Areas of Focus: The 5 Pillars of Reform.
PPC endorses several general goals upon which most of our efforts are based. These objectives seek to improve our ability to care for patients without being burdened by a regulatory environment and insurance rules that hamper true quality care and practitioner autonomy.
We believe that our goals can effectively improve the care of patients, reduce practitioner burnout, and decreased the cost of medical care. Any sensible health care delivery system should be centered around a vibrant primary care community, and we seek to redirect health care reform to assure that is exactly what will happen.
The following are our 5 pillars of health care reform:
PILLAR ONE: Reduce burnout.
Studies show that deleterious burnout is at a record high among physicians, and no group is more burned out that those who practice primary care. Some have called this an ethical crisis, since burnout impairs the ability of primary care practitioners to deliver optimal medical care, while many primary care practitioners are leaving the profession, becoming concierge doctors for the affluent, or falling into a depressed state that threatens their own lives. This trend is true for both doctors and nurse practitioners. Much of this burnout has been imposed upon primary care practitioners by hospitals, insurance companies (including but not limited to Medicare), a reliance on EMRs, and increasing government regulations/dictates (from HIPAA to ICD-10 to ever-changing coding and documentation rules to confusing new programs and payment methods). Many of these onerous changes being dropped on the backs of primary care practitioners are done in the name of reform, some ironically in the name of succoring primary care. Few to none have been demonstrated to actually improve patients’ medical care or our ailing health care delivery system; in fact, most do just the opposite. By imposing inflexible rules and regulations on our practices that prevent us from having meaningful discourse with our patients, by scripting how we must interact with our patients lest we be hit by painful audits and pay cuts, by scrutinizing how we communicate with patients and run our office through over-the-top HIPAA requirements that frighten all of us and prevent us from using common sense, by paying us substantially less and often making us work harder for every dime than our specialist colleagues, and by changing our job description from practitioner to that of data entry workers who must exert more effort into typing notes than looking into patients’ eyes and helping them, the agencies and people who have co-opted medical care are making our lives miserable, our patients’ lives miserable, and health care delivery both more expensive and less effective. Here are a few examples of what must change and what we at PCAC will be advocating for, some of which are separate pillars of care that we will discuss more in subsequent bullets:
We need significant reform of HIPAA, orchestrated by primary care practitioners and their patients, that can create a common sense system of communication in our current digital age that both values patient privacy and enables fluid and necessary discourse.Also, the penalties for minor HIPAA violations must be ramped down; currently a single violation can be enough to shut down an entire office practice.
We need to move toward some degree of pay equity between primary care and specialization, with primary care practitioners rewarded for their valuable patient-oriented work that does not involve highly reimbursed procedures.More about that later.
EMR and note-taking practices and requirements need to change.While electronic records are a positive and unalterable reality in health care, the rules guiding their use are burdensome and disrupt the practitioner-patient relationship.We must discard a reliance on scripted notes that demand an unfathomable combination of “elements” to be spelled out on every visit lest an auditor hit us with fines and penalties.We must remove the mandate for an incessant recording of “quality” measures in every note.Notes should reflect what transpires between practitioner and patient so that we and others who need it have a record of the visit.Notes should be brief and easy to read, and should not take more than 5 minutes to type or dictate.Common sense must supplant regulatory insanity.It is time to make the EMR a tool to assist medical care and discourse, rather than something we must stare at and type madly into as our focus verges away from the patient in front of us and to the note itself.
Quality measures and clinical practice guidelines that demand a top-down and rigid approach to clinical care must be eliminated or altered.More about that later.
Coding and billing rules need to be simplified so that a large chunk of primary care overhead and focus need not be on the minutia of how to get paid.
PILLAR TWO: Emphasize shared decision making.
