March 5, 2021
Dear Interested Readers,
More Thoughts About The Importance of Primary Care
Now that Donald Trump is off Twitter and mostly out of sight except for occasional appearances at places like CPAC, I find that I have more time to think about positive things. The post on Tuesday was a review of a recent “Perspectives” article in the New England Journal of Medicine entitled “Reform of Payment for Primary Care — From Evolution to Revolution” written by Allan H. Goroll, M.D., Ann C. Greiner, M.C.P., and Stephen C. Schoenbaum, M.D., M.P.H. It was an excellent overview of several important realities about primary care that we need to consider if we are going to move forward toward better care for everyone, healthier communities, and an improving efficiency that lowers the cost of care. It was refreshing to think about healthcare in some way other than how to protect it from Donald Trump.
The article was a call for the rapid transformation of primary care finance from fee for service payment to risk contracts and value-based reimbursement primarily in the form of a return to capitation that was common in the heyday of “managed care.” The authors called for an acceleration of practice transformation and practice finance from a slow “evolution” that has gone on for decades without much real improvement in care to a “revolution” that will quickly bring substantial improvements for patients and providers.
My great grandfather was a PCP in the mountains of North Carolina over a hundred years ago, and my great great great grandfather was a PCP in Shelbourne Falls, Massachusetts two hundred years ago. There are documents that suggest that the organization and finance of their practices were not much different than the typical office practice today except that the fee they received for service was often a bushel of apples or corn rather than cash from an insurance company. Technology and our knowledge of disease have changed a lot, but how we practice and how we finance practice has not evolved much in the last two hundred years. The authors made multiple points that I feel deserve more discussion. One paragraph deep into the paper contains some important ideas that we should consider:
Experience with capitation under managed care in the 1990s created a lingering distrust of payers and capitated payment systems. At that time, the capitated payment was typically little more than the reimbursement that clinicians would normally receive under FFS, paid out prospectively in per-member-per-month aliquots. There was no net investment to facilitate and sustain practice transformation, nor was there adequate risk adjustment or reward for improving quality and patient experience.
In my discussion of the paper on Tuesday, I expressed the concern that physicians who have graduated from medical school since the ’90s are unlikely to have had experience working in a capitated environment. That means that if a doctor is younger than his/her late forties it is likely that the bulk of their practice activity has been financed by Fee For Service payment. Most of the currently practicing physicians who are older and think that they know what capitation is may not understand the current thinking about how to create and manage a capitated budget to avoid some of the objectionable activities that caused managed care to crash in the late ’90s.
As the authors implied, the old way to come up with a capitation budget was to add up the previous FFS payments and then suggest if care could be delivered for less the savings would be shared or perhaps kept entirely by the provider. This process had many potential problems. The most significant problem was the potential for the denial of necessary care. The 1997 movie “As Good As It Gets” which produced Oscars for Helen Hunt and Jack Nickolson probably contributed to the death of managed care. I can remember the cheers in the theater when Helen Hunt’s character, a single mother with a severely asthmatic son, gave a long soliloquy with expletives to a doctor, played by Harold Ramis, who was Egon in “Ghostbusters,” about how her son had been abused by his HMO. I cried as I listened to those cheers.
After that Hollywood reprimand, it was a rapid downhill ride for HMOs and ‘90s style capitation. The authors of the NEJM paper are calling for a new kind of capitation in their “revolution” and are not advocating for a return to the abusive care that Helen Hunt’s character decried. I should add that the abuses she described did certainly occur in some HMOs that were very profit-oriented, but abusive care with a denial of needed services did not occur in the quality-oriented HMO organizations like Group Health of Pudget Sound, Kaiser, or Harvard Community Health Plan. The strongest point made by the authors was that a period of increased resources would be required as an effectively managed care infrastructure was established. They suggested a year of being held harmless to financial losses or “harm.” I registered some disagreement with only a year of protection because I think a more supportive transition would lead to greater success. I would go further and advocate for direct investments by the government similar to the IT grants of a decade ago to hasten the creation of an effective infrastructure and the dissemination of the population management skills in primary care that would hasten the desired “revolution.”
