Thursday, April 28, 2016

Comprehensive Primary Charade +

The most powerful persuasion tool in enlightened human society is language. The most powerful manipulation tool in any human society is language. Whereas in ancient times the pen was considered mightier than the sword, now the keyboard can be said to be mightier than any weapon of mass destruction, and nobody is mightier than the government of these United States. When our government wanted to strip citizens of privacy, it passed the Patriot act, because no one could oppose patriotism after 9/11. When it set out to facilitate corporate procurement of foreign slave labor, it enacted a set of XYZ Free Trade agreements, because this is the land of the Free. When it decided to ration health care services for the middle class, it put in place the Affordable care act, because we are all broke. Now that the U.S. government has decided to do away with the medical profession, it is feverishly rolling out Comprehensive primary care initiatives.

Comprehensive primary care is not a fuzzy, in the eye of the beholder, type of concept. Perhaps the most celebrated primary care advocate in recent times, Dr. Barbara Starfield, defined comprehensive primary care as “dealing with all health-related problems or interventions except those too uncommon to maintain competence”, where “common” means “encountered in at least one per thousand patients in a year”. The term comprehensive is an adjective intended to describe the spectrum of problems addressed in primary care without referrals to outside specialists. Comprehensive primary care is what country doctors used to provide to their patients from cradle to grave, and some still do. Comprehensive primary care is what family medicine was supposed to be all about, but it rarely is.

Taken at face value, encouraging primary care physicians to practice at the top of their license (to use a dumb cliché) sounds like a welcome nudge (to use another dumb cliché) towards longitudinal, high quality, relationship based, and lower cost health care.  Comprehensive primary care should mean treating most patients in house, expanding the spectrum of primary care procedures, and avoiding the often disastrous descent into specialty, sub-specialty and invasive care that may add nothing to ultimate outcomes, except grief accompanied by hefty price tags. It also means a return to having one’s personal physician in attendance if and when hospitalization is needed, replacing random hospitalist care and rendering specialty care a truly consultative service in most circumstances.

Unfortunately we cannot take anything our government says or does at face value. Back in 2012, the Centers for Medicare and Medicaid Services (CMS) rolled out the Comprehensive Primary Care (CPC) initiative. Medicare in collaboration with private insurers invested funds upfront and increased ongoing payments to primary care physicians who provide comprehensive care to their patients. There was only one small problem. The CMS redefined comprehensive care to mean the usual and customary concoction of patient engagement, coordination, risk management, same-day access and quality measures, sprinkled with technology fairy dust.

In what must have been a seismic shock to CMS experts (just kidding), the latest evaluation of the CPC initiative, concludes that very little, if anything, has been achieved during the first two years of this sprawling program. The study, commissioned and funded by the CMS, found that neither utilization nor overall costs were favorably impacted by this type of “comprehensive” care. As to “quality”, the study measured a handful of processes (i.e. timely diabetes testing and such) as surrogates for outcomes and found no changes there either. The net cost/saving analysis did not include the initial hundreds of millions of dollars spent by the CMS on consulting services for rolling this particular initiative out. The CMS evaluators concluded their analysis expressing hope that future studies of this ongoing initiative may be helpful to policy makers.

And as is always the case with CMS initiatives, when something is shown not to work as intended, the next step is to double down and do more of the same. One day before the CPC evaluation was published, the CMS announced a brand new, bigger and better, CPC+ initiative. Presumably the + stands for an increase in the size of the initiative, or alternatively, an increase in its comprehensiveness. So let’s count the ways….

Comprehensive Risk+

Risk is the new compassion. All these initiatives, programs, reforms, transformations, innovations, that you see floating around, are intended to train doctors to view patients as risks. All the technology flooding the health care market right now, with much more to come, is aimed at reducing every single patient walking through your door to a risk number. You have a 4.5 at 10am and a 2.0 at 10:30. Risk score will not become the sixth vital sign. It will become the only vital sign, the wonder measure that simplifies health care to something a third grader can understand. You want to pay doctors for value instead of volume? Pay them for reducing their risk scores. We can’t really measure processes or outcomes, but we can measure financial risk, a.k.a. value, or rather lack thereof, and by incorporating big data from all sources, we can calculate risk scores to the second or third decimal place.

