Curbside Consult with Dr. Jayne 6/27/11

My colleague Dr. Doug Farrago (self-proclaimed “King of Medicine,” who I interviewed back in March) has recently renamed the Placebo Journal Blog to the Authentic Medicine Blog in an attempt to connect readers back to the roots of medicine. The blog is targeted at identifying medico-political barriers in the way of providers actually treating patients.

I have to give him full credit for sharing a recent article from American Medical News that helps explain why it is that no matter how much money the Medicaid stimulus plan pays to providers who adopt certified EHR technology, it will never be enough to reimburse them adequately for what they do. Following the Accountable Care Organization trend, Arkansas is looking to bundle Medicaid pay. Arkansas Medicaid Director Eugene Gessow proposes groups of “partnerships” that would parallel ACOs but will avoid being labeled as such. Seeing how successful Medicare ACOs have been so far, I’m skeptical. And now we’re going to do it with patients that, unlike their 65-and-up counterparts, are in and out of the payer’s coverage?

This type of restructuring may push some providers over the edge. Many providers are reluctant to accept Medicaid due to the increased documentation and regulatory burden compared to other payers. Many of those with Medicaid populations comprising 30% of their panels (20% for pediatrics) saw the opportunity to receive Meaningful Use payments as a way to try to obtain funding they sorely need to continue that mission.

To put this in perspective, I receive $24 per visit for Medicaid for a visit that with private insurance pays out at $65 to $80. Do the math – it’s increasingly difficult to continue to see patients whose reimbursement is less than the cost of doing business, and these tend to be more medically needy patients with significant socioeconomic-related health issues. Mr. Gessow states, “We need to stop paying fees for the process of treatment and instead reward the successful results of that treatment.” In short: we’re going to take the most medically needy patients and make payment for their care outcomes dependent? It certainly sounds that way.

I understand what they’re trying to do. I, too want to see more funding for care teams, social workers, and ancillary staff so they can work with the patients more directly, allowing physicians and other licensed providers to do what we trained to do rather than figuring out transportation issues and prescription vouchers. Those are essential services for many patients, but it doesn’t take an MD to do it.

Arkansas plans to rely heavily on existing EHR and other health IT systems to meet their quality goals. As an “IT guy” watching the havoc caused in the EHR industry by Meaningful Use mandates, I can’t wait for all fifty states to jump on the bandwagon and come up with a patchwork of state-specific mandates that will disrupt development cycles and create make-work upgrades for medical practices and hospitals. Vendors can barely keep up with state requirements as it is. I’m still looking for a vendor who can correctly render every state prescription blank, has state-specific immunization consent forms, and who ships out of the box with state-specific EPSDT forms for Medicaid child well exams.

Trading my “IT guy” hat for my scrub cap, as a physician, I just don’t see it as a reality in a nation where free will and self determination are key social tenets. Ultimately, it doesn’t matter how fabulous your IT platform is, how endearing your health coaches are, or how persuasive your clinicians try to be. If the patient doesn’t want to do what’s recommended, you can’t make them. No amount of clinical decision support or orders tracking can fix that one (although it does help the process of cajoling, bargaining with, and ultimately harassing noncompliant patients).

I’ve been doing quite a lot of travel lately, and have seen some things that as a physician make my hair stand on end. I have no idea how to successfully counsel against behaviors that patients continue to choose regardless of how negatively they may affect their health. Recent favorites:

1. Motorcycle riders without helmets (regardless of the law).
2. Establishments that serve daiquiris through a drive-thru window as long as there is tape over the lid, rendering the container “closed.”
3. Parents at the airport absorbed in their iPhone and iPod universes who ignore their stroller-bound children (folks, have you ever heard of reading a book to your child? It’s recommended by a variety of evidence-based organizations and my state Medicaid program requires me to counsel you on it or I won’t get paid.)
4. My bikini-clad neighbors on the beach, discussing their wrinkle-preventing Botox injections while sunning themselves to a color that I believe Crayola calls “burnt umber” while smoking (some days I really wish I had trained in dermatology).
5. Parent holding an unrestrained infant in the front passenger seat of the car (yes, I know some of us grew up without car seats and lived to tell, but it’s dangerous and illegal in 2011.)
6. Patients who want to talk about whether Kim Kardashian’s alleged gluteal implants would actually show on a radiologic study  (no kidding, I had this question) rather than their diabetes.
7. Patients who can name the starting lineup of the local baseball team, but not their BMI or cholesterol numbers.
8. Folks who take the concept of the “all you can eat” buffet seriously.

So, good luck, Arkansas Medicaid providers. I wish you well. Good luck to the IT vendors as you scramble to meet whatever regulations they come up with and to the clients who pay for customization while waiting for the vendors to achieve an aggressive go-live timeline for mid-2012. And finally, good luck to the patients who are unwitting participants in an experiment that wouldn’t pass most Institutional Review Board approval processes.

The only silver lining here is for the hordes of consultants that will descend, trying to figure out ways to secure their piece of the “savings” that Medicaid anticipates.

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