Following the most basic model for success in business means minimizing overhead and maximizing revenues, Dr. Mark Laitos pointed out at TAFP’s Payment Reform Summit last Saturday. For doctors in private practice and other health care providers, this means billing for as many relative value units, or RVUs, as possible at the best conversion rate, and maximizing ancillary revenue, when possible.
And while this strategy is simple enough, Laitos said it has reduced the “proud field” of medicine to “conveyor belt medicine.” Worse, as payers – including health insurers, employers, and patients to some extent – strive to minimize RVUs, the solution to the cost crisis in a fee-for-service system is to slash payment to physicians and deny care to patients.
Of course neither patients nor doctors (nor the organizations that advocate for them) would allow this to happen considering the scale needed to rein in escalating health care costs. The solution, then, as speaker after speaker suggested, is to trade the volume-based model for a value-based model. This is also the cover story of the latest Texas Family Physician magazine.
Dr. Laitos was the first to bring up the triple aim – three things a health system should strive to do: improve the health of the population, improve the patient experience of care, and reduce the per capita costs of care. This Health Affairs article goes into more depth, but it sounds a lot like the concept behind accountable care organizations – that care should be primary care-based, consider population health, empower patients, and integrate with other care providers on a macro level.
Dr. Eduardo Sanchez, a family physician and medical director of Blue Cross and Blue Shield of Texas agreed on two points, referencing a still-amorphous “virtual medical community” that aims to connect smaller practices currently organized as “onesies, twosies, and foursies” by providing them with a platform for information exchange and management.
He also brought up BCBSTX’s Bridges To Excellence program as a way for physicians to be recognized as high-performing. “Physicians will have to be able to capture data, analyze that data, and have ability to adjust what those data reveal. BTE and PQRS [Physician Quality Reporting System] are not the answer, but they are a way to get started and learn how to manage the system for quality improvement.”
Dr. Chris Crow of Plano, another speaker at the summit, asserted his strong belief in using data and analytics to measure quality and costs; he’s used it in his practice to provide better, more efficient, and more cost-effective care, and he can demonstrate this through real figures to any interested party. Dr. Crow said that once a physician has access to quality and cost measures, he or she can begin to implement changes to improve care services. Not knowing the metrics is like “driving a car without a dashboard.”
Dr. Laitos asserted that there will be winners and losers in health care reform. “The winners will be the doctors who know how to demonstrate value.”
To read more about the Payment Reform Summit, check out TAFP’s coverage published in last week’s QuickInfo e-newsletter. Also stay tuned for video recordings of the lectures to be published later this fall.
As could be expected, Gov. Rick Perry’s decision to seek the Republican nomination for president has intensified state and national media scrutiny of Texas’ health care record, particularly regarding the uninsured, Medicaid, health care costs, and our medical liability climate.
TAFP has long been on record in our public positions—from “Fading Away” to “Fractured” to “The Primary Solution”—that starving down our primary care infrastructure and the continued fragmentation of care across the spectrum of settings transcends moral concerns and translates into very real economic consequences that threaten everyone from local taxpayers to employers and families. We have been equally ardent in our position that a vibrant primary care delivery system operating in a healthy liability climate is the solution to the crisis facing our health care delivery system.
Armed with these resources, TAFP’s physician leaders, lobby team, and advocacy staff have routinely briefed top Texas political and health care writers, as well as legislators and their staffs, particularly leading up to and during legislative sessions. Now TAFP has been called upon for similar briefings and interviews by a rapidly growing body of national writers from media outlets as diverse as CBS News, NBC News, NPR, the Wall Street Journal, the Los Angeles Times, the Washington Post, the New York Times, the Boston Globe, Kaiser Family Foundation and Politico, the Hill, and others.
TAFP anticipates that over the course of the next year and possibly beyond, the national attention paid to Texas will only escalate. This creates an opportunity to continue serving as a national leader to explain the socioeconomic and delivery system challenges plaguing our system, but more important to trumpet the role of family physicians as vital to the solution.
By Janet Hurley, M.D.
Having been a patient not too long ago, I am convinced that doctors should be patients more often. As we continue to talk more in health care about “patient-centeredness” and the “patient experience,” I have a few thoughts on things I learned during my convalescence period after a tonsillectomy in 2009.
