Three Population Health Management Principles for Reconciling Quality Based Pay for Performance and the Doctor Patient Relationship

Writing in the New England Journal, Robert Berenson and Deborah Kay of the Urban Institute say a linchpin of Washington DCs pursuit of quality is a "policy overreach [that] could undermine the quest for higher-value health care."

Yikes.  The Disease Management Care Blog turns to population health management to ponder their unhappiness.

The authors concern is over Medicares "Physician Quality Reporting System" or "PQRS."  As the DMCB understands it, PQRS rewards (and penalizes) physicians for outcomes that are calculated from a set of quality "modifiers" that are submitted as part of the Medicare billing statement (an example can be found here).  The amount of money at stake is in the range of 1%-2% of the Medicare reimbursements.

Berensen and Kay point out that while the system has been ramping up over 6 years, 70% of Medicare participating physicians do not submit any modifiers.  In their opinion, thats because:

1) the loss of 1% of any payment is practically meaningless,

2) physicians distrust the metrics and

3) there is a fundamental disconnect between the modifiers and the complex world of clinical practice. 

As examples, radiologists are being dinged for total x-ray exposure while surgeons are being held accountable for pre-op antibiotic administration. While these and other quality measures are important, they fall far short of recognizing what keeps docs up at night, like reading the x-ray correctly and getting a patient through surgery and out of the hospital.

"Hear hear!" says the Disease Management Care Blog.  In the course of a normal day, it is job of doctors to do "doctor stuff" involving one patient at a time. 

But, you ask, isnt that contrary to being accountable to the health of populations? 

The DMCB doesnt think so, because state-of-the-art population health management (PHM) agrees that:

A. Physicians need to be immunized from disruptions their "customer facing" (i.e., the patient) activities.  Otherwise known as the doctor-patient relationship, thats the part of the health care system that relies on the seven or more years of undergraduate and graduate training that turns smart people into exquisitely trained physicians.  Let the doctors be doctors, says the DMCB, and let them worry about their patients.

B. High performing systems - as much as possible - need to be configured around those customer-facing activities, further enabling the doc to focus on the patient who is right here and right now. 

From time to time, PHM might have to intrude.  When it does, the DMCB suggests policymakers recognize that they should proceed:

1) only when its really important

2) only infrequently and

3) whenever possible, when it reduces physician work by outsourcing (an example in primary care can be found here) those things that dont require the personal involvement of a doc.

It would seem that Medicares PQRS failed to recognize the fundamentals.

Image fromWikipedia

Going Long on the Patient Centered Medical Home PCMH Despite the Prattling Pinheads of Pessimism

Is the Disease Management Care Blog worried about the prognosis of the Patient Centered Medical Home (PCMH)?

Not in the least.

Its simply marching from its "Peak of Inflated Expectations" through the "Trough of Disillusionment." Before you decide to short the PCMH, check out this very enlightening Bloomberg editorial, Lure More Doctors Into Primary Care With Medical Homes.

Noting that many commercial insurers remain committed to the medical home model of care, Bloombergs business-savvy editorial board also points out that the PCMH has the added quality of attracting physicians to careers in primary care. The Josia Macy Jr. Foundation has some preliminary data suggesting that experience in medical home settings increases medical students enthusiasm for primary care.

Its a timely article.  While prattling pinheads of pessimism (examples here and here) glom onto imperfect research methodologies and findings that are unequal to the task at hand, top notch organizations like Sutter, University of Pittsburgh Medical Center and Horizon Blue Cross Blue Shield are going long on the PCMH.

These guys know something that the academics are missing.

Too bad there isnt a PCMH futures market; the DMCB could make some serious money.

Image from Wikipedia

Choosing Wisely Unnecessary Testing and the Simplistic Use of Web 1 0 to Attempt Physician and Patient Behavior Change

The Model T

There are certain Disease Management Care Blog behaviors that the spouse finds.... objectionable.  She has verbally educated the DMCB about them and has left written notes about them.  Since these communications havent worked all that well, are there any other "channels" she could use? 

The DMCB spouse may be tempted to use the approach of the Choosing Wisely web-site. It provides lists of widely used medical tests and treatments that are typically unnecessary.  The lists (located here) were compiled as part of a joint physician and education project by organizations such as the American College of Cardiology (dont do stress tests in patients without cardiac symptoms) and the American College of Physicians (dont get back x-rays if the ache is non-specific). According to the press reports heralding the availability of this just opened web-site (for example), its purpose is to prompt patients and physicians "to work together" to not only make clinically wise choices, but save the U.S. health care system a lot of money.

The DMCB knows that the academic experts and organizations that developed these lists have been talking and writing about these wasteful tests and treatments for decades.  Waste has been the subject of infinite numbers of continuing education programs, grand rounds, published review articles, national meetings and guidelines.

Those approaches havent worked. 

So is the fix is to repackage the information and post it as simple text on a web page?

The DMCB cant say its impressed.  While the evidence underlying the clinical recommendations themselves is superb, there isnt any evidence that internet-based physician instruction is any better than traditional methods.  And if the purpose of the Choosing Widely web site is to prompt patient behavior change, the evidence that web-based education is better than print is pretty skinny there too. 

Its ironic that the intellectual rigor of the lists themselves wasnt matched by the same evidence-based approach to using the internet for this exercise in the first place.

Whats more, if these groups insisted on using the internet, the least they could have done was deploy a Web 2.0 approach.  The current Choosing Wisely site is so.... has been. 

That being said, there is some information that could be of use to the population health management service providers.  In contrast to the physician organizations, the DMCB is confident that theyll know how to package and present the information so that it can have a real impact.

The DMCB wishes Choosing Wisely good luck.  And in the meantime, it looks like the DMCB spouse will have to continue to rely on verbal and written feedback.... for now.