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…


  1. I eagerly await your take on proposed CMS MACRA rule.

  2. Inexplicable? It seems to me you explained it pretty well. And I even found out there is an alternative form of bupkis. Who knew? I can hardly breathe as I await the evaluation of this new, fairy dust enhanced Five Year Leap Forward. 2022 is it?

  3. So I should only take healthy, compliant patients that never need or use health care?

    1. Isn't that great? Free money, no burnout... a glorious new era in medicine... (/s of course)