1) My surgeon, my anesthesiologist, and the surgical center staff were GREAT. As providers, the things we do become routine to us, but to patients they are extraordinary. Taking the time to explain a procedure carefully and thoughtfully can make a big difference.
2) Follow directions. Patient handouts have important information in them and the treatment team knows what they’re doing. I must remember to listen to their advice and review the patient materials when I have questions.
3) Don’t be your own doctor! If you have questions about medications or symptoms, ASK SOMEONE ELSE. You may choose to be a highly educated patient, but not your own doctor.
4) I am not too tough for pain medications. While I dislike the mental fogginess they create, I had to keep in mind steps I prescribe to my patients—maintain better hydration, better nutrition, and keep my throat moist—to make myself more comfortable.
5) I will never even think about accessing my Electronic Medical Record from home until fully off narcotics. Impairment was obvious.
6) When on narcotics, I communicate better with my fingers than my tongue. You can’t rush recovery, even when you know you have important work to do. E-mail communication with others kept me connected when my speech was slurred and my throat hurt.
7) I have great clinic coverage partners. I had no worries about who would check my messages, approve refill requests, and see my patients when I was out. We must remember that good patient care during such times requires that we receive help from our colleagues.
8) Don’t undervalue the significance of family and friends. I am grateful to my husband who took care of our kids and took care of me, and the friends and neighbors who looked for ways to help out during my recovery. It’s okay to lean on those closest to you in times of need!
Janet Hurley, M.D., is a family physician at Trinity Clinic in Whitehouse, Texas.
Now that the 12 members of the Joint Select Committee on Deficit Reduction have begun meeting to develop a plan to trim at least $1.2 trillion in federal spending, advocacy groups and politicos have ramped up their effort to influence what goes on to and what stays off of the chopping block.
Since our last blog post, AAFP has taken significant steps to encourage the supercommittee to avoid making damaging cuts to Medicare and graduate medical education. AAFP met with representatives from seven medical societies and seven professional organizations on Sept. 7 to develop a unified strategy for the house of medicine, with AAFP still holding strong to the position that the SGR should be repealed or, barring that, the committee should enact a five-year Medicare payment fix that includes a 3-percent higher payment rate for primary care physicians.
During this week’s Congress of Delegates meeting, AAFP launched a grassroots campaign that calls for AAFP Delegates and other members to send a letter to their Congressional representatives asking for immediate repeal of the SGR. AAFP already sent its own letter to the “super 12” on Aug. 10 outlining its asks, and the 12 AAFP state chapters in which a supercommittee member lives requested meetings with their super person during the Congressional recess that extended through Labor Day. Texas is, of course, home to committee co-chair U.S. Rep. Jeb Hensarling, and Doug Curran, M.D., TAFP past president, current TMA board member, and constituent from Athens, has a meeting scheduled with the representative in the next couple of weeks.
Additionally, AAFP Board Chair Roland Goertz, M.D., M.B.A., of Waco said in an interview with Family Practice News digital network that the Academy will produce videos featuring “real family physicians who describe the real impact of these cuts for their practices,” in the hope that the videos go viral and incite larger action.
Most important, Goertz told AAFP members in the FPN video interview that physicians need to step up and take action. “Don’t go to sleep on this issue. We’ve been fighting this for 10 years. Don’t get fatigued about contacting those who represent you.”
“This is a big, big deal. A 29.5-percent cut in a payer source, particularly in Medicare, is going to put some practices out of business in some locations. So mobilize yourself, contact your elected officials, and if you feel comfortable with it, make sure you involve your patients because your patients are going to be the ones who unfortunately will suffer the outcomes.”
AAFP and other experts have acknowledged that the supercommittee may not address the SGR in their budget plan – because once again it may be too big an issue to tackle along with all of the other considerations. Hence, AAFP’s request for a five-year fix and 3-percent pay bump for primary care.
Another SGR-replacement idea released recently by the Medicare Payment Advisory Commission would implement a 10-year fix at a cost of around $200 billion. Though MedPAC’s plan would just replace one form of automatic payment cuts with different automatic payment cuts, it does include protections for primary care.