Ultimately in this age of costly technology and medicines that purport to find and fix everything; in this age of fabricated medical fear where we all think we are sick; in this age of medical fantasy where we are convinced that there are easy fixes for health care woes and for the inevitable changes of aging, we need primary care practitioners to be there for our patients to discuss and explain medical truth to them. There is uncertainly tied to medical decisions, no right or wrong answers. Every patient has a unique set of needs and values, and each is willing to accept a unique set of risks. Some crave tests and medicines, others eschew them. It is our job to guide them through the morass of health care confusion by showing them actual risks and benefits of medical intervention, and discussing with them how they would like to proceed in the context of their own wishes and needs. It is time that our health care system demand and value shared decision making (SDM) from all practitioners, even specialists, something we in primary care do very well. That is what will increase quality and practitioner/patient satisfaction while decreasing cost more than any other measure. (Follow the blog at to see examples of the SDM’s power.) When a cardiologist can place an expensive and ineffective stent into a patient’s artery without discussing the procedure fully with the patient (only about 3% have a fully accurate discussion), when we know that when that discussion does ensue most patients elect not to get stents, and when we realize the financial rewards that cardiologists reap by not having the discussion, we must accept that SDM is one of the most powerful tools of health care reform that is being neglected and even discouraged. It is time that insurance companies pay more for the discussion than the procedure.
PILLAR THREE: Eliminate or reform clinical practice guidelines.
Primary care practitioners are being judged by a series of quality measures that rarely have relevance to the individual patients sitting in front of us and that can lead to both overtreatment and harm. No study has demonstrated any improved outcome with quality measures. And by imposing a specific agenda upon the practitioner-patient interaction, what health concerns matter most to the patients are often relegated to footnotes, while we spend much of our time satisfying an administrator’s erroneous assumptions of what constitutes good health care. Certain facts about clinical practice guidelines must be addressed immediately:
Tying financial incentives and disincentives to quality measures has been demonstrated to be ineffective, while it punishes practitioners who take care of the most challenging patients.The more that money is tied to quality indicators, the more it flows away from the sickest and most indigent patients, those in whom primary care providers have the most difficult time achieving quality measures for a variety of social and logistical reasons that are beyond the provider’s control.Currently Medicare and other insurance companies are on track to tie more than half of practitioner pay to quality measures.This would severely stress and hamper providers while making it more difficult to care for those who need us the most.
Quality measures must be patient and population specific.For instance, the frail elderly need not be on statins, should not have aggressive treatment of diabetes and hypertension, and have medical needs that are not reflected by measuring and fixing numbers.The poor and physically impaired often have a hard time lowering A1C to levels that are demanded by quality measures, cannot get out to have mammograms or colonoscopies, and have other needs that impact their health and well being far beyond what we can measure and fix.And many individuals either have reactions to or simply chose not to pursue some of the “necessary“ qualitymeasures that administrators seek to impose on them.Patient choice needs to be respected, and practitioners should not be punished if their patients make decisions that make sense to them.
Currently quality measures reward over-treatment.If we keep blood pressure below 120 we are rewarded, even if lowering that blood pressure causes patients to feint, be tired, and break a hip.Similarly aggressively treating cardiac disease, diabetes, osteoporosis, and even dementia can lead to copious tests and medicines that actually impair clinical outcomes.It is time we have common sense clinical guidelines that do address obvious under-treatment, but also chide doctors for over-treatment, over-testing, and over-medicating.
All clinical guidelines need to be based on SDM.If a patient decides, after a reasonable and accurate discussion of risks/benefits, not to have a mammogram, not to take statins, not to get a bone density test, then that decision needs to be respected, and the practitioner cannot be punished for the patient’s decision.In fact, shared decision making itself is the most valuable quality measure that can be implemented.It should be demanded of all practitioners, including specialists, and its implementation should be rewarded.
PILLAR FOUR: Shift care from the hospital to the home.