Average risk scores for your assigned population are an okay indicator of the value you provide, but can be misleading. A better indicator would be the size of risk percentile groups. For example, on a scale of 1 to 5, if you have no patients above 4.5, and only a handful above 4, you are an excellent value provider. If you can reduce the number of above fours next year, you’ll get a big fat bonus and a whole bunch of stars in some public provider directory, which is a great thing too, because sick people (who are not stupid), will quickly figure out that they need not apply for appointments with 5 star doctors. So you have this virtuous cycle going on now. Eventually the 4.5 and above population will dwindle out by natural attrition (maybe 5’s should be flagged as auto-DNR…) and your historical propensity to inadvertently get in trouble will plummet.  

To the immense delight of pundits everywhere, health care will become more like flying aeroplanes. You, and your computerized team, will run through standardized checklists before anything is done for a patient. If the slightest risk is identified, you get a new aircraft. Only perfect planes ever leave the runway. Only perfect patients get medical care. And health care will become more like the banks too. When you want to buy a car or a house, all that matters is your credit score. If your credit score is good, you get good financing. If your credit score sucks, you get bubkes. You only get a bank loan if you can prove you don’t need it in the first place. Health care will be similarly reserved for the healthy. As to CPC+, you can’t get a dime from anybody unless you slap a risk score on every single patient, which brings us to the next epiphany.

Comprehensive Finance+

More than anything else, CPC+ is a master class in finance. The CPC+ initiative offers two distinct financing tracks, one for less technology savvy beginners and one for savvier participants. Whereas currently you get paid a certain number of dollars per service, with CPC+ Medicare will be providing three distinct payment streams, with the third one signaling the way of the future:
  • Fixed care management fees commensurate with patients’ risk scores and ranging between $6 and $100 per patient per month, which must be used to hire more people, buy technology or pay for training.
  • Performance-based incentive payments ($2.50-$4 per patient per month) will be paid prospectively (before performance is measured) in full, but will be subject to partial recoupment if the practice fails to meet a predefined threshold score for quality and cost/utilization measures. For practices that fall under a predefined minimum score, performance-based payments will be recouped in their entirety.
  • Technologically advanced practices can select to have a portion of their estimated Medicare fee-for-service revenue made payable upfront as well, followed by reduced payments on ongoing claims. The maximum upfront payment is 65% of historically estimated E&M services, and this bulk payment will be marked up 10% (for an overall gain of 6.5%). This upfront capitation is subject to reconciliation on the other side and to recoupment if your patients increase use of outside primary care services, such as the much encouraged retail clinics.
But wait, there is more… The CPC+ is a multi-payer initiative and all participating commercial payers are free to devise their own payment schemes. A practice could easily find itself juggling half a dozen payment methodologies, with dozens of splintered revenue streams, each with its own rules, idiosyncrasies and accounting systems. Not only you have to continue submitting claims as before, but Medicare will eventually require documentation of previously non-billable activities (e.g. phone calls, portal messaging) and categorical proof that all the funds bestowed upon you are used as Medicare wants you to use them.

Yes, you read that right. The CMS, which is a government agency, will not only decide how much to pay you (or if to pay you), but also what you are allowed to do with those payments, which are essentially provisional and subject to recoupment on a whim. Why? Because aversion to loss, is a much more powerful motivator than desire for incentives when mindless conformance and subservience are the ultimate goals.

Comprehensive Acquaintanceships+

As was the case with CPC and practically all health care reform initiatives, CPC+ is encouraging, nay demanding, that the inconveniently personal one-to-one patient-doctor relationship is broken up and replaced by less intense acquaintanceships with care team members. There are good reasons to change the relationship model in health care. First, patients must be rendered receptive to a constant barrage of messaging regarding prevention, compliance and frugality, which is something you want to delegate anyway. Second, and the CPC+ proposal specifically suggests this, you can take on more patients if you don’t have to actually care for them. Third, the more random people you can have buzzing around each patient, sending messages, checking dashboards, managing lists, and conducting meetings to discuss all of the above, the more comprehensive the entire thing appears to be.

