I have reproduced the map so that you can see it, but it is much more fun to go to the link because there, if you let your cursor hover over a county, you will see the uninsured rates for 2014 and 2105 in any county. That game kept me busy for quite a while. The article is pretty good also.
To orient you to the map, the states that have accepted the expansion of Medicare are outlined in black. The whiter a state appears, the higher the rate of coverage. Massachusetts is a “paler shade of white”, a sort of faint gray pink. The more purple a state appears, the higher the rates of the uninsured. Mississippi and many of the other “red states” are a wine dark purple as you can easily see. If the governor-elect of Kentucky gets his way, in 2016 Kentucky will deny coverage to more than 400,000 people who enjoyed it for a little more than a year. He wants Kentucky to look once again like Tennessee, Mississippi, Texas and much of what was once called the “solid South” in its resistance to civil rights hinden under the camouflage of the acceptable philosophy known as “states’ rights”.
If you doubt the map or want to extend your search or read about Enroll America, a nonprofit that probably created the map that ended up in the NYT, click the link below:
A Sidebar on Adaptive ChangeBefore reporting on three examples of mindsets and opinions that exist in healthcare today and can raise my heart rate and blood pressure in a flash, let me become didactic and introduce again a subject that I believe explains a lot about resistance to change and our inability to have more productive conversations within healthcare. I was first introduced to the the concepts of a new relational contract between physicians, organizations and by extension society, by Jack Silversin, DMD, back in the mid 90s. Jack was building off of the work of Ron Heifetz, MD who about that time began to point out that there are two large categories of change that affect people as individuals and their organizations. They are technical and adaptive change. Technical change is often sort of fun. Adaptive change is usually a nightmare. It is resisted.
It has been my experience that when change is part of a response to events that are beyond individual control and derivative of societal stresses that are called “negative externalities”, the response that is necessary for individuals or organizations is challenging. It is Heifetz’s concept that gives us the best description of what is going on in each individual's mind during these moments of necessary change. His theories apply as well to the collective mind of the organization. I would even go so far as to say the work applies to groups within society, to nations and perhaps to all humankind.
Heifetz has authored books about “leadership’s responses to the challenges of adaptive change and you can see him as he discusses the subject on multiple YouTube presentations. The link is to a terrific description by Heifetz himself that is less than three minutes long. If you have access to a subscription to the Harvard Business Review there was a great article on the subject that was published there in 2009. Since you may not have access to HBR let me give you some of the abstract. Again the bolding is from me.
Adaptive challenges are difficult because their solutions require people to change their ways. Unlike known or routine problem solving for which past ways of thinking and operating are sufficient, adaptive work demands three challenging human tasks: figuring out what to conserve from past practices, figuring out what to discard from past practices, and inventing new ways that build from the best of the past. Your analysis of an adaptive challenge must take into account the human dimensions of the changes required--the human costs, pace of adjustment, tolerance for conflict, uncertainty, and risks, and the resilience of the culture and network of authority and lateral relationships necessary for carrying the organization through the pain of change…
The are some terrific summaries of the differences between technical and adaptive change from other sources building off of Heifetz’s concepts. I believe that applying these concepts to this moment in healthcare is very important as we try to deal with the multiplicity of personal and institutional stresses that challenge us these days and create the multiple mindsets that we experience as each of us does our best to deal with an uncertain future. Without empathy for what others are experiencing it is impossible to bring oneself to listen to their concerns, especially if they differ from your interests and concerns.
Physicians are often “dazed and confused” by their attempts to sustain heavy workloads driven by the volume demands of FFS finance while attempting to respond to the challenges of the ACA, understand and respond to the challenges of the Triple Aim, navigating “Meaningful Use”, conform to ICD 10 and process all of the other external pressures that simultaneously disrupt their world. What is worse is they perceive that fiercely held values like clinical autonomy and other foundational issues that are a part of their sense of professional life are being sacrificed to poorly constructed societal solutions and onerous regulations from places where they have little or no influence. Whether it is realistic or not, they feel vulnerable to physical and economic loss. They feel justified in their anger. Just as we are discovering in the presidential sweepstakes, there are some who are willing to articulate the anger that many others suffer in silence.Three Stories Begging to be ConversationsNot long ago I was chatting with a medical specialist. The conversation was friendly and not at all political. I made the mistake of asking a relatively normal question that is usually safe, “How are things going?”. I was as floored by the answer that came back as if I had failed to duck a left hook. To paraphrase and condense this person’s response let me say that the words that stick in my mind are, “I am tired of supporting primary care!” For orientation I should tell you that this doctor is part of a large and successful multispecialty group practice where compensation has always been near the top of the local and national ranges. The staffing ratios for clinical support exceed those in most organizations. The benefits offered are completely aligned with the best in the market and the organization offers physicians the opportunity to work less than full time if that is desired.
