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Curbside Consult with Dr. Jayne 4/11/16

April 11, 2016 Dr. Jayne No Comments

Although the majority of my consulting work revolves around healthcare IT, I’ve done a fair number of practice management and operations engagements along the way. Many of the opportunities have bubbled up as a result of a practice or medical group trying to implement EHR.

Going through the process tends to highlight overall inefficiencies, role confusion, lack of management, financial issues, and more. Over the last six months, I’ve seen the requests for those types of services increase, which is part of why I joined forces with another consultant. We’ve written a number of engagements that don’t really have any information technology components.

As we’ve been exploring the different kinds of services we can offer and the needs of our potential customers, we’re seeing more organizations that are at a crossroads. It seems that quite a few primary care organizations are having what amounts to an identity crisis. Should they press ahead towards value-based care? Should they transform their systems and prepare to accept full-risk contracts? Or should they retreat towards their roots with personalized (and sometimes concierge) care? Two emails this week from the American Academy of Family Physicians highlighted this looming crisis.

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On one hand, the AAFP has launched what is describes as a “full-court press” to ensure that family physicians are ready for payment reform. Calling it a “ground-breaking, knock-your-socks off change that opens to the door to a whole new era of Medicare physician payment,” the AAFP is positioning itself to help physicians “reap the benefits of a new payment system that, unlike fee-for-service, values the training, skill level… and time that goes into taking care of patients in a family medicine setting.”

In order to prepare for the transition, they’re encouraging physicians to participate in the Physician Quality Reporting System (PQRS). They also recommend that practices review their Quality Resource and Use Reports (QRURs) which will show physicians where they stand as far as future payments for the MIPS track. Most of the primary care physicians I know have never heard of a QRUR and would be put off by the process one needs to go through to obtain theirs.

AAFP also recommends that practices embark on clinical practice improvement activities around access to services, patient engagement, care coordination, and more. Smaller practices (and some larger organizations) are often ill-equipped to try to make these changes on their own. Their articles are pushing physicians towards the new models with comments that the process won’t go away or be delayed, and that “this train has left the station.” There’s going to be a huge market for services around helping physicians make the transition and I’m sure the AAFP teams will be gearing up with offerings of their own.

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On the other hand, AAFP is hedging its bets by also marketing services towards physicians who are choosing to opt out of payment reform entirely. They’ll be hosting a Direct Primary Care Summit in July. The meeting is targeted towards not only physicians who have already converted to direct primary care, but for those who are thinking about it or trying to figure out how to manage the transition. They’ll be educating physicians on the legal aspects of operating a direct care practice as well as how to address business development around the new model. The conference promotion materials cite the “momentum” and “growing excitement” saying Direct Primary Care is “no longer a trend” and is being supported by positive legislation across the country.

I certainly don’t fault AAFP for playing both angles. Primary care is at a crossroads. The National Residency Matching Program “Match Day” was last month. This year’s match saw only 1,481 graduates from United States medical schools choosing family medicine. There were some other interesting statistics coming out of the Match:

  • Family medicine offered 11.7 percent of all positions in the Match.
  • The fill rate in family medicine for US seniors has decreased from 1996 (72.6 percent) to 2005 (40.7 percent) with a slight increase this year (45.4 percent).
  • The fill rate in family medicine for US seniors has been below 50 percent since 2001.
  • Aggregate primary care positions (family med, general internal med, general pediatrics, and internal med/peds) filled with US seniors at a rate of 50.7 percent.
  • Only 12 percent of US seniors participating in the Match selected primary care residencies.

Looking at non-US seniors who matched into family medicine, the numbers are climbing overall. Although I’m happy to see qualified international graduates matching into primary care specialties, I think the fact that US grads continue to choose other pursuits is very telling. Primary care salaries are among the lowest in the physician ranks and primary care physicians report some of the highest burnout levels compared to their peers.

The loss of autonomy brought by shifting healthcare policy over the last decade has hit primary care physicians disproportionately compared to specialists in many markets. Although payment reform may extend that loss of autonomy more fairly across the board, if feels like we’re moving towards the lowest common denominator rather than trying to elevate everyone.

Lots of people are looking at the decline of primary care. A recent JAMA article looks as the expanded use of the term “primary care provider” as having negative consequences for the future of primary care. It asserts that although increased use of the term provider “reflects the importance of a multidisciplinary approach to modern primary care delivery, extending beyond the traditional dyad of patient and physician,” it has also had negative impacts. Patients may not be reaching the appropriate member of the primary care team if they can’t distinguish between different types of primary care providers. A mismatch in care delivery can lead to both over- and under-performance as well as challenges to patient safety and the delivery of cost-effective care.

The article specifically cites the rise of Direct Primary Care as being from “the resultant uncertainty and insecurity about who is going to handle their medical problem.” It also mentions that not differentiating between providers may put some individuals into “situations beyond their level of training and competence.”

I’ve seen this with one of our practice’s competitors, whose push for their nurse practitioners and physician assistants to practice independently is causing them to seek employment elsewhere. Healthcare IT is cited as a potential bridge for providers in those situations, who may be able to use protocols and clinical decision support mechanisms to “help mitigate some of the front-line diagnostic and management challenges for team members facing situations beyond their level of expertise.” I leverage technology often in practice, but it’s not a substitute for experience.

The authors also mention that the provider designation ”risks de-professionalizing” physicians, NPs, PAs, and nurses “who value their specific professional identities.” My favorite part of the article says it all:

Using the “provider” designation in primary care also suggests that primary care is simple care that can be commoditized and delivered piecemeal in a variety of settings by less well-trained personnel operating interchangeably at low cost. As such, use of the term may promote low levels of compensation and diminishes respect for the field, compromising its fundamental mission. Although low-cost approaches to some very basic elements of primary care, such as immunizations and treatment of upper respiratory infections, make enormous sense, they do not apply to the resources, skill, and training needed to deliver the full spectrum of comprehensive primary care in personalized, coordinated fashion, especially to an aging population with multiple comorbidities. “Provider” belies the complexity and amount of effort required. Note that the designation of “provider” has not been applied to such fields as surgery or cardiology, even though these too entail multidisciplinary, team-based care structures.

It goes on to recommend that we “cease referring to and treating primary care clinicians (as well as all other physicians and health care practitioners) as “providers” and address and relate to them as the highly trained professionals they are. If only things were that simple, that we could change some terminology and things would improve. Healthcare seems to just keep riding tide after tide and grabbing after the next shiny object that they think will solve the problems. We hoped for the last decade that technology would solve all our problems, that if we just added automation to the practice of medicine that we’d solve problems. Unfortunately, automation was often poorly applied and shifted the work to physicians.

Now we think that if we make the data more accessible, we can fix the problem. It feels like we’re pinning our hopes on interoperability, but we’re not doing what we need to make better use of the data, whether by physicians and other care providers or by patients themselves. Professional and educational organizations are weighing in, but are somewhat hampered by the lack of details on how new care models will unfold.

“Providers” are tired of waiting and continue to leave practice or pursue alternatives such as Direct Primary Care or to opt out of Meaningful Use or Medicare/Medicaid. The giants of our industry are increasingly reactive rather than being proactive or innovative. Eventually, something will have to give, and I fear it will be the people on the front lines.

Do you think emerging payment models will fix the healthcare crisis? Email me.

Email Dr. Jayne.

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