The Users' Guide to the Health Reform Galaxy

Rx for Primary Care

Sheldon D. Horowitz, M.D., a special advisor to the president of the American Board of Medical Specialties and principal investigator of the Improving Performance in Practice (IPIP) initiative, writes about an effort to give small physician practices the tools they need to improve quality.

Today is National Doctors Day, a day set aside to thank physicians for all they do in applying modern medical science and technology to the special calling of preventing and treating people’s injuries and illnesses. It seems appropriate, then, to recognize a program devoted to helping doctors in primary-care practices do that more effectively.

The program, called Improving Performance in Practice (IPIP), provides practices with tools, support, coaching and a collaborative learning environment in which they can assess their performance and engage systematically in quality-improvement activities using their own practice data. Doctors can also compare their data to others in their cohort groups as benchmarks.

As everyone involved in quality improvement knows, translating the latest and best medical techniques and protocols into practice is easier said than done. That’s especially true for the small offices where 60 percent of U.S. physicians work. Compared to big hospitals and integrated group practices, they typically have fewer resources available for quality-improvement efforts. IPIP fills the resource gap for small practices in seven states by giving them process-improvement kits based on the Chronic Care Model and providing quality-improvement coaches, typically registered nurses, to guide practices through the steps involved in taking full advantage of the program’s resources.

To enroll, practices choose a focus area—asthma or diabetes in most cases—and commit to using a registry or electronic medical records to manage their patient populations, if they don’t already. Then they begin providing monthly data on a set of quality measures covering care processes and outcomes.

Such measurement and reporting are essential. As one Colorado doctor told IPIP staff, “Until I saw my data, I thought I was providing excellent care. Now I see we have a lot of work to do.”

Among other things, coaches help practices improve their division of labor and work flow by relentlessly asking the question: “Is this physician work or non-physician work?” If a doctor isn’t needed for a particular task—say, administering an annual sensory exam to diabetics to test for nerve damage—then someone else in the office should take care of it so doctors can focus on the things that only they can do. These work-flow improvements help practices get more done—and also improve job satisfaction. “I was considering leaving the profession,” Dr. Tracy Hofeditz of Lakewood, Colo., told IPIP staff. “But now I have rediscovered the joy of practicing medicine.”

One key benefit of participating in the program is that it helps practices comply with ABMS Maintenance of Certification®, professional recognition for quality and pay-for-performance programs.

Patients, meanwhile, get more effective care. For example, in the 16-month period between June 2008 and October 2009, Pennsylvania IPIP practices saw a 15-percentage-point increase in the share of diabetes patients with blood pressure of 140/90 or less—an important threshold level to stay below.

That kind of success helps explain why IPIP, which began as a small pilot program in Fall 2006, has quickly grown to serve more than 350 practices with 1,400 doctors and 350,000 asthma and diabetes patients from Colorado to North Carolina.

For more about IPIP, which is sponsored in part by the Robert Wood Johnson Foundation and convened by the American Board of Medical Specialties, download a copy of its recently released program brief.

Health Reformer’s Lexicon: Patient-Centered Medical Home

The Health Reformer’s Lexicon is a regular feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.

The term: Patient-centered medical home

The National Committee for Quality Assurance (NCQA) provides the following definition:

The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients and their personal physicians, and, when appropriate, the patient’s family.

It is a model of care that aims to provide structured, proactive and coordinated care for patients rather than episodic treatments for illnesses.

In a medical home, the primary-care doctor operates as a “home base” for patients, overseeing all aspects of patients’ health; scheduling regular tests and check-ups by tracking health records electronically; advocating for patients with specialists; and, with nurses and other personnel, helping patients navigate the medical system so they don’t fall through the cracks or neglect to care for a chronic condition such as heart disease.

Why it matters: The medical-home model promotes coordinated care—especially for patients with chronic conditions. This in turn cuts costs while improving the quality of care.

Roots: Pediatricians were first to coin the term “medical home.” Concerned that the care of children, especially kids with chronic conditions, was not being coordinated effectively between specialists and the child’s pediatrician, the American Academy of Pediatrics advanced the concept of coordinating care through one doctor in 1967.