This physician’s office was in an affluent suburb. I asked for further explanation. The best I could get was some sense of a taxation to support other clinicians and some curtailment of clinical autonomy that would not exist in solo or small group practice. I made a feeble attempt to explore what was received as fair trade for the dollars extracted from salary to support primary care. I asked if it could be considered a trade off for a steady stream of referrals that enabled a more than comfortable income and rich clinical supports. I also suggested considering the security of being a part of a group that had good reserves in a time of financial transition. Nothing that I said seemed to make sense as a balance to this doctor’s sense of violation.
Not long after this interesting conversation I wrote about the debate over the utility of the annual physical. One comment that came back from that letter was from a nurse manager who was mostly speaking as a patient but who also is involved with clinical improvement utilizing Lean to focus on patient service, more efficient resource utilization, and better outcomes. The comment is one that I think many doctors could benefit from considering with the wisdom of the Gaelic verse of Robert Burns , "O wad some Power the giftie gie us To see oursels as ithers see us!". The comment goes much deeper than the issue about annual physicals. It touches on an alternative orientation to practice that I know must be considered as we continue the dialog about change in healthcare. I have bolded a very important statement.
I found your topic of the annual physical quite interesting as it's a timely topic for me. As I have been approaching my annual physical in December (scheduled a year in advance with my pcp of >25 years who has horrible access now that she only does one day of clinical/week......) I found myself thinking a lot about what I actually need versus what I want from my pcp from this upcoming visit. I happen to have a very short list of things to discuss with her this year and they are not time sensitive. But, I do need prescriptions renewed. So as far as I am concerned the only things I think I need right now are script renewals. The annual physical seems like a clunky vehicle for doing that, although I recognize there is an assessment that goes into renewing medications that takes place in the exam room.
So 7 weeks ahead of my scheduled physical I realized I needed to reschedule. Next available physical appointment is in 9 months....next July (told you she has horrible access......). At first I was disappointed, but then I figured 18 months probably makes a lot more sense than 12 since I never felt I needed to be seen at the 12 month mark anyway, and they'll just have to figure out how to deal with renewing meds between now and then. I kind of like the idea of stretching the window of time between physicals and forcing them to find a 'work around' that meets my needs.
This is a long way of saying I completely agree with the notion of the annual physical being challenged and reinvented to be aligned with what patients need and want. In reality, the annual physical is just another example of a system that is designed either for the convenience/profit of the providers, OR that assumes all patients need/want the same thing. I did some consulting work with a primary care group that aggressively pulls patients in for annual physicals as an organization-wide tactic to meet revenue targets for the year. Absolutely no consideration for anything other than revenue (needless to say they still are largely a FFS group.....).
What I want is to be able to see my pcp when I need to see her. That is actually impossible with this particular provider and will be the reason I eventually leave her practice. The annual physical scheduled 9 months in advance is the only way to guarantee I will ever see her. Sadly, what will be lost is the relationship piece of our relationship that has been built over decades. Patients and pcp's do need to actually sit in the same room and have dialogue once in awhile (or do they...........could I convey 'how I am doing' via an email exchange since we know each other so well?).
This situation begs for A3 thinking!!! What is the problem being solved? What is the target state? Imagine how long could be spent (...or is being spent) on just those two questions by groups of thoughtful people?
My final “story” comes from KevinMD.com. You may read online healthcare offerings like the Kaiser Health News, Becker’s Hospital Review, FierceHealthcare, Medical Economics and KevinMD.com. With the exception of the Kaiser Health News and KevinMD.com, these online services are the equivalent of some of my old favorite “throwaway” journals. Back in the day when “throwaways” filed our mailboxes there was no equivalent to KevinMD which has its roots in the explosion of social media. KevinMD offers clinical tips, comments on the evolution of healthcare and lots of stories as told from the point of view of physicians struggling with the challenges of change.
I do not read every issue completely but I do regularly scan KevinMD’s offerings. The readership is huge (52,000 Facebook “likes”). The page suggests that it is a product of MedPageToday which offers medical “news” plus ads. On its site MedPageToday describes itself, “MedPageToday is a trusted and reliable source for clinical and policy coverage that directly affects the lives and practices of healthcare professionals”.