There is nothing more expensive than hospitalization. And yet multiple studies have shown that for a variety of conditions, and especially in the elderly, home care is more efficacious, less costly, and more desired than hospital care. Almost three-quarters of elderly people spend time in the hospital their last year of life, and more than half die in the hospital, despite a strong desire by them to die at home, and despite clear evidence that hospitalization is dangerous and unhelpful. For many chronic conditions like COPD and CHF, and many acute conditions such as pneumonia and syncope, home palliative care has been shown to be superior than hospital level care. Hundreds of thousands of patients annually die and clinically deteriorate from what transpires in the hospital. Primary care practitioners know this, are increasingly going to be financially held accountable for the cost of their patients’ excessive hospitalization (the so-called “value” portion of reform). But there is nothing we can do to stem the tide.
That is because insurances like Medicare pay for and reward hospitalization while relegating comprehensive home care to a complex and frustrating caldron of limitations and rules that make it virtually impossible for patients and practitioners to negotiate. A trip to the hospital buys patients free 24 hour care, free medicines, and 100 days of inpatient sub-acute care if they stay for 3 nights. A trip to the hospital enriches many people and institutions in the health care consortium. A trip to the hospital requires no work for the primary care practitioner. Treatment at home is not so well valued. For the patient they have to pay for custodial care, for medicines, and for treatments. They have to hope home health aides and medicines arrive on time. IVs and other basic treatments are virtually impossible to obtain. They do not get the 100 day subacute benefit. For practitioners and their office staffs, treating someone at home requires hours of uncompensated time filling out forms, pleading with DME agencies, calling patients and families.
It is time to change that reality. As long as hospitals remain at the help of reform efforts, no meaningful shift in the hospital-home paradox can occur. Microscopic “fixes” and “tinkering” being championed by ACOs, Medicare reformers, and the ACA’s innovation center does not get to the meat of the problem. We need to make home care easier and loss costly than hospitalization for patients and practitioners for it to be the norm. Primary care practitioners need to be in charge of that effort. We get it, and know that the current madness needs to be fixed. Rather than blame us if our patients follow the only course that is open to them, allow us to create a new sensible system of health care delivery.
PILLAR FIVE: Reward and Value Primary Care.
Currently a vast majority of medical students purse specialty fields, with very few students actually entering primary care practices. While some of this void is being filled by capable nurse practitioners, it still floods the medical landscape with specialized care that is both unneeded and potentially deleterious. Population studies carried out at Dartmouth and elsewhere clearly show that in areas of the country where there are high concentrations of specialists, health outcomes are worse, cost is higher, and overtreatment is epidemic. Contrarily, it has also been shown that in patients who rely on primary care, their outcomes and satisfaction are improved. Still, we spew out more specialists and reward them for their excessive care, while the system continues to trample upon primary care. Several factors must change for this to change:
The blatant pay inequity between primary care and specialist providers must end.This is not an inequity derived from the free market or any logical mechanism of determining pay. The Relative Value Scale Update Committee (RUC) is a small group of mostly specialists who meet secretly under AMA auspices and determine rules for physician (and by default NP) payment, which are then accepted by Medicare and most other insurances.Under RUC, the gap between primary care reimbursement and specialist reimbursement has widened to unacceptable levels.Now a primary care practitioner must see a day’s worth of patients at a rapid pace to equal what a specialist might earn by doing one or two procedures.This must change.Procedure-based health care leads to over-treatment, worse quality, and higher cost.Spending time with patients, which is deemphasized under the RUC formula, does just the opposite, and is exactly what patients are craving.Our goal is to advocate for a pay scale that values practitioners and patients having meaningful conversations about medical issues, rather than practitioners simply ordering tests and procedures that enrich them.
A cap should be placed on residency training slots for specialists.It is important to realize that residency training is heavily subsidized by Medicare, and thus the government has a right to insist that we train the doctors that this country most needs, not more specialists.
Nurse Practitioners need to be given a larger and more independent role in caring for patients, with compensation commensurate with their skills and work.
As discussed above, we need to remove many of the regulatory, administrative, and accounting burdens that are hampering primary care and making primary care practitioners some of the most burnt out in the country.
See subsequent pages for ideas about how to institute these very important changes in our health care delivery system.