Kaiser Health News reports on their blog: “Reimbursements for primary care physicians would be frozen for 10 years, and specialists would see a reduction in payments for three years, at which time their rates would also be frozen.”
As Goertz said in an interview with AAFP News Now, “This is a game in evolution, and there are going to be some twists and turns.”
Last month’s debate on the U.S. debt ceiling brought to light the ugly side of how we finance the nation’s operations, and as lawmakers move forward on a deal to reduce the deficit, they will inevitably turn their eyes to one of the country’s biggest expenses: Medicare. Federal spending for fiscal year 2010 totaled $3.5 trillion and Medicare comprised 15 percent of the total amount.
However, with crisis comes opportunity and a convergence of factors may make this the time to address a structural deficit in how the country pays physicians and other providers for the services they provide to Medicare beneficiaries.
Under the debt deal, a 12-member joint committee has until Thanksgiving to formulate a plan to cut at least $1.2 trillion in spending over the next 10 years. Then, recommendations made by the so-called “supercommittee” must go before Congress and pass by a simple majority in both chambers by Christmas. If the committee can’t agree on cuts or Congress fails to pass them, a series of across-the-board reductions would be triggered. One cuts pay to Medicare providers by up to 2 percent starting in 2013, which experts estimate would add up to around $12 billion.
While a reduction of any amount hurts, there is a bigger problem on the horizon: the Medicare physician payment formula, known as the Sustainable Growth Rate or SGR. Under the SGR, a across-the-board 29.5-percent cut would take effect on Jan. 1, 2012.
Every congressional budget cycle since 1997 has included a reduction in Medicare payments that has eventually been modified. Since 2002, Congress has stepped in 12 times to stop the cut, including four times last year. And each year that Congress provides a temporary patch, the price tag gets steeper. According to the AMA, if Congress were to wait until 2016 to eliminate the SGR, the combined price of providing temporary patches and fixing the structural problem would approach $600 billion.
Now it boils down to deficit reduction; if Congress doesn’t address the broken SGR in some way, it will continue adding to the deficit. This gives the argument to repeal the SGR strength it hasn’t had in previous years.
The real value of the supercommittee is that there are no restrictions on what they can recommend to cut or how it scores savings; its jurisdiction gives the 12 members the ability to find offsets for other spending in all areas of government. By virtue of normal committee jurisdiction, fixing the SGR—a Medicare Part B issue—would usually mean finding offsets only within Medicare Part B, and that hasn’t been possible without hurting the program. Similarly, the supercommittee could recommend federal medical liability reform and score those savings toward deficit reduction.
Late last month, the American Medical Association and 10 specialty societies (including AAFP) sent a video to Congress on the need for full repeal of Medicare’s flawed Sustainable Growth Rate formula. At just over two minutes long, a combination of text and eerie techno-classical music sets the scene: “By acting now, Congress can preserve access to care for people on Medicare and reduce Medicare spending by hundreds of billions of dollars. Or it can put off a solution…again.” Weaving through charts and graphs, they make the golden deficit-reduction argument, ending with the final statement: “Stop digging the hole. Pay the bill. Repeal the SGR.”
[Can’t see the embedded video above? View here: http://youtu.be/jNmuyZWi3qc]
The AMA proposes a three-pronged approach: repeal the SGR; provide five years of stable payments with positive annual updates; and transition to a broad array of payment and delivery innovations.
AAFP outlined similar asks in a letter sent to supercommittee members last week. First, stabilize Medicare payments to physicians by repealing the SGR, and specify a payment rate for the next 3 to 5 years with a 3-percent higher rate for primary care physicians delivering primary care services. Second, avoid making reductions in Graduate Medical Education, especially GME payments for primary care education and training, to protect the physician workforce.