One of the few measurable successes of the CPC initiative was a 3% reduction in primary care visits, attributed to the “comprehensiveness” of “wrap-around” electronic and ancillary services. Same amounts of referrals and specialty services, same levels of inpatient and emergency services, and markedly less interaction with one’s personal physician. This is how the CMS defines comprehensive primary care. I know what my thoughts are, and I see how practicing docs feel, but sometimes I wonder what Barbara Starfield would have said about this inexplicable charade…

Monday, April 11, 2016

Hacking Doctors… to Pieces

For decades and decades we have been counting the number of doctors in America. For decades and decades we have been coming up short compared to other developed nations, and some less developed ones as well. A poorly educated person may be tempted to suggest that we should “make” more doctors. After all, there is hardly a shortage of young people willing and able to undergo the rigors of a medical education. But luckily we are not poorly educated, so we devised much smarter solutions. If people can’t get a doctor appointment, it must be the doctor’s fault. Hence, we put our foot down and mandated that doctors see people the same day they want to be seen, or shortly thereafter. It sounds great and it worked perfectly for the Veterans Administration (VA), so it should scale terrifically to everybody else.

Taking a page from the highly respected Samuel Hahnemann, we decreed that physically “seeing” an actual doctor is not only completely unnecessary, but it may very well be detrimental to the healing process. A doctor effect is created by simply having an MD somewhere in the building, and as technology continues to improve, a virtual doctor presence should do the trick. Some have argued that Mr. Hahnemann’s homeopathic fantasy is no better than a placebo, but we have plenty of research showing that placebos are indeed effective. More importantly, unlike Mr. Hahnemann’s distilled water base, our technology solvent is very potent on its own merits. Imagine how successful homeopathy could have been if they used whiskey to dilute whatever the hell they are diluting.

As infallible as our highly educated reasoning may be, there is resistance to its widespread adoption, both from rich doctors who don’t want to see their gravy train derailed, and from simple minded herds of patients who are failing to grasp the infinite power of virtualization. We certainly can move, and are moving, forward with our powerful solution, but it would be easier and more humane, for all parties involved, if the barriers to change could be swiftly eliminated.

Barrier One: Our Doctors

The anachronistic habituation of people to seek help from a doctor when experiencing physical, and sometimes mental, pain and anguish, is perhaps the toughest problem we are facing. There is a bilateral dependency between physicians and patients which must be disrupted. People who tend to the sick and people who are sick refer to this phenomenon as the “patient-doctor relationship”. Our most immediate task is to impress upon the uneducated masses we are protecting that this relationship is one of abuse, exploitation and misplaced trust in professional conmen (and women). Hundreds of thousands of doctors may be scoffing dismissively right now, and as they do, we are half way there already.

The art of the smear goes by the name of “news” or “research” in our instantly connected tabloid society. In a country with a million degreed physicians it is easy to find a rapist, an arsonist, a thief, a drug dealer, a murderer, or any other criminal individual, who happens to be a doctor. Once we find those individuals, the hyperjump to general statements about a group of people is easy peasy, as long as our grouping of people is not along gender, race, ethnicity, religion or sexual orientation lines (except white men who are fair game).

The formula is deceptively simple: find a handful of criminal doctors, write a big exposé about doctors and pepper it with sex, money and drugs stories, add instructions on when to call the police “for, say, sexual or physical abuse”, package it all in a not-for-profit (previously) respected container, and wrap the whole thing in menacing pictures with menacing headlines (preferably all caps, large red font), such as “DOCTOR COULD HURT YOU”. And then you reinforce the message with a constant barrage of civic minded initiatives to address the fear you want to create. We must measure and rate doctors. We must have more transparency. We must improve care, or rather the experience of care (subtle, but big difference). We must take back control over our own health (from those overbearing, overentitled, perhaps criminal, money grubbing doctors).

Will it work? Can an irresponsible and sleazy messaging campaign in service of greed and avarice, overcome centuries of earned trust? It will take time, but look at the “truths” that became “evident” over time. Our teachers are incompetent. Labor unions are destroying our way of life. Police officers are racist murderers. And since the “democratic” election season is upon us, Bernie Sanders is a sexist communist like Guevara or Castro, and Donald Trump is a sexist fascist like Mussolini or Hitler. All you need is a concerted and sustained effort of money and media (a.k.a. “New York values”), which contrary to another artificially generated truism are not controlled by “the Jews”, but are run by a global cartel of egomaniacal sorry excuses for human beings.

Barrier Two: Our Expectations

Over the last hundred years or so, medicine has achieved almost miraculous success and in the process it changed our expectations. We expect to have malfunctioning organs replaced. We expect to not die of HIV and other infections. We expect to live free of pain and even free of wrinkles. We expect tiny babies that fit in the palm of our hand to grow up and go to college. We expect many cancers to be cured. We expect crushed bones, open arteries and charred skin to be fixed. And we expect to have a “good doctor” for all of the above.