I find KevinMD interesting because much of what I read there is an expression of the anger of physicians who are struggling with a world that is changing too fast for them to keep up. Its articles drip with the angst adaptive change. The editors seem to be pretty savvy about finding sensational content that draws attention. I read KevinMD because I want to be aware of what attracts and concerns many physicians. My guess is that the revenue from the site is huge because drug companies want to place their ads next to what thousands of physicians are regularly reading with passion.They are angry and KevinMD is offering them a way to share their anger with one another. If you clicked on the KevinMD link above you saw an open letter from a PCP in Florida to her patients.
My first response to the letter was to consider it as an expression of manipulative outrage from a narcissistic physician who was just venting her anger. Perhaps my judgement was influenced by the note at the bottom of the article that said she was the author of How to Be a Rock Star Doctor: The Complete Guide to Taking Back Control of Your Life and Your Profession. Her book gets five stars on Amazon. It would have been easy for the “old me” to dismiss her concerns or if I met her in person to attempt to shout her down, but on further reflection I asked myself, “What would happen if we acknowledged her concerns and empathetically considered her complaints?”
To form your own opinion and make sense of what I am going to say you need to read the letter. Here it is complete with the links that she has inserted. It is long but an exercise worth your time, particularly if your job description involves “engaging physicians”. I assure you that many of them have read it and some said “amen, sister”.
Dear patients,
This is a hard letter to write, but it is important that you know about a major change that is coming for both of us in 2017, just a short year away.
As you recall, last year I left a large hospital group practice and opened my own office, and I want to thank you for your faithfulness in following me to my new location. With the newfound freedom of running my own practice, I love being your doctor more than ever.
As a family physician in Southwest Florida, the majority of my patients are insured by Medicare, and you, my Medicare patients, are very important to me. Not just for my financial livelihood, but because of the relationships that we have formed together over the last 15 years in this community.
I have welcomed you to Medicare with screening tests, explaining the risks and benefits, and keeping you up to date with the constant changes in guidelines. I cared for you through various medical crises, and helped you to control your chronic diseases. I was there to treat your acute illnesses, and coordinate your care with your various medical specialists. I requested prior authorizations when your preferred drugs weren’t covered, and helped you get free medicines when you were in the donut hole. I did your preoperative clearances, your disabled parking forms, and the pages of paperwork you needed when we decided it was time to consider transitioning into an assisted living facility. We’ve talked about end-of-life issues, and I’ve helped you understand advance directives and DNR forms. I’ve visited you in hospice, and even held your hand as you died.
This is the side that you know about, and the part that is most important to both of us. But unfortunately, what I have described is only half of my reality. The other half is the regulatory burden that I have to bear in order to provide your medical care.
For every office visit that we spend together, I spend at least as much time on what Medicare deems as necessary documentation, especially a new program called meaningful use. While the goals of meaningful use in improving quality of health care are admirable, the regulatory burden is intense. To comply with Medicare requirements, I’ve had to spend thousands of dollars and massive amounts of time instituting electronic health records, adapting my practice to conform to the computer technology that wasn’t created to help me, your physician.
During and after every visit, I type away at my keyboard, clicking boxes to demonstrate to Medicare that I did my job. My notes, which used to be informative and succinct, now include pages of irrelevant information, disclaimers and computer-generated statements to “document” that I am playing by the rules.
But even though I detest some of these new processes, I know that if I want to care for you, my Medicare patients, I must do everything that I can to follow the rules, no matter how burdensome. You see, the problem isn’t just that the doctor doesn’t get paid if she fails to follow the letter of the law. If Medicare detects any questionable billing processes or inadequate documentation, honest or not, the physician faces heavy fines and even jail time.
And I get it. Costs have to be contained, and true Medicare fraud, unfortunately, does exist. There is no doubt that medical costs have been spiraling upwards for years, and as our Baby Boomer generation reaches Medicare age, naturally our health care spending will have to increase in turn.
Although physician payments only make up about 10 percent of the cost of health care in the United States, the government has looked to increasing regulation on physicians as a way of reining in cost. And next year the whole ballgame changes for physicians as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) goes into full effect, with a complete paradigm shift in Medicare payment from “fee-for-service” (I send a bill for your medical care, Medicare pays me), to “value-based payment” (I submit a bill, and I get paid if Medicare thinks that I’ve done a good enough job).
Basically, in 2017, all doctors that care for Medicare patients will have to make a choice. The first option is to join an accountable care organization (ACO), which is a large group that acts kind of like an HMO to control costs and accept financial risk. Having just left a large hospital system with daily productivity reports and a glut of middle managers, this option does not appeal to me.
