Health Care Reform at the Office

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Francis J. Crosson, MD seeks "a rationale designed to influence the physician microenvironment so as to support physicians in developing patterns of clinical decision making that result in better health outcomes and lower costs."

In "Change the Microenvironment: Delivery System Reform Essential to Controlling Costs" (April 27, 2009), this, the Founding Executive Director, The Permanente Federation and Chair of the Council of Accountable Physician Practices (CAPP) states: "U.S. health care costs are excessive, both by international benchmarks and, by inference, from observation of the degree of cost variation within the U.S., as demonstrated in the Dartmouth Atlas of Health Care." Also, expanding coverage will be costly and "not supportable for private insurance or public programs."

Main Causes:

Aging population, living longer with more disease or conditions
Adverse lifestyle choices (e.g., "smoking and poor diet that lead to cardiovascular disease, cancer and diabetes")
Acquisitions as driven by the technological Imperative—e.g., new drugs and medical procedures
Appropriate or Inappropriate--a reimbursement system that "often rewards" either, indiscriminately

The microenvironment of which he speaks is the practitioner's office where past experiences, prescriptive guidelines, arcane policies, notorious precedents and fear of malpractice wreak havoc on a daily basis. It is also the place where the financial pressures of running a practice are palpable.

Sarah Kliff, a writer on the Ezras Klein's WonkBlog, poignantly writes about the last bullet, above–incentive alignment, or, in this case, misalignment in "Why are we seeing so many specialists?"

"The big question is why doctors have become more likely to send their patients to specialists. Part of the answer.... has to do with health care becoming more complex, with new technology that demands more specialty care. Physicians have also found themselves with more preventive tests and screenings to handle, which may cut into time to deal with other issues. And, part of it likely has to do with the economics of referrals: Doctors who have an ownership stake in their practice are 50 percent more likely to refer to a specialist, which would increase the total revenue generated by a given patient."

As any medical director can testify, insurance and entitlement programs show little understanding for how medicine is practiced, let alone how to make it better. Their concentration has always been utilization management, more than quality improvement and value enhancement. Crosson understands this as he divides delivery system reform proposals into three areas of interest:

Structural—medical home, physician-hospital integration, and accountable-care organizations;
Payment—for care coordination, in and outpatient bundled case rates, pay-for-performance, and "other 'shared savings' proposals, and various forms of prospective payment or capitation";
"Tools" that facilitate and monitor either or both of the above such as medical information systems (e.g., EHR, acuity-adjustment, episodes of care and comparative-effectiveness data). He adds: "Comparative-effectiveness information is more likely to be accepted by society as a tool for appropriate clinical decision making rather than as a mechanism for coverage determinations."

Although he pushes for group practice to effect these reforms, these goals and objective belong to the provider community, regardless of structural differences.

Comment:

It is important, in this context to also review some of the hidden, non-reimbursable costs involved in the business of medicine: image and laboratory test interpretation, prescriptions, phone and other consultations, form completion, negotiating on behalf of patients with insurance companies' utilization managers, responding to patient care–oriented messages; and create, review, edit, and sign EMR documents, etc.

"Nonvisit" care or non-clinical activity may reduce the need for some office visits and may help improve patient outcomes. It certainly contributes to the office workload, but it is not reimbursed.

"Provision of primary care requires a substantial number of tasks beyond face-to-face patient interactions. Although vital to the actualization of health care reform goals (eg, increase preventative care, better manage chronic diseases, improve health care quality, decrease hospital readmissions), much of this work is unrecognized. Efforts to improve practice efficiency and increase access to primary care providers must take into account these important but under-appreciated tasks."

Dyrbye LN, West CP, Burriss TC, Shanafelt TD. "Providing Primary Care in the United States: The Work No One Sees." Arch Intern Med. 2012;172(18):1-2. doi:10.1001/archinternmed.2012.3166. [Pub online Research Letters | Oct 8, 2012]

See Also The Following Related Articles:

Chen MA, Hollenberg JP, Michelen W, Peterson JC, Casalino LP. Patient care outside of office visits: a primary care physician time study. J Gen Intern Med. 2011;26(1):58-63

Brook RH, Young RT. The primary care physician and health care reform. JAMA. 2010;303(15):1535-1536

Coller BS. Realigning incentives to achieve health care reform. JAMA. 2011;306(2):204-205

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