grandfather. They wait in their office to see what comes, and are only paid for this visit "piece work". It is as if the telephone was never invented, much less the Internet! They do not manage their patient panel in such a way as to improve their overall care, because they do not have the tools to know how the group is doing, and indeed, they may not even have thought about it.

Recently, Dr. Kevin Grumbach, professor and chair of the Department of Family and Community Medicine at the University of California, San Francisco, has renewed the call for a thorough "Revitalization of Primary Care". He correctly notes that the traditional model of primary care has not been very well supported by payers, purchasers or government agencies, and that people are turning away from it. In a recent article, he is quoted as saying, "This model of 19th-century practice -- of the doctor in the office and patients coming in -- is not going to work in the 21st century. We have come to the proverbial fork in the road." He identifies physician payment reform as one of the first steps we must take in revitalizing primary care, to provide the personal medical home. This is the work that we have been engaged in at Family Care Network.

Dr. Grumbach notes that the worsening shortage of primary care physicians is fueling "medical homelessness," which leaves patients without adequate access to primary care services and patient-centered medical homes. This is particularly tragic, since the ratio of primary care doctors to the population is the only statistic that has ever been shown to correlate with both improved health care quality and decreased cost of care. We must change now. The need has never been greater.

What does the Election of Barack Obama Really Mean for Health Care

We have chosen Barack Obama as our next President! This means that his proposal for how to reform health care will certainly set the tone for our discussion about how to improve quality, cut rising costs and extend medical coverage to about 45 million additional Americans.

Since any proposal must be submited to Congress, it is reasonable to assume that elements of Obama's proposal may well be modified, but at the core of his proposal are principles that would change health care delivery and coverage in the U.S.

The cornerstones of Obama's plan are:

• Expand Medicaid eligibility to include greater numbers of the uninsured
• Mandate coverage for children
• Create a national exchange where uninsured folks can purchase a public or private policy;
  
• Provide subsidies to lower-income individuals and small businesses to help defray the cost of purchasing insurance; and,
• Tax medium and large-size employers that decline to provide their employees with health insurance.

Of crucial importance in all of this is the need for us to remember that quality of care, and value for the money we spend, must be improved dramatically for any plan to be truly successful. Obama has chosen great advisers who understand this, but there is great danger that economic concerns could drive attention into only cost cutting steps, without insuring that we adequately pay for improved access and provision of primary care services. We could do the most to improve access and quality, while simultaneously lowering costs, by supporting legislation requiring all plans to provide payment for the personal medical home. Simply expanding programs like Medicaid, without this type of reform, will fail, since they do not pay primary care physician adequately for providing the care!

We have discussed the specific benfits of the personal medical home previously, and it is important to remember in a time of scarce resources, that by supporting the provision of primary care first, we are supporting the only thing that has ever been shown to be associated with both improved quality and decreased cost of medical care! Although well intentioned, throwing more money at our current health care mess will be bound to dissapoint us, by making more people eligable for the dysfunctional, and unorganized type of care that is currently bankrupting us.

Senate Hearing Links Physician Payment Rates to Primary Care Shortage

Several witnesses testified before a Senate committee on Feb. 12th that our nation's health care system continues to undervalue primary care services, and that this is leading to a skewed physician payment structure that is rapidly creating a shortage of primary care physicians throughout the nation.

Amazingly, although he agrees with and understands the data, the governments spokesman on this issue reaches an illogical conclusion, however. "When I say primary care services are undervalued, that does not mean that just increasing the prices paid to primary care is the solution," said Bruce Steinwald, director of health care for the United States Government Accountability Office, or GAO, during testimony before the Senate Health Education, Labor and Pensions Committee. "As you are well aware, we face unsustainable trends in the Medicare program and in the health care system as a whole. And, just as payment incentives are misaligned in primary care, they are misaligned in specialty medicine as well."

Yes, that is all true, I guess, but retaining primary care physicians will involve paying them more!

Medicare operates under a fee-for-service system, which rewards doctors based on the volume of services they provide. Medicare is the prime example of "how the system undervalues primary care services," and this discourages medical school students from pursuing a career in the primary care field, and causesthose in practice to restrict who they will see and retire early. These payment disparities have been exacerbated by technological improvements that allow subspecialists to provide more procedure type services in a shorter period of time, which leads them to an increase in payments and income, making these specialities more attractive career options for medical school students. In contrast, primary care physicians rely primarily on face to face time during office visits for their income. This means their ony option to be "more efficient" is to reduce time with their patients, which leads to rushed care and compromised quality.

I agree with the director, when he said, "This undervaluing of primary care services appears to be counter productive given the vast literature describing the relationship between health care costs and quality".

How do people in different countries view their health care ? How do their opinions compare to those in the US?

As we debate how to achieve an improved health care system for the United States, the opponents of change often raise the specter of "socialized medicine", and invoke stories about the horrible care and service in other countries. What has been lacking in this discussion is, how do the residents of the United States and other countries actually feel themselves about their experiences within their respective health care systems?

A new seven-nation survey has just been released by The Commonwealth Fund. It shows that U.S. adults were the most likely to say they experienced medical errors, more likely to report they went without care because of the cost, and more likely to feel the health care system needs to be rebuilt completely. The results, are published in the journal Health Affairs.

The article, Higher-Performance Health Systems: Adults' Health Care Experiences in Seven Countries, 2007, also shows that U.S. adults have the highest out-of-pocket costs and the greatest difficulty paying for needed medical care.

The survey was conducted among 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. One-third of U.S. adults surveyed called for rebuilding the system, and this was the highest rate of any country surveyed. In addition to cost concerns, the experiences of U.S. patients indicated more fragmented and inefficient care in the U.S., including medical record and test delays.