The second option, for those who choose to stay in solo or small practices, is for the physician to enter into a Merit-Based Incentive Payment System (MIPS), in which payment will be determined by where the doctor ranks on a physician scorecard. The kicker is that the pot of money remains constant – so even if every doctor makes an ‘A’ grade, half of them will be paid less money, just by nature of this “budget-neutral” payment system.
And of course, this system begs the question: what happens to the doctors who care for sicker or less compliant patients? Will doctors have to cherry-pick, dismissing patients simply because they choose not to take a statin drug for cholesterol? What doctor will want to be paid less to care for patients in higher risk areas, such as centers of lower socioeconomic status, where patients may be inherently sicker?
And is there a conflict of interest when doctors are paid more to do less? There is the potential not only for patients to suffer if doctors cut back on tests and treatments, but also for the physician to face malpractice lawsuits – the new Medicare law offers inadequate liability protection for doctors who are being required to keep medical expenses down simply to get paid for their work.
Up to this point, I have managed to play by the rules that Medicare has set. Yes, I’ve had to spend hours of additional work on documentation, and hire additional staff to help me comply with the new rules. And yes, I’ve taken a pay cut from Medicare this year because I chose not to invest another $15,000 in an electronic patient portal, as required by the second phase of Meaningful Use. But so far I have been able to absorb the increased expenses and decrease in payment, and I have been able to continue to care for my Medicare patients.
In 2017, this may no longer be the case.
I wonder if I will be able to afford to care for Medicare patients as a solo physician, not knowing if or when I will be paid, while my expenses remain fixed or increase with inflation. On the other hand, I do not want to return to a large group, losing the freedom to run my own practice in the way that I feel is best for me, my patients, and my staff.
I understand that whoever pays the bills makes the rules. The only recourse a player has is to choose whether or not to play the game, especially when the deck is stacked against them.
Perhaps the rules will change again before 2017, but it will take a loud voice not only from physicians and health care providers, but from you, my Medicare patients.
Sincerely,
Rebekah Bernard, MD
My guess is that if my dear departed mother had read such a letter in her lifetime she would have been effusive in her supportive response to her doctor whom she loved, respected and trusted. Dr. Bernard probably has a loyal following of many older patients who are appreciative of her care. She implies that they have long and trusting relationships and now the tables are turned. She needs their help. I do not doubt that she cares deeply for every patient in her practice. It is also clear from the letter that her personal values include self reliance and clinical autonomy. She has already resigned from her hospital’s PHO or whatever collaborative practice opportunity was available to her. Perhaps that move was justified by a disconnected hospital leadership or disrespectful treatment by a medical environment that valued her only as a commodity. She certainly is aware of all the rules and all the upcoming changes. She is no dummy.
She alludes to the compromises to her usual pattern of practice that have been forced on her by CMS and the ACA with her link to the “welcome to Medicare” visit description supplied by CMS to Medicare patients, but she assures them that nevertheless she has been there for them. Her links provide connections to studies that support the physical and fiscal stresses that she has experienced as she attempts to deliver care to valued patients in an increasingly demanding environment with unprecedented demands for her to complete tedious paperwork.
There is more that she says in a way that would make any caring patient feel either guilty for the stress their needs have induced on their beloved doctor or might motivate them to join her in outrage as they feel they are vulnerable to losing her as an asset. As she says, they do not know the half of it. She has made sacrifices of time and income for them and now she is about to be asked to do even more with less. As bad as things have been, the tone of her letter suggests that they are about to get worse. Between the lines there is a hint of the possibility that she is breaking under the burden that she carries for them.
It was a surprise to me that she has not availed herself of the substantial financial supports (her share of 30 billion) that are available to physicians with large numbers of Medicare and Medicaid patients in their practices which is the other side of “meaningful use”. Her complaint that beyond the expense of the EHR she is still shackled to her computer is a legitimate universal complaint that has recently been eloquently described by Lisa Rosenbaum in the NEJM who writes persuasively about the dark side of the EHR experience that many physicians have tolerated.
I really do not know what to say about her complaints about the crackdown on Medicare fraud and abuse but I can see one of her elderly patients becoming very concerned that through some gross injustice this beloved PCP will be lead away to imprisonment because of some marginal variation, “honest or not”. The letter continues in the “victim motif”. She understands the realities that have combined to make her a victim. External forces and the misdeeds of others have created an environment where those attempting to do their best and who care deeply about their patients are personally vulnerable to injustice.
