Remember That Comprehensive Primary Care Initiative? Yeah, It Lost Money.
And now an update on a recent initiative by the government and the ivory tower idiots who think they can fix our healthcare system. Here is the abstract from Health Affairs:
The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative’s effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions. The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures. As CMS and other payers increasingly use alternative payment models that reward quality and value, CPC provides important lessons about supporting practices in transforming care.
So, to summarize, the extra cost to make this monstrosity happen wasn’t worth the money. Who would have thunk it? Me. Check out my blog in August of 2016. And this one here. Nostradougus strikes again.
Hire Dr. Farrago as a keynote speaker.
These inane “alternative payment methods” are all based on a deeply flawed premise:
i.e., that greedy, unethical physicians are ordering unneeded tests and procedures to line their wallets; and if we just throw a few measly management dollars at primary care docs, they will unleash their super hero powers and physically divert ambulances from ERs, barricade cath labs, and storm heme offices and pull IVs delivering ineffective chemo out of the arms of grateful patients.
Well, it just ain’t so – we know from multiple studies that patients in USA consume medical care at the same or slightly lower rates than patients in other industrialized countries; we know that primary care docs aren’t going to override the instructions of sub-specialists; and we know patients won’t accept any limits on their access to medical procedures.
There simply are no savings to be achieved by this approach. The savings to be tapped are in facility fees, highway robbery fee schedules for hospital-owned practices, pharma, DME, home health, and ADMINISTRATIVE waste.
But those are sacred cows and can’t be touched.
Here’s a bell-ringer for me.
However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures.
Most important question – does it INCREASE PROFITABILITY enough to make it pay for itself? No. Larding on new personnel does not make it pay for itself. However, it does create jobs, and jobs are created in healthcare by “sharing the wealth.”
There’s an interesting calculation that may be relevant beyond just its narrow scope.
[WIKIPEDIA]
Price’s square root law or Price’s law pertains to the relationship between the literature on a subject and the number of authors in the subject area, stating that half of the publications come from the square root of all contributors. Thus, if 100 papers are written by 25 authors, five authors will have contributed 50 papers.
Expanding this into unproven but suggested generalities, in an organization with number N, the number of people who do half the work is the square root of N; the others do the rest of it.
In an organization with 4 people, one does half the work. This sounds like a small clinic. The rest of the employees do the other half – and the income they make is proportionate to what they do.
In a mega-corp hiring 10,000 people, there are 100 people doing half the work, and another 9900 who are doing chair races in the hall between chores. The study proves that bumping that number up 10% – from 9900 to 10,900 – doesn’t exactly increase productivity by 10%
And Price’s law doesn’t take into consideration that the 9900 aren’t just being honest and producing a fraction of what they need to do. Many of them actually impede and subvert the 100 that do the job. (e.g. healthcare).
One of my patients had a visit from one of these “care coordinators” recently. She never called me despite the fact that I give all my patients my cell phone number. She told my patient that he should tell me to refer him to a vascular surgeon because she did some sort of half-baked test on him that indicated he had PVD. He had zero symptoms or physical findings PVD, mind you, except the sparse hair on his legs. If I was cynical enough I would have just done it and wasted the insurance company’s money but my reputation with my colleagues is too important so I did an ABI on him to prove that he has normal circulation.
I’m losing hair on my legs, have no symptoms and booming pulses. Guess what? For vain people
better to lose body hair than the hair on your head!
Look it up. People can lose body hair with age and doesn’t mean a thing.
I’m guessing the patient has Medicare Advantage. He now has been diagnosed with end-stage atherosclerotic peripheral vascular disease, and the insurer gets lots more money from the feds – way more than the cost of a one-time visit to the vascular surgeon.
Same thing happened to one of my patients! Was told they needed a vascular surgeon purely because of a lack of hair on the legs! The guy had great pulses and no claudication symptoms. Must be something they’re teaching these coordinators..
The bottom line which no one in charge seems to grasp:
Better care costs money. Preventive care costs money. You don’t do preventive care to save money. You do preventive care because it is the right thing to do.
….But it still costs more money.
You do not save money doing prevention.
The way to save money is to let people get very sick and then die relatively cheaply.
Sorry, it’s just the way it is.
But, but, but…Barack Obama told us over and over that preventive care is cost effective and he is the smartest guy in the world.
I actually put a pen to paper and calculated that it costs about $100,000 to prevent one MI or otherwise serious case of CAD by treating hypercholesterolemia in our patients. I don’t know what doing a PTCA costs (who can tell with the way medical billing is done these days) but I would bet it is less than that. And then you get into the question of how cost effective it would be to actually not treat these conditions at all and let people die in their 60’s.
PTCA costs around $20, 000 for everything. My husband had one a year ago.
There ya go! I am not saying I would prefer to allow a patient to develop CAD rather than treat their hypercholesterolemia….just that it is more expensive to do so.
I think I read some study at one point in time that resulted in the only preventive care they could identify as being cost effective was screening colonoscopy (but only your first one) and immunizations.
Notice that the deciders don’t have to look at the patient.
The moment that humans are “kept” to turn a profit is the moment that the rules of the ranch prevail. “Downer” humans need to go. Once your cost-benefit curve goes negative…
And……………………….. If patients aren’t held accountable for their lousy health behaviors,
not a “blankety-blank” thing is going to change in this country except medical students
will eventually avoid going into primary care. If I was starting over, I’d kiss a– to specialize.
I love the smell of value-based payment failure in the morning . . .
Our local Blues has a PCMH. They encourage us to put high risk (expensive) patients in their Care Coordination program. We found out from a patient that it costs over $400 per month for these nurse coordinators to babysit the patients. That could simply be two to three more doctor visits per month. Why not just do that!?? Or pay ME to make those phone calls. But they’d rather pay some nurse who doesn’t know the patient.
The PCMH has been around for hundreds of years. It’s called the family doctor. These boneheads should leave well enough alone.
Medicare will never understand that they cannot legislate or mandate a patient-physician relationship which will actually lead elderly patients into trusting their doctor that they really don’t need all the tests they read about in the newspaper that morning. To tell a dying patient (and his daughter), “Things are not going to get better from here” is much more productive if the patient/daughter actually trust the speaker.
PCMH was supposed to help increase reimbursements, it did NOTHING but give me and my staff a huge headache. Binder sits in my office, waste of trees, and it has happily expired now that I am DPC.
That’s the AAFP practice management philosophy:
Do all the extra work and hire all the extra staff, and pray that eventually some payer will throw a few pennies in your direction.
But they never do.