Thirty years later, in 2007, leading primary-care doctors’ organizations—the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and American Osteopathic Association—listed requirements for a medical home in a formal statement.

Among these requirements is the idea that insurers recognize doctors’ additional work and the added value to patients for “work that falls outside of the face-to-face visit” and reward it with more compensation.

In the last few years, the American Medical Association has backed the medical-home concept; and by last year, 10 states had bills promoting medical homes.

Where the term appears: The president’s health reform proposal, like the Senate bill, sees the medical home more as an answer to shortages of primary-care doctors, nurses and others. It would spend money on training medical personnel in more efficient ways to deliver primary medical care, such as medical homes.

NCQA has established a recognition program to evaluate whether practices are operating as medical homes. Select health plans are using recognition standards like these to reward qualifying practices for improving health care quality.

Previous Lexicon entries include:
- Sustainable Growth Rate
- Accountable Care Organization
- Meaningful Use

Wrapping up the week with a shout-out and a few words

As this week’s host of Health Wonk Review, Brady Augustine at medicaidfirstaid.com suggests that “watching politics right now is like watching the intimate moments of a dysfunctional relationship. One person groping for the other in a very awkward way and the other disengaged with their back turned and suffering from the imaginary headache.” Noting the need for a “relationship rescue,” the latest edition features posts that support efforts to rebuild and repair reform. Included as a “formula for success” is Bruce Siegel’s post about the Aligning Forces for Quality initiative in Maine and its push for high-value health care.

And now, for something completely different.... 

With this next bit, we launch The Health Reformer’s Lexicon, a new weekly feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.

The term: Sustainable growth rate (SGR)

The sustainable growth rate is Medicare’s formula for setting total payments to physicians. It was designed essentially to hold growth in physician spending in line with economic growth.

While the Medicare program pays individual doctors based on a fee schedule, the Congressional Research Service (CRS) notes that,

“The SGR system was established because of the concern that the Medicare fee schedule itself would not adequately constrain overall increases in spending for physicians’ services.”

And here is how CRS explains how it was supposed to work:

“… If expenditures over a period are less than the cumulative spending target for the period, the update is increased. However, if spending exceeds the cumulative spending target over a certain period, the update for a future year is reduced, with the goal to bring spending back in line with the target.”

Why it matters:  The SGR is often mentioned in association with another phrase widely used on Capitol Hill – the “doc fix” – so named because Congress each year votes to “fix” the payments to doctors instead of cutting them. Since 2002, Congress has voted not to follow the SGR formula because it has not wanted to cut physicians’ payments.

As a result, there is a growing gap between what physicians are actually paid and what the formula calls for, so much so that Congress would have to cut physician payments by more than 21 percent this year to bring spending in line with the formula. This politically dicey proposition created uproar on Capitol Hill, where a decision on the cut must be made before the end of this month, since cuts are scheduled to take effect March 1.

To address this upcoming deadline, both the Senate and the House recently passed a pay-as-you-go law, which would require the government to offset any new spending with cuts in existing spending or with revenue increases.  But with an eye toward the SGR issue, this measure also contains an exemption for new spending for doctors’ pay, at a cost of $82 billion, enough to avoid cutting the doctors’ payments for another five years.

As another alternative to temporarily address the problem, the Senate considered including a patch in its jobs bill to address the rate cuts; but recently removed the provision.

Roots: The SGR was created by the Balanced Budget Act of 1997. It replaced another formula called the Medicare Volume Performance Standard that set payment targets that were also exceeded.

Usage: Patches created under laws like pay-go only temporarily address SGR pay cut issues. When it comes to more permanent solutions, perhaps one of the more prominent uses of SGR is in H.R. 3961, which passed the House last November. The measure would resolve the “doc fix” permanently by changing the formula, at a cost of about $210 billion over 10 years, according to this Congressional Budget Office estimate.

How Maine Used Its Clout to Press for Higher-Value Health Care

Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, recounts how a big health care purchaser applied its considerable leverage to insist on public reports about hospital performance. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

What does a heavyweight look like in the fight for high-value health care? Take a look at how the state of Maine has used its muscle as the administrator of health plans for 34,000 employees, retirees and their families. It is an especially noteworthy story since the health care reform bills before Congress include a number of provisions to encourage the use of quality measures and value-based purchasing.
 
