Like any revolution, there are many factors at play (not all of them can be addressed in one article). As a doctor would take a medical history, make a diagnosis and then layout a prescription with accompanying risk factors, I will use this same format for what I believe is fueling the revolution.
[Disclosure: My patient relationship management company, Avado, works with some of the companies/individuals mentioned in this article which is why I'm familiar with their work.]
Medical History of a Sick Healthcare System
Dr. Ted Epperly, the recent past president of the American Academy of Family Physicians describes the shortcomings of our healthcare "system" in his upcoming book "Fractured: America’s Broken Health Care System and What We Must Do to Heal It." He touches on a similar set of issues to the following:
- Under-valuing primary care while consistent data demonstrates the highest ROI for healthcare is primary care. Industry commentators Brian Klepper, PhD, and David C. Kibbe, MD, MBA outline the roots of this in a piece about the playing field being extremely tilted towards sub-specialists in this Kaiser Health News piece.
- It was IBM's study of their $2B spend on healthcare globally that sprung them into action. The findings of their global study was a surprisingly simple formula. More primary care access led to a healthier population which, in turn, led to less money spent. For example, in Denmark, the number of hospitals (and hospital days) has dropped by more than half proving the old adage "an ounce of prevention is worth a pound of cure."
- Piecemeal payment for healthcare has led to a "system" that is really a collection of silos. As Dr. Atul Gawande has put it, the system is more about cowboys when it is pit crews that are needed.
In healthcare, it’s as though we are building better firehouses and investing in more firefighting equipment while we do the equivalent of leaving oily rags around, letting kids play with fireworks on dry hillsides, and building structures with one exit. We may have the best “firefighting” tools and talent in the world but we’d be much better off if we prevented those “fires” from starting in the first place.
It's long been said that the patient is the most important member of the care team. In reality, the fundamental design point of the vast majority of EMR and HealthIT systems is the patient is merely a vessel for billing codes. At best, an individual can view their medical records as though their only role was as a spectator in their health and they can, in some cases, email their doctor. The diagram below shows the reality of who really is in control of decisions driving health outcomes. Since 75% of healthcare costs emanate from chronic conditions where an individual's actions are the primary determinant of outcome, the legacy HealthIT blindspot is symptomatic of a "sick care" system.
Diagnosis of the U.S. Primary Care Situation Today
Testament to the economic oddities of healthcare is that there is broad recognition of the value of primary care and there is a shortage as a result. Health plans such as Humana are buying up organizations such as Concentra in large part to secure primary care providers or else they risk their members going to the Emergency Department for primary care. This is exactly what has happened in Massachusetts which is a preview of what is coming. Despite the demand, at the moment the predominant reimbursement model remains the "do more, bill more" fee-for-service system that assigns more value to procedures than avoiding them all together. For example, it's more profitable to amputate a diabetics leg than to care for them and prevent an amputation from even being needed. Consequently, primary care in the old model remains an economic loser compared to sub-specialist practices.
From its study, IBM recognized that nothing less than the renaissance of primary care was needed. At the heart of their effort to revive primary care, is the Patient Centered Medical Home led by an IBMer and physician, Dr. Paul Grundy. Even though there is a long way to go, the results so far have been impressive including the following:
- A broad coalition of organizations, particularly large employers have created and put into action the Patient Centered Primary Care Collaborative.
- Virtually every major healthcare provider and health plan is poised to deploy a Patient Centered Medical Home (PCMH) pilot. One of the core tenets of the PCMH has been to break down the silos inherent in healthcare that lead to greater spend and worse outcomes. The pilot results have been very promising bending the proverbial cost curve.
- At the federal level, $1.8B has been allocated (note PDF) to 8 state pilots adding greater scope to the PCMH movement.
The video below is from the Mayo Transform conference. Dr. Paul Grundy of IBM explains how major employers are radically and rapidly shifting what type of healthcare they are willing to pay for in light of their dissatisfaction with status quo.
Meanwhile, the federal health legislation clause for Medical Loss Ratio (MLR) minimums has already had the effect I predicted 21 months ago in a piece entitled Health Insurance's Bunker Buster. Smart health insurance providers such as Aetna are aggressively reinventing themselves. As their CEO stated, "we're increasingly a healthIT company with an insurance component." With over $1.5B of acquisitions in the last year or so, Aetna is putting its money where its mouth is. Among the effects of MLR minimums is the greater prevalence of is high deductible policies. Insurance companies will realize the medical equivalent of a car tune-up is best paid for without introducing the Gordian Knot of insurance claims processing.