As a die-hard fan of the Texas Longhorns, I have no shame in telling you that after last year’s 5-7 record, I was glad the college football season was over. Even though I’m a self-admitted policy wonk and political news junkie, I was equally relieved—even somewhat jubilant—when the 82nd Texas Legislature finally closed up shop and went home. If you followed the frustrating struggle to balance the state budget without additional revenue, and witnessed the resulting cuts to higher education, public education, and health and human services, you might have been just as ready for it to end as I was. At least when they’re not in session, they can’t do any more damage, right? Now is not the time to bury our heads in the sand. In fact, the legislative interim is perhaps our best opportunity to formulate and articulate our most effective arguments for renewed investment in Texas’ primary care infrastructure. We can document the ill effects of the drastic reduction in state support for graduate medical education, especially in family medicine residency training, and we can illustrate the broken promise of access to primary care physicians for underserved communities made manifest by the 76-percent cut to the state’s Physician Education Loan Repayment Program.
And now is the time to begin preparations for a major initiative in the next legislative session. In the late ’80s, rural medicine in Texas was in terrible need of state investment. Health care organizations and advocates rallied around a broad set of goals encompassed in what was called the Omnibus Rural Healthcare Rescue Act, which the Legislature passed in 1989. The law created the Center for Rural Health Initiatives and the Office of Rural Health Care, and it contained tort reforms, benefits for rural hospitals, several reforms to strengthen the state’s trauma care infrastructure, and new recruitment and training programs for primary care physicians. Family medicine won funding for third-year clerkships, among other valuable reforms.
As our state demographics change, and following the decision of the 82nd Legislature to withdraw almost 80 percent of its investment in programs intended to increase the state’s primary care workforce, we believe primary care in Texas is in desperate need of something like that landmark omnibus package of reforms and initiatives. Let’s call it the Primary Care Rescue Act. Obviously we would want to include the restoration of state support for GME, especially the funds that go directly to family medicine residency programs through the Texas Higher Education Coordinating Board. Also we would include full restoration of funds for the Statewide Primary Care Preceptorship Program, and the Physician Education Loan Repayment Program. But what else should we include?
We wish to engage you—the membership of TAFP—in this endeavor from the very beginning. What state reforms would make your practice easier, more efficient, and provide better care for your patients? What kind of administrative simplification requests should we make in state programs? What about managed care reforms? Would a standardized pre-authorization process help? Standardized contracts? Real-time claims adjudication? What could the state do to make primary care more attractive to medical students?
The sooner we can begin to craft a set of reforms to use during the election cycle, the more likely our success becomes. Remember, politics drives the process that sets policy. That’s why we want to hear your ideas for the Primary Care Rescue Act. Use this space, here on the blog, to comment with your ideas, and we’ll pay close attention to the discussion. If you’d rather send us your ideas individually, feel free to e-mail me, Jonathan Nelson, at email@example.com. Or you can e-mail Tom Banning at firstname.lastname@example.org, or Kate Alfano at email@example.com. However you choose to share your ideas, we are eager to hear them. The legislative interim can be a time filled with promise and hope, and it’s the perfect time to lay the groundwork for big initiatives in the next session. Let’s take advantage of that opportunity.
This Annual Session ushered in a new era of communication, and we asked members to interact with us, their fellow attendees, and their colleagues from around the state and country. Now that the dust has settled on a busy conference filled with CME, business meetings, and special events, we want to encourage you to continue the commentary.
So…what did you think? How were our posts/pictures/tweets? What can we do to improve our communication and interaction with you? And, in a very simple sense, what did you like or not like about our effort (so we can be better next time)?
As a recap, the total effort centered around the Annual Session Social Media Portal – http://tafp11.txfamilydocs.org/ – a page within our TXFamilyDocs.org blog. We had an ASSA Flickr stream updated nightly, as well as a daily news wrap. Staff tweeted more frequently than posting on Facebook, but that goes along with the urgency of the platforms.
The highlight of the conference was our live stream of the lecture “Know Before You Sign! What to Look for in a Physician Employment Contract, Including Employment by Non-Profit Health Corporations.” Though it occurred from 5:15 – 6:15 p.m. on a Saturday afternoon, we had about a dozen viewers join us live, and we continue to have hits on the archived video on our Ustream channel: http://www.ustream.tv/channel/texas-academy-of-family-physicians. We even received a shout-out from Dr. Sevilla on his Family Medicine Rocks blog for this effort.
As fleeting as it seems, there is a certain longevity to social media tweets and posts, and I encourage you to revisit them. There is still time to upload pictures to our Flickr account (become a member and join our group: http://www.flickr.com/groups/txfamilydocs/), and it only takes a minute to scroll through our tweets and Facebook posts.