Maine’s State Employee Health Commission, responding to a call from the state legislature to contain health care expenses, developed a new health-benefits plan in 2006. No ordinary plan, its goals included engaging employees and retirees in the health care process, improving quality of care and encouraging providers to publicly report their performance information.

The upshot has been a value-based purchasing strategy based on public reports developed by the employer-led Maine Health Management Coalition, which works closely with the Robert Wood Johnson Foundation’s Aligning Forces for Quality grantee, Quality Counts, and the state government’s quality-improvement initiative, called the Maine Quality Forum.

Teaming Up to Improve Care of Diabetes Patients in Minnesota

As Congress and the president figure out their next steps on national health care reform, we want to continue shining a light on local laboratories of reform. Here, Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, writes about the effort to encourage high-performing health care providers in the Land of 10,000 Lakes.

Quality reformers have a mantra: You can’t improve what you don’t measure. But in Minnesota, the local team that the Robert Wood Johnson Foundation tapped to manage its Aligning Forces for Quality initiative, also knows you can’t lose weight by just standing on the scale. You have to act on what you learn.

The Foundation’s grantee, Minnesota Community Measurement, operates the scale. Its HealthScores project gathers performance data from Minnesota health plans as well as 300 medical clinics statewide. But it is part of a multi-pronged action team that is driving change in Minnesota by helping providers improve on their performance and then rewarding them when they do.

Addressing the primary care workforce shortage to come

Deanna Okrent, senior health policy associate with the Alliance for Health Reform, writes here about a predicted shortage of primary care providers to treat a larger pool of insured Americans.

With the prospect that an additional 31 million Americans may gain insurance coverage under national health reform, many warn there may be too few primary care providers to treat them. 

Following enactment of reform in Massachusetts -- a state often studied to help inform the current debate -- increased demand for primary care led to longer waits for medical appointments and unmet needs for some types of care.  This may have been the result of pent-up demand from previously uninsured individuals. In a May 2009 paper on health reform in Massachusetts, Sharon Long notes that this demand is expected to stabilize as people have coverage for a full year and longer.

Many predict a similar phenomenon after national reform is implemented.  A contributing factor is the declining interest in primary care as a professional goal. Far fewer medical graduates entered residencies in family medicine and internal medicine in 2009 than they did in 1999. Among the reasons graduating physicians choose specialties and subspecialties over general practice are: 1) their large educational debts and  2) the relatively low compensation of primary care physicians, which means it takes longer to pay back that debt. 

Are accountable care organizations the answer to our problems?

Kelly Devers and Bob Berenson of the Urban Institute write about the latest policy brief by Urban and RWJF, which focuses on the concept of creating more accountable entities in health care.
 
In the often contentious health reform discussions, ideas that are good in theory often gain quick currency, but deserve closer examination as to whether they might actually work.  One such idea is the accountable care organization (ACOs).  Accountable care organization are entities—and we’ll clarify what we mean by “entities” in a second—that are intended to address one of the conundrums of our current health care system:  how to pay providers for high-quality, efficient care.  Under our current fee-for-service payment system, we end up paying for volume, not quality or value, that is better quality for the money we spend. In addition, many of the ways we deliver health care, especially for common chronic conditions like diabetes or heart disease, have become increasingly fragmented and cumbersome for both the provider and the patient.
 
To address these interrelated problems of provider payment and delivery, many health care leaders and experts have become increasingly interested in ACOs as a way to bend the cost curve, i.e., deliver higher-quality care to more people without contributing to our escalating health care tab.  ACOs are commonly understood to be local entities comprised of clinicians—primary care and specialty physicians, hospitals—that are responsible for delivering quality care and controlling health care costs in ways that current providers are not. 
 
However, the concept of what ACOs are and how they might work is still murky.  Therefore, in a new policy paper out today from the Urban Institute and the Robert Wood Johnson Foundation, we try to go to uncharted territory, and wrestle the ACO concept into the real world. 