In the late ‘90s, Harvard Vanguard Medical Associates was launched from Harvard Pilgrim Health Care with a well-established managed care infrastructure that included a fully operational Epic medical record and an advanced IT infrastructure. Vanguard also inherited a rich history of managed care expertise and practitioners with tools that were developed over three decades of applied pragmatism by the professionals at Harvard Community Health Plan. Unfortunately, things immediately crashed. Public attitudes changed. Employers moved to self-insured sole source payment programs built on FFS being managed by third-party network managers that provided administrative services. By 2008 after a difficult nine-year transition to FFS that was necessary for survival much of that managed care machinery was lost. We had also developed many of the bad habits of FFS practice which I would characterize as “overuse, underuse, and misuse” of medical resources. We still had a high measured quality and were slightly less expensive than our competitors, but we had low patient satisfaction in a market that had strong competitors that successfully argued that their world-class reputations entitled them to a financial advantage.
In the aftermath of “Romneycare”, the Massachuset legislature had passed a law that called for risk contracts to be the sole form of payment in Massachusetts by 2013. Unfortunately, the medical community pushed back and that never happened. Nevertheless, as I began my tenure as CEO in 2008, I felt that my most important responsibility was to prepare the practice to successfully move toward the Triple Aim with an infrastructure that was designed to succeed in a “risk” environment. We had much to create and much to rebuild. We conceptualized our challenge as the equivalent of “retooling” the factory, not dissimilar to an auto manufacturer moving from building cars that ran on gasoline to electric cars. The problem was that we could not shut down the factory between models. Our job was similar to rebuilding your car while driving it on the Interstate at the speed limit.
We were fortunate to have Massachusett Blue Cross encourage us with its Alternative Quality Contract. Later we were encouraged by the CMMI’s Pioneer ACO project. To guide our work we wrote a strategic plan. The core objective of the plan was to eliminate waste and improve operational efficiency while simultaneously improving patient satisfaction, employee satisfaction, and lowering the cost of care. Our mantra was “rescue and reallocate.” What we were trying to do was to rescue resources from waste, overuse, underuse (which leads to bad outcomes and rework), and misuse. To facilitate our transition we began to implement Lean and poured resources into further development of our data warehouse capabilities, mental health resources, patient satisfaction efforts, staff support and training, and the enhancement of our medical home capabilities. In our best contracts, we managed the total “cost of care.” Optimally the PCP should be able to direct the use of specialty care which is a major component of “overuse and misuse.”
I believe that the “revolution” in primary care will require years of increased emphasis on the importance of the primary care physician and the development of well-integrated team-based care. For many years I have been convinced that a major component of America’s excessive cost of care is driven by the inefficient use of healthcare personnel in dysfunctional processes of care. Paul Batalben assured us that systems deliver what we design them to do. Better systems deliver safer care with greater satisfaction for the patient and for the care providers. We now have a financial crisis that in part is driven by workforce inadequacies that include professional shortages coupled with poorly designed systems that have evolved in many dysfunctional ways. Poor system architecture and function have created widespread professional “burnout” and frustration with low satisfaction for patients and families. To me, these problems are a call for a system redesign as well as a revolution in finance
Ultimately how physicians and medical institutions are paid is the primary driver of what they chose to do. I wish that were not true, but experience has taught me it is true. If we are to ever move toward the Triple Aim it will occur when the finance of healthcare changes. Staying with FFS means staying with what we have or worse with pooer access still creating healthcare inequality and disparities. We have something that is much worse than a decimated cohort of underpaid PCPs. Primary care suffers from underpayment in comparison to other specialties and “under” respect and a lack of appreciation for a difficult role that is often undermined by other specialties. This professional disrespect has created damage that will take time to repair. Collectively these issues have dissuaded many medical students from experiencing the joy of primary care practice. We don’t have enough PCPs to make primary care as currently practiced in most places available to every patient. That is also true if we throw in all of our NPs and PAs to expand the workforce. Our workforce issues translate into financial problems. Workforce or adequate staffing issues may be our greatest problem that we do not fully appreciate yet.