And, as mentioned above, this conference provided the building blocks for what we hope will be a larger effort to draw in our members and connect them beyond the walls of a host hotel. Watch as we work to further integrate all of our social media platforms at future conferences, and also please continue sending your suggestions. That’s the beauty of social media – it’s not about the person with the account password, it’s an fluid stream of interaction constructed for and by its contributors.
TAFP is embarking on a new experience for the 2011 Annual Session and Scientific Assembly, July 27-31, in Dallas. We have developed the Annual Session Social Media Portal, a new blog page on TXFamilyDocs.org that presents an opportunity for all TAFP members to participate, provide input, and interact with our fully-integrated social media program during the entire gathering.
This page, http://tafp11.txfamilydocs.org/, will be your hub for a live-streamed lecture; TAFP’s social media feeds; and discussion topics before, during, and after Annual Session. We encourage all to participate, especially if you can’t physically attend Annual Session in Dallas.
On this page we’ll post the latest news, gather attendee feedback, and stream a lecture from the 2011 Annual Session, TMLT’s “Know Before You Sign! What to Look for in a Physician Employment Contract, Including Employment by Non-Profit Health Corporations” with Douglas Kennedy, J.D.
If you tweet during the conference, don’t forget to follow TAFP on Twitter and include the hashtag #TAFP in your tweets so it’s logged in our conference feed. Also make sure to check in on TAFP’s Facebook page. Post your thoughts on speakers, special events, and exhibitors. Shooting photos? Sign up through Flickr and upload them to our group, www.flickr.com/groups/txfamilydocs, so they’ll be displayed through the social media portal. Be sure to tag them to our set “TAFP Annual Session 2011.”
Not only will you be able to keep up with your colleagues in Dallas, but you’ll also be able to enrich your experience by connecting with your colleagues around the state, our top-rated speakers, vendors, and staff, and participating in discussions of your choosing— all right here through TAFP’s blog, TXFamilyDocs.org. For more information about Annual Session, go to www.tafp.org/education/programs/2011as.
Need some more convincing? Check out this great post from The National Association of County and City Health Officials on the top 10 reasons to use social media at a professional conference. The short version is that you get to connect to people you might not otherwise, extend your professional network, stay on top of meeting logistics, and provide information to those who aren’t able to attend. I found it useful to follow TAFP’s Twitter feed during AAFP’s NCSC and ALF conferences so I could get the scoop on concurrent sessions!
Physician workforce – particularly in family medicine and primary care – has dominated TAFP’s focus during the past six months of the 82nd Texas Legislature and special session. Workforce issues emerge in all policy areas: health and human services, education, and their respective budgets – through medical school funding, graduate medical education, the Texas Statewide Preceptorship Program, and Texas Physician Education Loan Repayment program.
On June 11th, 2011, after the regular session ended and in the middle of the special session, I was very fortunate to be in the audience at the Stanford Medical School Commencement to see my sister receive her M.D./Ph.D., and to hear one of her classmates, David Austin Craig, M.D., give a thoughtful and humorous speech reflecting on his experience in med school and looking forward to the future.
Seeing the class of nearly 100 brand-new doctors “preparing to go from the frying pan of medical school to the Armageddon of residency,” as Craig said, reminded me why TAFP members spent so much time at the Capitol and in district offices meeting with legislators, testifying at hearings, developing and distributing issue briefs and policy papers, and reporting back to friends and colleagues in their communities. It’s all to support and protect the noble profession of medicine.
To each physician who participated in TAFP’s advocacy effort this year, we are grateful to you and hope you are proud of the myriad accomplishments you achieved in the midst of a tough session. We’ll need your help in the interim and the 83rd Legislature to keep the momentum going.
Until then, I invite you to read an excerpt from Dr. Craig’s speech and remember how you felt when you graduated from medical school and prepared to enter residency and beyond.
“We are headed far and wide next year, the newest foot soldiers in the war against disease that leaves not one of us on this planet untouched – a true World War in a pure and timeless sense.