What Massachusetts docs think about health reform

Gillian K. SteelFisher, a research scientist at the Harvard School of Public Health, writes about a recent poll she and her colleagues conducted with physicians on health reform in Massachusetts, highlighted today in the New England Journal of Medicine.

With the passage of the 2006 health insurance law, Massachusetts has made significant changes in health insurance coverage and now can claim the lowest uninsured rate in the country.  As the debate on health reform in Washington, D.C. unfolds, policymakers at the national level have turned their attention to the state’s health reform; in fact many of the Congressional proposals currently on the table include elements from the Massachusetts plan.  In this process, there have been some criticisms of the reform, with suggestions, for example, that the reform has made it more difficult for people to access care.

We already know from past research that the reforms hold majority support among the public, but what about physicians who are on the front lines of care and directly see the potential impacts of that reform?
To address that question, my colleagues and I polled more than 2,000 Massachusetts physicians.  Our goal was to assess their perceptions in three areas: their overall support for the legislation, their views of its impact on their own practice, and their views of its impact on health care across the state.

Physicians support the public option

Salomeh Keyhani and Alex Federman from the Mount Sinai School of Medicine write about recent findings from a survey of physicians on health reform.

The health reform debate has aired out a number of issues about how we can do better at health care, as a country, and one issue that consistently gets zeroed in on—even though it’s by no means the only issue—is whether health reform legislation includes a public insurance option, or not.  Over the last year, polling data has consistently shown majority support for the inclusion of a public option in the final health care reform legislation.  We knew what many of our physician colleagues felt about the public option--they all supported it. They thought of the public option as a moderate solution to unite everyone in covering the uninsured, a policy proposal that tried to sidestep the failures of the past—you could keep your private insurance if you liked it, you could buy private insurance subsidized by the government, or you could buy a public plan similar in design to Medicare.

However, on the national stage, many members of Congress were denouncing the public option as government-run health care, and declaring it would never pass the Senate.  In addition, the AMA initially appeared to be supportive of private-only health care coverage expansions.  We wondered whether the voices of all physicians were being heard.  Were our colleagues who supported the public option among the minority or majority of physicians in the field? 

'Death panels?' What really happens in end-of-life discussions

Diane E. Meier, a geriatrician at Mount Sinai Medical Center in New York and director of the Center to Advance Palliative Care, explains how advance-care planning empowers patients.

Despite persistent falsehoods alleging that pending health reform legislation would create panels to decide which patients were worthy of living, the facts surrounding the debate are clear – and they clearly disprove these misrepresentations.

The provision in question would compensate physicians for offering their Medicare patients an opportunity to engage in  conversation about their preferences for care under future conditions of serious illness - this is advance-care planning. My patients are uniformly fearful of being overtaken and harmed by the health care system, and their greatest concern is that they will lose control over their lives and their options once caught up in it. They have read about hospital infection rates and medical errors, and they have watched and worried as friends and loved ones with serious and chronic illnesses try to negotiate the fragmented and confusing health care system.

My patients want to know that their goals, values and hopes will be the primary considerations when healthcare decisions need to be made. They are frustrated by how little time most of their doctors can devote to talking with them and how rushed these encounters have become. They hesitate to ask questions about their illness because they are afraid to take any extra time that might burden their busy doctor, who is always harried, always behind, and always has a waiting room full of other patients.
The reasons for these time pressures are clear. Physicians do not have time to devote to patient/family counseling because these so-called cognitive services are so poorly compensated that few can afford to provide them. Doctors are paid for doing things to patients – X rays, chemotherapy, procedures, surgery – but we are paid almost nothing for talking with our patients.

This is what these conversations are like in the real world of doctor and patient.  So that the patient's voice and values remain front and center when serious medical problems arise, I ask them the following question: "Who would you trust to help me make health care decisions on your behalf if you were unable to make your own decisions? This person can be a family member but does not have to be, and they will only be asked to represent you if and when you are unable to represent yourself."  Most of my patients appoint one or more of their children, or their spouse, but some prefer to spare their family this burden of responsibility and appoint a friend or other counselor. 