More than a dozen years ago when I first met Allan Goroll, the lead author on the NEJM paper calling for a revolution to replace slow evolution, he told me that his work on the medical home was motivated by the desire to make primary care the choice of the best and the brightest of all of our medical students. I understood what he meant and was quick to want to share his objective. We are still a long way from that objective but I firmly believe that it can be achieved and it is a necessary early step in a successful move toward better more equitable care for everyone, health that is not distributed by ZIP code and ethnicity. We need to reorganize and support primary care delivery in a way that will rescue resources now wasted by healthcare that we need for the other necessities that support the improvement of the social determinants of health: housing for everyone, good nutrition for everyone, educational opportunities that allow everyone to achieve their potential, good jobs that add meaning to existence, and with enough resources left over to share an improved community infrastructure.
As we move past Donald Trump and the pandemic, the best strategy to avoid the reemergence of either plague is to focus on greater equity in every aspect of community life and the protection of the planet from the impact of global warming. These are daunting tasks. A good place to start will be the sort of transformation of primary care that maximizes the health of the nation.
The End of Winter Blahs Are Worse in The Era Of COVID
Today’s header captures some of the shoreline along part of my backyard. In truth, we use the lake as an extension of our backyard. In the spring I will need to take down the birdfeeders in the evenings to prevent them from being bear feeders. The chairs on the stone patio around the firepit are still under what was about two feet of snow that is now two feet of ice mixed with a little snow. I am sure that the ice on the lake is also about two feet thick. To the left, you can get a partial glimpse of a shed where we store deck furniture, water sports gear, fishing tackle, and gardening tools. To the right of the kayak and canoe rack is a Sunfish under a tarp that is lying behind an old aluminum fishing boat also covered with a tarp that I will be launching as soon as we have “ice out.”
The earliest “ice out” that I can remember in the dozen years we have owned this place was in mid-March. Early to mid-April is the more usual time. It has been as late as late April. I find it interesting to realize that the Red Sox are playing baseball in Florida now and that it is most likely that the lake will still be frozen when the Sox have “opening day” at Fenway.
I have said in these notes that I love winter. I even love what is described as “bleak mid-winter” in the old carol based on the poem by 19th century English poet, Christina Rossetti. I love the days with falling snow in the bleak midwinter, and I love seeing the snow-covered trees in the bright sun on the clear days that follow a storm.
I really enjoy the intense brightness coming off the blanket of snow on the lake that you can experience mid-day when the sky is totally clear of clouds as it was yesterday when I took the picture that became the header for today. What I don’t enjoy so much is the transition from winter to spring or what we call “mud season.” Mud season for me is a tedious time. Mud season can feature storms that begin as snow but end as rain that turns everything into a treacherous block of ice. Those “mixed precipitation events” are often followed by warmer days when there is melting during the day followed by the water from the melt becoming treacherous ice at night. Even on a day with a temp in the high thirties ice persists in shady spots on the road and sometimes I fall on the ice during one of my walks as I did last week. Initially, I had a sore hip. Now I am struggling with sciatica. The melt/freeze cycle goes on for several weeks until it becomes just melt and mud followed by “ice out.” When the ice is out winter with all of its joys and occasional tribulations is gone.
With my fall, the end of winter is not off to a good start for me during this year of COVID. The temp will not be above 27 until next Monday. By next Wednesday we will see 50! Everything is tedious at the end of winter as we wait for our turn for vaccination. Our turn is scheduled for 3:30 today, and I am looking forward to when the snow and ice will be replaced by a few crocuses and early daffodils.
Wherever you are, and even if you have COVID fatigue, don’t act like a Texan. Be wise. Be cautious. Wear your mask. Keep your distance. Wash your hands. It would be a real shame to have come this far and then come down with COVID at the end of the pandemic.
Be well,
Gene
