I attended a Payment Reform Summit sponsored by the Texas Academy of Family Physicians this past weekend. It was a good conference and provided a snapshot of current views and attempts to grow family medicine and pay for it. There were some emotional ups and downs for me as I listened to the presentations (and I realize how pitiful it is that I get my emotional excitement from attending a conference on healthcare reform). I thought I’d share a few of my reactions to the information presented this week and next week. First, the bad news.
I was disappointed, but unfortunately not surprised at all, at the complete lack of understanding among insurance executives of basic medical cost-effectiveness realities. The conference started off very well with two speakers reminding us of how frightfully expensive U.S. healthcare is and how family medicine has been shown repeatedly to give the same or better quality care at a lower cost. A call was given for all of us to work to reduce the cost of healthcare and its damaging effect on the rest of the economy.
A few insurance company executives attended and they talked about the importance of prevention, and how every time one of them heard that one of his members was discovered to have metastatic breast cancer, he worked harder for women to get mammograms to decrease the cost of treating breast cancer. As readers of American Health Scare undoubtedly know by now, this is voodoo medical economics.
For a quick review of reality, I invite you to read one of the early works on the net costs of mammography from 1989 by one of the pioneers of the medical cost-effectiveness literature, David Eddy. In case you wonder if the overall conclusions have changed in the last 20+ years, here is an article from this past July that reaches the same conclusion – an ounce of prevention costs a ton of money (OK, they didn’t say it that way). Another great article explaining the limits of mammography was published in NEJM in 1993. The insurance people made similar erroneous statements about colon cancer screening and hypertension treatment.
This lack of understanding bothers me because it means physicians at the top levels of insurance company management do not understand some of the core drivers of healthcare costs, or what meaningful solutions to reduce those costs might look like. I’ve talked with insurance company medical directors for almost two decades and I’m sad to say none of them understand the 36-year-old medical cost-effectiveness literature. I’m sure some of their work successfully impacts healthcare costs, but clearly some of their efforts are misguided.
For the good news, I was very impressed with the presentation of Christopher Crow, MD, MBA, the president of Village Health Partners in Plano, Texas. He runs a ten-physician family medicine group that has committed itself to providing extensive access to their patients. The group is one of the few I’ve heard of that is effectively using its IT infrastructure to promote its value to insurance companies and employers. They generate reports on the usual suspects – hemoglobin A1Cs, lipids, etc. – which raise the cost of healthcare (more on this topic next week). But where they really nailed it was that they have gone through great pains to show that their patients visit the ER less often and are hospitalized less often. In other words, they have figured out how to measure one of the most cost-saving realities of family medicine, our ability to use excellent judgment in treating sick people in our offices for whom it is safe to do so.
An interesting finding of this measurement effort was they learned that half of their patients’ visits to the ER occurred during their office hours. This happened in a practice that is dedicated to seeing walk-in patients, including evenings and weekends. Dr. Crow talked about how it is a constant educational battle to convince his patients that 90% of their needs can be met in his offices.
If there are any insurance medical executives reading this, here’s a suggestion. If you really want to lower the cost of healthcare, stop wasting your personal efforts and your company’s efforts trying to inch up the mammogram and colonoscopy rates. Instead, pay groups like Dr. Crow’s for providing extensive out-of-hours comprehensive family medicine care. And have your marketing department develop 4-color brochures that tell your members the next time they sprain their ankle, they shouldn’t go to the ER, they should see their family physician.
Dr Young:
As far as the insurance companies go (and their MD directors), it’s a game to show how “innovative” they are. All we have to remember is that insurance is its own endgame agenda. Agreed? So I guess it is necessary to move on from there and hopefully leave the corporate medical complex to wallow in its own brine as more dedicated thinkers pursue how to get the message across. Isn’t it maddening to know that the realities of medical cost management are to be found in the primary care offices that are in such short supply, and that there is rock-solid data to demonstrate that we are stuffing cotton in our ears when it comes to these truths. The GIMeC has wrapped its coils around the truth.
As far as Village Health Partners, Drs Crow and Gothard are way cutting edge in many respects. I know because one of their docs is a client of mine and equally passionate about medical cost smarts.
Any information as to whether Village Health is being paid for the services they provide at a level that covers overhead and pays the docs fairly for the work they are doing? (I’ve had insurers tell me that they would rather pay for a $3000 ER visit than pay my $50 after hours fee).
Dr. Crow talked about this a little. They had some luck getting a little more for after hours and weekend care, but I didn’t get the sense they’d made major inroads in their overall payment structure.
Dr. Goertz recently reported that 42% of the 8% of AAFP members who work in NCQA-certified medical homes receive SOME increased payment for the extra work they’re doing, as if this were something to crow about! Anecdotal reports are that the payments don’t even cover increased overhead, much less pay the docs for the extra work they’re doing. Of course, you won’t hear this from the PCMH prostelytizers.