The statement about physician compensation is financially tricky. Whether the 10% number is correct or not, limiting physician accountability to the percent of the total healthcare bill that is physician compensation neglects the fact that physicians write the prescriptions for drugs that may or may not be good choices, order tests that may or may not contribute to effective management and make clinical decisions that may or may not represent optimal clinical management. If there is significant waste that could be eliminated with better processes of care, then it would follow that physicians are accountable for much more of the cost of care than just their compensation. That responsibility is recognized by MACRA which is the legislation that disposed of the SGR as we discussed several weeks ago.
She clearly understands the new law that was passed with bipartisan support. She understands that performance on quality metrics and the outcomes of her patients will be increasingly important determinants of compensation, and as a solo practitioner who has made the personal professional decision to leave collaborative practice she has made herself vulnerable by giving up the supports that practicing within a larger enterprise offers. I could argue that when she made the personal decision to leave the larger group for solo practice she probably denied her complex patients (without their knowledge) of some of the support that they might have enjoyed in an integrated clinical environment.
She has projected the regulations and the financial implications of MACRA even further than is currently known for sure since there are still many undecided issues of implementation that have been left to CMS. As Meredith Rosenthal wrote in the NEJM the details remain to be determined.
Because what qualifies as a sufficient incentive depends on the effort required to attain a specific performance goal — which itself varies by measure and person — there is no magic number for the optimal share of physician payment that is determined by pay for performance. Nonetheless, the dollar amounts at stake under the MIPS on their face appear to be a meaningful incentive, assuming that the performance criteria are reasonably achievable for most physicians and are not set so low that they inspire little or no effort.
Medical Economics published a readable review of the status on the law last July. There is no question that the law was creatively designed to replace the uncertainty of the impact of the SGR on FFS compensation with choices and a path toward value based reimbursement with a transitional process that will extend out to 2024, if not longer. Many of her colleagues have applauded this legislation and it is not a part of the ACA, although it is highly supportive of the further development of ACOs.
In her letter Dr. Bernard raises some concerns by using rhetorical questions in a fashion that could introduce concern for either less informed physicians or patients. Perhaps she should be a trial lawyer. It was her use of rhetorical questions that are perceived by the uninformed reader as fact; that was the origin of my original concern. I am trying to read her concerns in a way that give her the benefit of the doubt, but I have seen this strategy before. There is a clear suggestion that care that is needed will be denied and that vulnerable populations will suffer even as she is vulnerable to financial jeopardy.
Her decision not to comply with meaningful use is an option that saves her time and money even as it denies her patients a benefit that many other patients highly value. Her current status is the outcome of her own choices in response to decisions about questions that she would prefer to ignore. Of interest is the fact that my “songwriting son” has recently written an essay on the subject of how we create the future one decision at a time, today. Check it out. He is an insightful writer.
She finishes her letter by soliciting her patients to help her fight the injustice that she perceives in her life that will threaten their welfare. Collectively with her, their voices might make a difference.
I do not live in Dr. Bernard’s world and I do not know if I would have made the same decisions or come to the same conclusions that she has as she has experienced practice in Southwest Florida. Just looking at the map near the top of this letter shows that we have practiced in very different worlds and given the variation in the map I must assume that her world shares much with many clinicians across the country. We need to have a dialog about solving shared problems. Despite the fact that I reject her interpretation of the facts, I do respect her right to her opinion. I am frustrated also by what is not right. I must believe that a search for common ground is necessary. How do we begin a conversation that honors what we both seem to profess? We must begin with a shared concern, the welfare of patients. We both care about the future of our patients and the practice of medicine which we love. What is the next step?
What a Fall!
Can you believe the last week? The jet stream and a well positioned high pressure focus have given me a high that I know can’t last forever. Perhaps there is an upside to global warming. The fish are dazed and confused. It has been a while since I have had a decent catch but I have never had more glorious walks. I am feeling very akin to Thoreau who famously said, “I have travelled much in Concord”. I can experience much of the world in New London without the hassle of traffic and the increased difficulties of “daily living” in the congestion of a metropolitan environment.
Not long ago my day was made by the scene in the header at the top of this letter. What is more beautiful than a bright blue sky, a sugar maple exploding with color and our flag waving in a breeze? I do not know when all politicians began to feel obligated to wear a flag pin and sometimes I worry that the political conservatives have claimed the flag as their exclusive possession. Veterans’ Day is next Tuesday. I plan to visit this same scene on the eleventh and even if the sky is gray and the leaves are now brown and on the ground, I will look at the flag and be thankful for the sacrifices that hundreds of thousands of veterans have given us so that we can have the opportunity to have the debates that are core to any successful society.
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