This leads perfectly into one of the least reported upon facets of the federal health legislation cleverly baked into the bill. That is, Direct Primary Care Medical Homes (D-PCMH or DPC for short) are allowed into the health insurance exchanges even though they are a non-insurance offering. Smart health plans have realized that one of the key ways to compete in the insurance exchanges is price. When coupled with a high deductible wrap-around policy, they can still be at least 20% less than a traditional health plan and have better coverage.
If you would like to be notified when the seminal paper on Direct Primary Care is published this Fall, please contact me via my LinkedIn profile - http://www.linkedin.com/in/chasedave.
DPC practices are one of the fastest growing facets of what I call the DIY health reform movement. Already, searching for health information is the third most common online activity among US internet users, with 80% reporting that they look for information about medical problems, treatments, hospitals, professionals and similar topics. This is why WebMD has over 100 million people visit its sites every month. Taking this DIY approach further, entrepreneurs have identified the opportunity with DPC practices. An array of new entrepreneurs to highly successful business veterans such as Rich Barton, Jeff Bezos, Michael Dell, Bob Fabbio, Nick Hanauer have invested in or launched DPC models that are proving to be very well received in the market. Because DPC models are a more pure form of primary care not having to worry about how to weave in cumbersome insurance-driven processes, they have shown an even more dramatic impact than the aforementioned PCMH. While garnering customer satisfaction scores higher than Google or Apple, achieving more 5 star ratings on CitySearch than any other business DPC practices such as Qliance, Iora Health and WhiteGlove Health have reduced expensive downstream costs (surgical, emergency department and specialist visits) by 40-80%. I predict some of the PCMH models being piloted will shift to DPC as payment reform continues.
Prognosis for Primary Care: Time for a Renaissance
"It is darkest just before dawn." Unknown
Many stories have been written about the so-called death of primary care. Yet, I believe that primary care is due for a renaissance. The Arab Spring rolled from one country to another as their citizens saw that the unthinkable was possible. Likewise, primary care doctors are seeing similar phenomena and increasingly there are organizations such as Physician Care Direct and the American Academy of Private Physicians which are setup to transition a primary care practice into a model that can be described as two parts Marcus Welby, one part Steve Jobs. It's remarkable to see the transformation from extreme pessimism about the future to a virtual rebirth. The contrast is stark. The most unhappy physicians I've spoken with are in insurance-bound primary care practices. In contrast, the happiest physicians I know are unshackled in low overhead, high service Direct Primary Care practices. Zina Moukheiber highlighted one of the low overhead, high service practices in a piece entitled Concierge Medicine for the Poorest. The Chen family are an example to many other primary care physicians who are dissatisfied with the status quo.
Once transitioned, these practices can think about how best to care for patients. The new model doesn't have to be based on Rube Goldbergian insurance reimbursement requirements that require face-to-face appointments even though two-thirds of appointments don't medically require a face-to-face interaction.
Historically, in the "do more, bill more" reimbursement model, the financial incentive was to invest in better and better "firefighting" equipment that has resulted in truly amazing technology (and accompanying price tag). In contrast, today's severely budget constrained environment will drive investment and innovation into "fire prevention."
Utilizing a collaborative care model, the patient becomes a valued member of the care team -- more than just a vessel for billing codes. Patients win. Physicians Win. Employers Win. Even forward-thinking insurance companies win. In fact, most major health insurance companies have major efforts to make primary care the foundation of their plans and it's not a moment too early. Not only is IBM and other major employers demanding it, the Office of Personnel Management (in effect, the HR department for federal workers) has just announced it is demanding plans that have the PCMH model at their core. It's clear that employers (private and public) are the market makers.
There are leaders who have been operating in these more patient-centric and accountable models. They are taking the next step and moving beyond simple patient portals that just allow viewing of information after the fact and simple email exchange. These forward-looking providers realize that the revolution they desire demands a collaborative care approach that necessitates active involvement during the care process. The forward-looking primary care physicians leading the revolution are thrilled that they are rewarded not on their skills at coding billing forms properly but about a partnership with their patients. The reward is healthier patients who spend less time at healthcare providers and a physician who spends more time in patient care and less time coding billing forms.
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