These expectations, prevalent throughout affluent Western societies, pose a huge problem for the global money cartel. The Earth is flat, you see, and there are billions of people in this world who have no such expectations, billions of people who produce the finest iPhones, the trendiest footwear, the fanciest apparel, every single computer in the world, and are grateful for the privilege. If this mass of third world laborers begins to develop similar medical expectations, financial calamity is sure to rise from the Earth's flatness all the way up to Mount Davos. It is therefore imperative to reduce medicine to something free or nearly free that can be easily distributed across the scorched plains of humanity.

This is where our technology solution comes in. Google is dreaming of connectivity balloons while Facebook prefers drones as the means to connect billions of laborers to the mobile virtual reality we all partake in. Having Google makes you feel educated and well informed. Having Facebook makes you feel connected, important and well liked. Having virtualized health care will make you feel healthy and well cared for. And it’s all free, infinitely abundant and available equally to all, regardless of socioeconomic condition.  The Internet is your friend, your confidant, your teacher, your counsel, your entertainer, and now it will be your doctor, because the Internet knows you better than you know yourself, is there for you when no one else is, misses you terribly when you stay away, and cares for you as nobody cared for you before. The Internet is you.

You are controlling your information, your social interactions, your opinions, your shopping, your wealth (or lack thereof), and now you should take control of your health (or lack thereof). You can bank with the Internet without tellers and financial advisors, you can buy stuff without cashiers and sales associates, you can learn without teachers, you can fix a toilet without plumbers, you can manage your business without accountants, and you will manage your health without doctors. You will have all the tools at your fingertips in the comfort of your home (or trailer, or hut, or sidewalk under a bridge). You will no longer face the inconvenience and outright danger of going to an antiquated, flawed, rude and dishonest doctor. You will get health services that you and the Internet value most, and much, much more, because less is always more.

Barrier Three: Their Technology

As the two previous barriers are disintegrating before our eyes (or screens), we have one last barrier that is painfully real. We don’t have the technology to hack the doctors. We are certainly talking up a big game while scrambling to put something together that at least looks at first glance like the real McCoy. We talk about tricorders and artificial intelligence. We talk about deep machine learning and veritable oceans of omniscient data. We talk a lot about robots, genomes, bloodless tests and iPhones that deliver intensive medical care. But we have no idea how to mix the doctor solute into the virtual technology solvent to generate the coveted solution we put forward as fait accompli.

Technology in its current state cannot absorb and distill, let alone replicate, highly variable processes that lack both a clear starting point and a predefined endpoint. We don’t know what we don’t know, and in spite of flowery rhetoric, computers can only perform, and can indeed improve upon, tasks we fully understand and are able to precisely codify down to the most minute detail. Simply put, without an atomic level understanding of clinical decision making, we cannot dilute the doctor over and over again, until there is no visible trace of human physicians in our high tech brew of health care. We can however abstract a coarse approximation of relatively straightforward scenarios at the low risk end of the clinical spectrum, and advertise aggressively that the Southwest Airlines or its evil younger cousin Uber of medicine has arrived.

Here is the watershed event to watch for: the first FDA approved app that will diagnose, prescribe and deliver medications to your house by secure drone. It may initially be confined to over the counter stuff, but once that is mainstreamed, simple meds like antibiotics, high end antacids, allergy pills and such, will certainly follow. Next up will be staples such as simvastatin, Lisinopril and metformin, first the renewals and then a slew of new diagnoses of pre-this and pre-that. At the high end of disease, “precision” medicine will isolate one or two rare scenarios that affect one in a million people, script them and execute them flawlessly once or twice without physician intervention. Then we declare victory and spread the gospel to every $5 mobile phone from Guizhou province to the Appalachian Mountains to the banks of the Ganges river.

Médecine sans Médecins

There is no doubt in my mind that we shall overcome the first two barriers at very short order. There is no doubt in my mind that even if we fail to hack doctors in the abstract sense, we will be hacking the medical profession to pieces in the most physical sense. And there should be no doubt in anybody’s mind that whatever these cheap hacks are doing to our health care, the effects will not be apparent for decades, and even then the results will be attributed to the inevitability of external factors such as cultural change, climate change, famine, wars, migrations, solar flares, or random disturbances in the Force. Three centuries later, it looks like John Dryden had it right after all, and “God never made his Work, for Man to mend.”