The Ghosts of IMP

By HL Admin posted 07-04-2016 20:03


December 2015   Jean Antonucci, M.D.

Sometimes I go back to the earlier days of IMP and the lessons I learned, as I find that helps keep me focused. Here are a collection of some random nuggets delivered in a kind of hodgepodge fashion. Though some are nearly a decade old, they are just as apropos today.

  • If you’re working toward the goal of delivering superb care and have data to guide you, and you’re structured to deliver on the fundamental attributes of effective primary with great access, huge continuity, and work and expansive scope of services & work at least on the foothills of the mountain called “coordination of care,” then I’d call you an IMP.

  • How would we know that a practice is delivering quality care?

  1. Does the practice frustrate those who would seek care by wasting their time with inefficient processes and poor follow-through?

  2. Has the practice eliminated barriers to access?

  3. Does the practice fragment care over several providers or provide true continuity?

  4. Does the practice engage in meaningful patient-centered care by unmasking the patient's real wants and needs?

  5. Does the practice work with patients collaboratively to support them to the extent possible given the context of that patient's non health care determinants?

  6. Does the practice engage other parts of the health care "system" to defragment care across silos?

  • Unlike unproven "Gizmo" care exemplified by "EMR" and "ePrescribing," scores on these indicators are linked to patient experience of care, clinical outcomes, and the per-capital cost of health care.*

  1. *Wasson, J. H., Stukel, T. A., Weiss, J. E., Hays, R. D., Jette, A. M., & Nelson, E. C. (1999). A randomized trial of using patient self-assessment data to improve community practices. Effective Clinical Practice, 2, 1–10.

  2. Moore, L. G., & Wasson, J. H. (2006). An introduction to technology for patient-centered, collaborative care. Journal of Ambulatory Care Management, July-September 2006  29(3), 195–198.

  • An ideal system would support our desire to deliver on the promise of effective primary care. The work of effective primary care takes time and tools that are out of reach of our practices because of the woefully inadequate payment that is focused on “encounters” and the crushing burden of administrative trivia that includes the incredibly expensive and absurd game of chasing after huge insurance companies to get them to pay a pittance for legitimate work.

  • Primary care is (with some exceptions) a repugnant and illogical career choice.

  • A hugely helpful commentary from the October 1, 2008 JAMA by Henry Heng describes “The conflict between complex systems and reductionism.”  This commentary perfectly describes the way current thinking of measurement and evaluation has run to an illogical extreme of reductionism.  Heng is talking about how we understand the value of chemotherapy and other therapies.  When we focus on initial tumor burden we may count a course of chemotherapy a “success” even when the patient is manifestly worse off after the treatment and the intervention has lead to a surge in secondary tumors.  Too narrow a focus misses the big picture.

  • Patients know this stuff.  They are very aware of how well we perform.  What they have to say about this defines with great precision the degree to which we have organized our work.  This is no mere “patient satisfaction” thing, this defines the very essence of what we do and how we do it in a way that we’ll never achieve by looking at disease metrics.I’m not saying we stop measuring A1c, doing monofilament exams, referring for retinal exams.  We help people manage their diabetes.  In doing so we check A1c and do all those things that the literatures says can make a difference for our patients.  We help patients follow through with their intention to live healthier by reminding them of what they could do, facilitating their use of preventive and specialty services.  We must stop this reductionist thinking that somehow the evaluation of these thousands of things we do each day defines who we are and what we do.  We are complex systems, not A1c testing engines.  We are professionals, not monofilament pokers and slit-lamp referrers.  Reductionism diminishes us and ultimately gets in the way of the care we would deliver to our patients.

  • How can we judge the quality of care delivered in an office practice?  The dominant answer of the moment is to look for gaps between expert-derived guidelines and observed care.  Those in the position to judge office practices admit freely the imperfections of the methodology but say "this is the data we have, we must do something, so we will use what we have."

    An interesting article in Annals if Internal Medicine points out numerous flaws in this methodology.

    [Landon BE. Normand SL. Performance measurement in the small office practice: challenges and potential solutions.  Annals of Internal Medicine. 148(5):353-7, 2008 Mar 4.]

    Among the flaws:
             1:  Bad PCP-patient link in the administrative data:  "this is not my patient” patients in larger practices often have some random MD assigned on their card and receive care from a revolving cast of characters.
             2:  Claims data were wrong (e.g. claim for eye exam was rejected due to technical glitch and now the data reflect "no diabetic retinal exam")
             3:  Sample size problem (a.k.a. the "small N" problem): denominator insufficient as we look at small patient populations for individual providers further subdivided by insurer.

As if that were not enough, this methodology ignores all the non-office practice factors that have an impact on the patient.  It is a good idea to occasionally review the nine major determinants of health and wellness as described by Evans and Stoddart so that we may recall that disease and the health care delivery system are only two of the nine determinants.

[Evans RG, Stoddart GL. Producing health, consuming health care. Soc Sci Med 1990;31(12):1347-63.Evans RG, Stoddart GL. Consuming research, producing policy? Am J Public Health. 2003 Mar;93(3):371-9. ]

  • The “high functioning care team” approach is quite rare but should be what you aspire to deliver.  With careful planning and constant feedback that includes case discussion and role definition with attention to hand-offs and follow-through (and includes means to share care plans within the practice and with patients), you can grow the size of the team you bring to serve your patient needs.  NPs in particular have training in skills that MDs do not and their complementary skill set can be a real boon to your patients, but only if you actively design this into a coherent system and only if you carefully choreograph patient care over time.

  • Specific components of the current system that are irrevocably broken:
    -E&M coding
    -Fee for service that rewards "visits" and "procedures"
    -Overall underfunding of primary care exacerbated by intolerable regional variation
    -The bewildering and extremely wasteful multiplicity of policy and rules stemming from the bewildering array of payers, insurers, plans,
    -Benefit packages that spends more money per capita than any other country in the world but leaves almost a quarter of the population without health coverage.

  • Most initiatives out there fail to address the underlying problems and may therefore further exacerbate our current problems. Barbara Starfield and others have decades of research documenting a striking correlation between primary care and quality, and inverse relationship to total cost of care. We can't just funnel more money or increase access to current primary care as it is not effective primary care

  • While some doctors are willing to go out on the ledge of true innovation in the delivery of care, they do so at their own financial peril.  Current reimbursement rewards utilization without regard to quality.  Many of the behaviors of effective primary care are uncompensated, making it difficult if not impossible for most practices to engage in the work.  The financial environment for primary care is so poisonous that we have a supply shortage due to smart trainees seeking greener pastures coupled with shocking attrition in the current work force.

  • Four policy changes are needed to support primary care:

    1. Low or no copays for primary care

    2. Distribution of resources equitably /organize services to  support primary care

    3. Universal access under a publicly accountable body

    4. Commitment to comprehensive care

  • Status quo must be off the table
    Shift money to effective primary care.
    Create a payment system that rewards effective primary care.
    Measure effective primary care(and not the typical multiplicity of specialty driven organ system metrics that miss the essential point of total person care)
    Business leaders, patient advocates, physicians, and any other natural ally must work together to overcome the immense inertia invested in the status quo