The Crisis Masters of Health and Death

There are three visions of peace in the seemingly never ending, but really rather brief, Israeli-Palestinian perpetual crisis. One peace features two independent countries living in collaborative harmony on a piece of land approximately the size of New Jersey. Another peace yearns for a messianic Jewish state stretching from the blue Mediterranean shores to the Jordan River, and possibly beyond. The third and final peace is expected to materialize after the Zionist entity has been permanently erased from the face of this earth, or at least from the face of that New Jersey size holy piece of land.  Each definition is amenable to slight compromises in form, but not at all in substance.

There are three visions for the future of medicine in the seemingly insurmountable, but really rather minor, perpetual health care crisis in America. One future of medicine sees physicians unencumbered by useless administrative tasks, wielding sleek and useful technology tools, offering the best medical care to all patients who need and want attention. Another future is yearning for the revival of chickens and charity as bona fide methods of payment for whatever medical care the free market wishes to bestow on the less fortunate. The third and final future is one devoid of most middling and often faulty doctors, where the health of the nation is enforced by constant computerized surveillance with fully automated preemptive interventions.  Each definition is amenable to slight compromises in form, but not at all in substance.

Years ago I used to walk the streets of East Jerusalem, buy dates in the open air markets of Jericho, and search for the perfect plate of hummus in Ramallah. Everywhere I went people wanted the same things I did. They wanted the rain to stop, or the hamsin to break. They wanted their coffee hot and strong and their bread soft and warm. I said shalom and they said salaam and we all meant the same thing, because ironically people in the Middle East always wish peace upon each other, and people like us, who buy and sell cheap jewelry or dates or hummus, actually mean it.   

Years ago I used to hang out with software programmers, writing code for hospitals, doctors, nurses, billers and schedulers. Everywhere I went these strange looking techie nerds wanted the same things I did. They wanted the overhead lights in the office to be off, and the whiteboards to be bigger. They wanted their Java to compile without error and their curly braces to be perfectly aligned. They worked days, nights, weekends and holidays to keep the lab printers running on every floor. They managed to convince themselves that somewhere in a hospital far away, a patient may get better sooner, or a doctor will see something he may have missed, and an exhausted nurse will breathe a sigh of relief, if they managed to get the face sheets to look just right.   

There is always some effort underway to fix the Israeli-Palestinian problem. Many such efforts have gotten as close to an equitable solution as Moses got to the Promised Land, only to discover that the last barrier is insurmountable. What’s to become of Jerusalem? Who owns the holy ruins of past civilizations, and the tombs of dead prophets? Whose religion bestows the ultimate rights of ownership over rocks and boulders that are coveted by all religions? Should it be the religion that started it all? Should it be the religion with the biggest cathedral, or the religion with the biggest guns? Is possession nine-tenths of the law? Perhaps ownership is the wrong way to think about this. Perhaps access is a more pertinent concept and the historical manifestations of God on this earth should become the commons of all religions. Perhaps, but not today.

There is always some effort underway to fix health care in America. Decades of legislative, regulatory and business driven efforts have gotten us almost universal access to the most unaffordable health care system in the world, only to discover that “information blocking” is a barrier to health. Information is power, but aggregate information is also a tool for amassing wealth, and massive information, of the big data type, is practically legal tender. What’s to become of this seemingly self-generating big data? Who owns the streams of life once they are transformed into data? Whose role in the digital extraction process bestows the ultimate rights of ownership over the monetary value of people? Should individuals own their digital emissions (defeating the entire purpose of this exercise)? Should the collectors own the data? Should the purveyors of data containers own what’s being accumulated inside? Is possession nine-tenths of the law?  Perhaps ownership is the wrong way to think about this. Perhaps access is a more pertinent concept and our aggregate digital lives should become the commons of all people everywhere. Perhaps, but not today.

Jerusalem is not the real problem. There will be no resolution for the Israeli-Palestinian crisis until hate is defeated, or at the very least silenced. Standing with your back against the deep sea and listening to incessant drumrolls of death, dismemberment and extermination is enough to ruin the best gin and tonic at the best club on the most beautiful night on the Tel-Aviv promenade. Deep down you know that the people you met in Jericho, Ramallah and East Jerusalem would much rather get drunk with you in the club, than blow themselves up at the door, but that doesn’t seem very comforting tonight. Jerusalem and all its holy ghosts will be solemnly shared only when everybody benefits from this arrangement, including the millions of people whose lives are at stake here, and excluding the fiery tongued hate mongers who pass as leaders in some parts of this world. Until that day comes, Jerusalem will keep taking our lives, our children, and worst of all, our humanity, in the biggest hoax ever staged by mankind.