“And, my classmates, though your staggering debt load may prevent you from sleeping on an actual bed, you can at least sleep soundly knowing that you have chosen to fight on the right side of this war.
“We all know that there is profit to be made quickly and in abundance by spreading fear and ignorance, in promoting poor health, in disregarding or denying the sorrow of another human being. You have instead chosen to hold a candle against these things, to enter into a profession where even your daily commute is a statement against suffering and a habitual reaffirmation that good exists.
“And, believe me, this is the only way that a 1993 rusted Geo Metro driving at 6 a.m. will ever be considered a sign of good in the world.”
“In truth, after spending the last several years with you, I can say honestly that medical school has only made you doctors in the way that a microphone makes somebody a singer. The letters “M.D.” will magnify your impact and open doors for you; will let you reach into more and darker corners of the world to spread hope and comfort there. That is true.
“However, those letters work only like a microphone, only amplifying what you put into them, and a microphone will never make you a singer just as an “M.D.” will never make you a doctor. It is now, just as it has always been: You have to bring your own voice and it is, in the end, the only thing that matters.”
See the full speech on YouTube: Stanford Medical School Commencement 2011 David Craig
Last Friday, the medical community was shocked and saddened by the sudden death of pediatrician and primary care advocate Barbara Starfield, M.D., M.P.H. During her decades spent at Johns Hopkins, she authored and co-authored numerous studies on the value of primary care that provided proof that many of us believed in our hearts but couldn’t quantify—that patients are healthier and costs are lower in a system based on primary care.
However, her work provided more than just facts; it provided the footing for a movement to redesign the fragmented system to one that is better for patients. She inspired us to really take a look at family medicine’s contribution and advocate for its importance. The process has been slow, but her momentum kept it going.
Because of her tremendous contributions to health care research and patient care, several organizations have released poignant and appropriate statements in tribute that must be shared. The first is the full statement from Roland Goertz, M.D., M.B.A., president of AAFP, and the second is an excerpt from Richard Roberts, M.D., J.D., president of the World Organization of Family Doctors.
A statement from Dr. Goertz:
“Patients throughout the world lost a dedicated advocate Friday, June 10, with the sudden death of Barbara Starfield, M.D., M.P.H. We have lost a committed scientist whose work focused the attention of policymakers and the entire health care community on meeting the needs of patients.
“As the University Distinguished Service Professor at the Johns Hopkins University Bloomberg School of Public Health and School of Medicine and as Director of its Primary Care Policy Center, Barbara was a tireless advocate for primary medical care. Her prolific research demonstrated that patients’ health, community health, and the nation’s health care system improved when people had access to primary medical care. She showed the world that family physicians’ expertise is essential to individual people, the communities where they live, and the soundness of the nation’s health care. She reminded family physicians why they chose their specialty—to help people improve the care they received and create a system that respected each person, regardless of their station in life. She painted a new vision for what family medicine could be and urged us to fulfill that vision.
“As a result, Barbara taught the nation that primary medical care is instrumental in turning the ship of health care policy toward a system that serves the needs of the people with efficiency. Her work earned her numerous awards, including the American Academy of Family Physicians’ highly prestigious John G. Walsh Award for Lifetime Contributions to Family Medicine. In giving the award, the AAFP cited Barbara’s dedicated, long-term and effective research in the advancement and development of family medicine.
“We will greatly miss Barbara Starfield’s energy, her commitment to building a system that serves patients and her leadership in teaching all of us about the value of the work we do. We have lost a good friend, an inspiring teacher and an exceptional researcher whose work helped make the world a better place for all of us.”
An excerpt from Dr. Roberts:
“She opened the eyes of family doctors to the considerable abilities we have, the weighty responsibilities we carry, and the unrealized possibilities we represent. She saw family doctors as the best hope for health care. Many times, she challenged our vision of what family medicine should look like, and nudged us to see further and clearer.
“She will be remembered for her passion for social justice, incisive intelligence, and incredible energy. Great people have an extraordinary vitality, which makes them seem immortal and lulls us into thinking we will have them forever. And then they are gone. The best tribute we can offer Barbara is to continue to work toward her vision of a world in which everyone has access to quality health care centered in a trusted relationship with a compassionate, competent, and comprehensive family doctor.”