Commonwealth Fund Senior Vice President Cathy Schoen, the lead author of the study, said "Patients in the U.S. are frustrated by high costs and a complicated health care system,".

The survey also examined the experiences of adults who have a "medical home", which was defined in this study as a regular source of care that is accessible and helps coordinate their care. Across all seven countries, only about half to 60 percent of the adults reported having such a relationship with a health care provider. In each of the countries in the survey, those adults who did have a medical home reported a significantly more positive care experience.

Food for thought as we discuss how to improve our system!

The Medicare Crisis, National in Scope, Local in Impact

Medicare was founded in 1965 to help cover the costs associated with health care for older Americans and those with certain disabilities. Since that time it has evolved into one of the most needed and important programs in U.S. Government history. Unforunately, however, as our nation’s health care system now braces for a Medicare Population explosion, caused by the Baby Boom Generation aging into Medicare, primary care medicine finds itself on the verge of collapse due to drastically insufficient Medicare reimbursement.

Some Medicare beneficiaries have already felt this on a personal level, as they have had difficulty finding a family doctor for their primary care needs. This is due to the fact that Medicare funding for the services provided by family physicians often does not cover the actual cost to the doctor of providing that care! In fact, according to a 2006 report from the American College of Physicians, "Primary care is on the verge of collapse. Very few young physicians are going into primary care and those already in practice are under such stress that they are looking for an exit strategy". The report further notes that the key contributor to the problem they describe is the "inadequate and dysfunctional payment policies" of the government and insurance companies. "Unless immediate and comprehensive reforms are implemented by Congress and CMS (Medicare), primary care - the backbone of the U.S. healthcare system - will collapse," concludes the report. "The consequences will be higher costs and lower quality as patients find themselves in a confusing, fragmented, over-specialized system in which no one physician accepts responsibility for their care, and no one physician is accountable to them for the quality of care provided."

The problem described in this report is very familiar to your family doctor, and all of us here in my practice at Family Care Network (FCN). A Family Medicine practice is really a small business which simply cannot remain viable if revenue does not exceed expense. If the current inadequate and dysfunctional Medicare payment policies continue, and with the Medicare population about to increase dramatically, doctors will have no choice but to close their practice to Medicare patients. It is simply not possible for physicians to subsidize the care of so many without becoming economically non-viable. This is a terrible prospect, at the very time when the need will be the greatest! I believe that this is unacceptable, and that is why I am sharing this information about steps we are taking in my medical group, The Family Care Network Solution.

Family Care Network (FCN) has been working diligently to bring this crisis to the attention of our elected officials. While we sincerely hope that our State and Federal Governments will eventually address this crisis on both a national and local level, we have taken a position that FCN must seek out a more immediate solution to ensure our long term viability for survival.

FCN has developed a long term strategic plan for Medicare which we believe will enable us to:

1. Remain in Practice.
2. Continue practicing family medicine according to the Personal Medical Home model of health care as advocated by the American Academy of Family Physicians (AAFP) (see next page).
3. Continue providing care for our existing Medicare Patients.
4. Care for existing patients who become Medicare eligible.
5. Accept new Medicare patients into our practice (beginning in 2007).

The central component to the FCN Medicare Strategy is partnering ONLY with Medicare insurance companies that recognize the critical role played by family medicine in the overall health care system, and choosing ONLY insurance partners that financially support the "Personal Medical Home" as advocated by the AAFP and ACP.

We realize that patients have different needs and preferences when it comes to their Medicare health insurance. As such, FCN will provide our patients with access to multiple Medicare insurance plan options. We also recognize how confusing Medicare insurance has become and therefore FCN will provide insurance counseling services at no cost to our patients. Licensed insurance professionals well versed in all of the various Medicare insurance plans accepted by FCN, will be on-hand to help you understand your options and enroll in the Medicare insurance plan that is best suited to your personal needs.

Finally, FCN believes that healthy communication correlates directly to healthy patients. FCN requires that all Medicare insurance company partners provide internet connectivity between patient and provider via the DocInTouch web messaging program, at no cost to the patient. DocInTouch is a secure internet-based service that enables patients and physicians to communicate efficiently and effectively, and this type of functionality is part of the personal medical home concept.

The Personal Medical Home

All physicians and staff at FCN firmly embrace and support the Personal Medical Home model of health care advocated by the American Academy of Family Physicians (AAFP). FCN supports the Personal Medical Home in the following ways:

1. The physician makes a commitment to the patient to know them as a person, and to provide ongoing, continuity of care for illness and injury, as well as medical planning and advice for screening for illnesses and maintenance of good health.
2. Our office team shares this commitment, assisting the physician in providing hospital care, home care and consultation when needed.
3. Maintain accurate medical records for the care delivered and provide patient education using current technology.
4. Maintain patient registries for certain chronic diseases (Diabetes, Congestive Heart Failure) in order to study, monitor and improve the adequacy of their care, as well as to seek out patients who have not received needed care.
5. Provide planned chronic care visits for diabetes and other appropriate conditions, so that needed information is present for treatment and education at the time of the visit.
6. Integrate patient feedback to improve the performance of the practice.
7. Implement the “New Model of Family Medicine” described in the Future of Family Medicine Report, including secure web messaging.

As we communicate with our patients about these changes, we are letting them know that we greatly appreciate their continued support and patronage. Providing their Personal Medical Home is something that we take very seriously and we remain fully committed to providing the absolute best primary care medicine possible. We recognize that re-evaluating Medicare insurance needs involves significant effort, time and stress. We hope that they understand the challenge we are currently facing, but with stheir support we are confident that we will overcome this challenge, together.