Information blocking is not a real problem. There will be no solution to our health care crisis until greed is defeated, or at the very least tightly controlled. Siphoning hard cash in the form of “information” from medical facilities into the coffers of third party data processors, seeking to supplant traditional medicine with computerized cost-benefit analysis, cannot possibly be met with enthusiasm by the doomed. Serenading the public with psychopathic prophecies of eternal health, while stealing their personal information to more accurately find and extract money from their wallets, and to curtail all freedom of choice, is not helping either. Information will flow freely only when everybody benefits from the torrent, including the millions of people whose lives and liberty are at stake here, and excluding the smooth tongued wealth extracting machines which we call leaders. Until that day comes, information will flow haltingly, under duress, in the biggest jail ever created by mankind.

There is an old saying in Hebrew stating that a dead fish stinks from the head, but there is also an old saying in Arabic promising that each dog shall have his day, so there may still be some hope. We the people who are happy and satisfied with hot coffee, a loaf of bread, a nice whiteboard and a little less light shining on us, have no use for crises of any kind. It is the power drunk, greedy and shamelessly opportunistic (mostly) men calling themselves leaders, who manufacture crisis after crisis, to justify their own miserably exalted existence, because crisis and leadership are like a nightmarish version of the chicken and the egg dilemma.  There is no material difference between the rough lunatics, preaching fear of thy neighbor, and promising boundless paradise in return for mindless violence in this world, and the sleek captains of industry, preaching fear of natural life, and promising boundless health on this earth in return for mindless submission to infallible algorithms for the duration.

The crisis masters of Middle East death and American health are both driven by the same “selfish and boundless thirst for power and material prosperity” (to put it delicately). The former manifests itself in the lucrative fire and brimstone raining over that hapless portion of the world since the day Abram chose to change his name to Abraham. The latter is how we the people of the new world go gentle into that good night.

How much is that PCMH in the Window?

Much has been written about the Patient Centered Medical Home (PCMH) model of primary care, both complimentary and critical. Most evaluations and opinion pieces refer to the particular PCMH flavor defined by the National Committee for Quality Assurance (NCQA), since this is by far the most widely adopted model, and all other models are just minor variations of the same. Practically all reviews, studies, opinions and assessments pertain to the ability of PCMH practices to improve “quality” measures and generate savings for the system, and in all fairness both evidence and opinions are mixed. One aspect of the PCMH that is rarely discussed, is the cost incurred by the practice for sustaining PCMH operations over time.

A new article published in the Annals of Family Medicine estimates ongoing PCMH costs to be approximately $105,000 per physician FTE per year, in personnel costs only. Data was collected through interviews and staff surveys at 20 primary care practices, 8 owned by an academic institution in Utah, 7 private practices and 5 sites of a Federally Qualified Health Center (FQHC) in Colorado. Only the Colorado practices were recognized by NCQA, while the Utah practices had their own proprietary definition of PCMH. The authors reached their shock and awe inducing figure by adding self-reported increases in time spent by staff on each task listed in the NCQA PCMH 2011 Standards, and then priced this incremental effort based on staff compensation.

Unfortunately, the cost of individual PCMH Elements and Factors is not available, but even in aggregate form, the analysis is perplexing. The average $105,000 per physician per year is not an absolute number. It is the incremental difference, according to the authors, between running a “traditional high-performing” practice and running a PCMH practice. As such, the dollar amounts depend on how one defines the baseline. The article does not provide an exact definition for the “traditional high-performing” primary care practice baseline and this is obviously problematic. The authors mention that not all PCMH Elements were fully implemented in the surveyed practices, but an exact list of implemented functions is not available either.

Basically, we don’t know what the starting point was, and we don’t know what the end point is, but we are told that it takes an outlandish $105,000 worth of work to get from the former to the latter. Outlandish, because any independent solo practice faced with half of those costs would go bankrupt in six months or less, and in spite of that, there are many solo practices recognized by NCQA at the highest possible PCMH level, which is more than the practices in this study have accomplished. Here is a riddle for you: how does a micro practice, with one physician and no staff, sustain the highest levels of PCMH operations when according to this study, one would need to add approximately 2 FTEs to the traditional model?

The answer is that the lump sums presented in this article are meaningless. For example, the highest incremental expenditure for the studied practices, to the tune of $3,000 per physician per month, was attributed to NCQA Standard 3, which deals with providing medical care to patients. There are several items selectively listed by the authors in the description of Standard 3, so let’s assume that those are the tasks that generated incremental effort and costs. The first task on the list is the notorious daily huddle. This is most certainly a new PCMH construct that wasn’t there before. However, would the daily 5 or 10 minutes spent on huddles in a PCMH, not be spent on the same exact tasks peppered throughout the day in a traditional practice? Did the study account for such considerations? We don’t know.