Secondly, although most of us really do want all the facts about what is happening to our bodies, some of my patients prefer to sustain a certain level of denial.  That's fine, but I need to know how they would like me to handle information and shared decision-making.  I say, "Some of my patients like to know all the details about their medical condition and their treatment options, and others prefer a more general outline, or ask that I discuss treatment planning with a family member.  Which kind of person are you?"  Roughly 90% of my patients respond that they do want to know everything, but a substantial minority do not. If I try to force unwanted information on this group of patients, they will no longer trust me and are unlikely to feel safe in my care. Hence, I will honor their request that I confer with their family when medical decisions need to be made, though I will check in frequently to see if they are ready to learn more as time passes.  

Lastly, I ask my patients one more, very important, question.  "If you ever got so sick that your brain was permanently injured to the point where you could no longer recognize or interact with your loved ones -  the kind of condition that Terri Schiavo had or what typically happens in the late stages of Alzheimers’ dementia - in this situation some of my patients say they would want care focused only on assuring their comfort and not on prolonging their existence in this state; but others tell me they would want everything possible done to prolong their existence no matter what the quality of their mental functions or ability to connect with others.  Which kind of person are you?"  

Again, the clear majority opt for comfort measures when they reach this state of loss of self. But a consistent minority are either so fearful of death or so convinced that a miracle will restore them to health that they tell me to "do everything to keep me going, no matter what."  Whatever they say, I write down in the medical record as a guide for when (not if) serious medical problems arise.  The patient's wishes and goals are my guide as I work with other doctors and family members to try to come to the best plan of care.  Whenever possible and with the patient's permission, we have these conversations together with family and surrogate decision makers.  That way, when the family decision makers are faced with wrenching and painful medical choices for a very ill loved one, as they inevitably will, they know what the patient's wishes are, and they take great comfort in their ability to honor them.

Family decision makers who know what their loved one - the patient – wanted, and who are able to advocate for these wishes and goals, are better able to heal after their loss and are less likely to undergo complicated or prolonged bereavement periods.  Of course, these conversations are not mandatory, but I have yet to encounter a patient who is not tremendously relieved by the chance to talk out some of their deepest worries and fears about what might happen to them in the future and how we will work together to face these situations.  I have this kind of discussion with all my patients, early in my relationship with them, just as I discuss getting a flu shot, or wearing seat belts, or using sun block outside.  It is a routine part of good primary care.  It is not rationing. It is not euthanasia.  It is not a death panel. These are outright lies.

Actually compensating doctors to speak with patients about their illness and its implications is a small effort to restore the balance back towards our patients and away from the financial pressures in our medical marketplace. It recognizes that conversations between doctors and patients about the patients' illness, the patients' goals, the treatment alternatives and their pros and cons are time consuming and require skill and expertise. It is a misnomer to call these "end of life" conversations. These conversations are needed throughout the typically multi-year course of a chronic illness (such as cancer or heart disease or emphysema) and are not limited to the "end" of life.

The real truth is that we doctors don't know who is actually at the end of life until only a few weeks before death in most cases. Advance-care planning  is a small step towards restoring power and control to the objects of all this effort and expense – the patient.

 

Part II: Putting meaningful use into action for providers

This is the second in a three-part series of posts on the implementation of the health information technology (HIT) provisions in the stimulus package, which called for "meaningful use" of HIT for those who give and get care.  This series was written for us by a team of people at the Health Information Technology Resource Center (HITRC) at Brigham and Women's Hospital in Boston, which provides technical assistance to RWJF’s Aligning Forces for Quality program.  David K. Ahern, PhD is the Director, Judith M. Phalen, MPH is the Associate Director, and D. Matthew Brothers, BA is the Program Associate.

In Part I of this series, we argued that the definition of ‘meaningful use’ should go beyond the matrix of outcomes, goals, and objectives developed by the federal government’s HIT Policy Committee.  We believe it should also determine what those who get, give, and pay for care – healthcare’s agents – need to do in order successfully achieve better health outcomes for all.  In this post we examine these questions:  What behaviors must be adopted by healthcare providers (and how can we reinforce them?) so that they will move lock-step towards an evidence-based, effective, and efficient healthcare system? And, what interferes with the good intentions of those who are trying to do the right thing?