Another item listed for this Standard is implementation of evidence-based guidelines. What does this even mean? Should we presume that traditional high-performing practices are not practicing evidence-based medicine? Were they using magic 8-balls to diagnose and treat patients prior to PCMH implementation? The same can be said for multiple other items, such as medications reconciliation or monitoring patients on high-risk medications or making sure that lab orders are resulted at some point, and a host of other tasks routinely performed in any practice, although in different form and perhaps in a more ad-hoc fashion. Of course, we can only speculate here, since the details behind the $105,000 figure are not available, but these seem to be typical examples of the rampant misconceptions regarding the meaning of PCMH operations.

What sets the NCQA PCMH initiative apart from your run of the mill data collection and reporting programs, such as Meaningful Use, PQRS and even ACO, is that it provides a holistic framework for improving practice operations without being narrowly prescriptive on how to accomplish that. It is a comprehensive tool for the practice to examine its inner workings once every three years and brainstorm on ways to improve its processes. There is nothing in the NCQA PCMH framework that does not occur or should not occur in a modern “high-performing” practice. With the exception of some Meaningful Use measures, I would challenge anyone to point out to even one PCMH factor that cannot, or should not, be implemented in a way that benefits patients and the practice itself. And it all starts with the initial recognition process.

Much has been written about the trials and tribulations of obtaining NCQA PCMH recognition, from the extensive documentation requirements to the onerous costs of labor and expertise. There are two approaches to PCMH recognition that generate these types of complaints, and later on may generate the theoretical $105,000 costs. One approach common in large institutions is to view PCMH as a top down initiative managed and executed by a central office, with little or no input from practice staff, including physicians.  The other extreme is the small practice chugging through each PCMH factor, trying its best to generate mountains of screenshots and reports with no particular strategy in mind other than getting enough points to pass the “test”. Both models may get you PCMH recognition, but with much frustration and zero benefits to the practice.

And then there is the right way, which harnesses the PCMH recognition process to benefit the practice and its patients. Forget about “readiness assessments” and “culture change” indoctrination. You were ready and fairly well cultured the day you finished residency. The question you should ask yourself is not whether we do this or that thing, but whether we are doing it well. You may have some pink colored slot on your schedule called same day appointment, but is it where it should be? Is it solving a problem, or is it creating one, or is it there for decoration purposes only? How are you planning to stop the upcoming hemorrhage of patients to non-descript retail clinics and iPhone “doctors”? Should you maybe use this opportunity to revisit your 10 years old scheduling process?  This is not about NCQA. This is about dollars and cents for your practice.

How about “implementing evidence-based guidelines”? Should you be deeply offended because someone dares to ask you to implement clinical practice guidelines for a sore throat? Or should you look at this as an opportunity to write some standing orders for your staff, so that you don’t have to go in an out that exam room more than once, and maybe, just maybe, you can squeeze in a couple more minutes with your little patient, and notice that mom seems to be unusually worried and distracted? And maybe you'd want to ask her about it. And maybe that’s what “patient-centered” is all about. And maybe all the administrative PCMH stuff you do, should be purpose built by you to make this possible. And maybe this is not about recognition, but about creating a safe little space where you can be the doctor you always wanted to be.

We don’t know how the PCMH was implemented in the study. We just know that it was implemented to a certain degree. We don’t know if the missing pieces are minute or crucial for practice financial health and patient care. We don’t know if the physicians in these practices were given the opportunity to build their own medical home, or if someone else decided how to shuffle the deck chairs. We don’t know if the subjective incremental effort reported by staff on each factor was offset by reduced effort elsewhere, or if it represents better use of previously underutilized positions. We have no objective numbers for “before and after” payroll expenditures, although those should be rather easy to obtain for large facilities. There is more than enough missing and undisclosed data in this study to render the $105,000 suspect.

Are there ongoing costs for a PCMH practice? No doubt, there are plenty, but these costs are no different than the costs of running a traditional (or non-traditional) high-performing practice, because PCMH is just another name for high-performing practice. Perhaps the most useful conclusion from this paper is that high quality primary care costs more than mediocre or outright irresponsible primary care, and those who decide how much primary care doctors get paid, should bring this largely self-evident fact into account, when defining physician fee schedules and future payment schemes.

[Disclosure: I am the founder of BizMed, a company whose mission is to support the viability of independent medical practice, and to that end it offers free software and tools to reduce administrative complexity in private practice in general, and for PCMH recognition in particular]