By David Brown
Tuesday, May 4, 2010; HE01
In many respects, American doctors today labor much the way their counterparts did 50 years ago.
Most are in practices with five or fewer other physicians. They keep their records on paper in longhand. When they need to consult a colleague, they reach for the telephone. They bill for each visit. They have little idea about how their skills compare to those of fellow practitioners, nor do most know what their patients really think about the care they give.
The new health-care law aims to change most of that.
Fifty years from now, it is likely that almost all doctors will be members of teams that include case managers, social workers, dietitians, telephone counselors, data crunchers, guideline instructors, performance evaluators and external reviewers. They will be parts of organizations (which either employ them or contract with them) that are responsible for patients in and out of the hospital, in sickness and in health, over decades.
The records of what they do for a patient -- and what every other doctor does -- will be in electronic form, accessible from any computer. Software will gently remind them what to consider as they treat, and try to prevent, diseases. How the patients fare will be measured and publicized, and used in part to judge practitioners' performance. At the same time, the health-care organizations, aided by the government, will make an effort to let caregivers know the "best practices" they're expected to follow.
These edifices, with primary care as the chief structural support, will go by names such as "accountable care organizations" and "patient-centered medical homes." Versions of them already exist in health-care systems such as Kaiser Permanente, Group Health Cooperative and the Mayo Clinic.
Some physicians resent the fact that the new law promotes this evolutionary change. Others think it is liberating.
But one thing is clear: There are a lot of unhappy people practicing medicine right now.
A survey of physicians in 119 clinics in New York and the Midwest published in the Annals of Internal Medicine in 2009 found that 48 percent reported working in "chaotic" environments. Thirty percent said they needed at least half again as much time for appointments as they were given. Only a quarter said their practices strongly emphasized quality. Nearly a third said they were likely to leave their jobs in the next two years.
If the new types of practice envisioned by the Patient Protection and Affordable Care Act take hold, much of that could change for the better.
"It appears that when a doctor happens to be in a place that moves to a 'medical home' model, they can turn their frustration into excitement again. That is huge," said J. Fred Ralston Jr., president of the American College of Physicians. "We are getting reports that patients are happy, physicians are happy and that, in at least some cases, [these new sorts of practices] are saving money."Emphasis on primary care
Key to the new law's goals is primary care. Through many routes, the law provides a total of $26.4 billion over 10 years to support this broad field of medicine, which, dozens of studies have shown, improves health and controls costs.
States with a higher per-capita ratio of primary-care physicians have lower mortality rates from cancer, heart disease and stroke. Having one additional primary-care physician per 10,000 people was associated with a 6 percent decrease in total mortality and a 3 percent decrease in infant mortality and low-birth-weight babies. In 2000, 5 million hospital admissions, costing a total of $26.5 billion, might have been prevented with better primary care, according to one analysis.
The trouble is that there aren't enough primary-care physicians. So the law has several provisions designed to make primary care more attractive.
It increases Medicare reimbursement for "evaluation and management" services, the government's name for examining and talking to the patient. It provides about $350 million in additional support for training programs in primary care. It provides loan-forgiveness incentives to medical school graduates who practice primary care in under-served areas. There are also incentives for the training of nurse practitioners and physician assistants, two professions likely to have growing roles in primary care.Better coordination
The law also addresses another long-standing problem: the lack of coordination among private practitioners in the fee-for-service world (which is most of American medicine). The scope of that problem was made clear in an astonishing study published in 2009.
On average, a Medicare patient sees seven doctors, most of them specialists, in four practices each year. Researchers at the Center for Studying Health System Change looked at what that might mean to a primary-care doctor who has many Medicare patients.
They examined the experiences of 2,284 physicians, who treated an average of 264 Medicare patients each. To care for these patients each year, they determined, the typical practitioner needed to interact with 229 physicians working in 117 practices.
That nightmarish prospect may partly explain the appallingly high hospital readmission rate for Medicare patients. A study published in 2009 found that 20 percent of Medicare beneficiaries discharged from the hospital were readmitted within 30 days. Half had not visited a doctor during that period, when they were often in shaky health and taking new or higher-dose medication.
What the "right" readmission rate might be is unknown. However, it is almost certainly less than 20 percent.
A study of a large health-care organization in Colorado in which reduction of hospital use was already a main focus found it could reduce the readmission rate in elderly patients from 15 percent to 8 percent with a program that featured frequent phone calls, home visits from a "transition coach" on the lookout for a worsening condition and a medical record maintained by the patient.
Whatever the exact strategy, it seems that readmissions could be reduced if all the practitioners were in the same organization, or at least in a defined "web," with seamless access to patient records and a shared financial interest in helping their patients recover.
The law has numerous provisions, many laid out only in general terms, for testing alternatives to the fee-for-service model that Medicare and Medicaid operate under now. They include "bundled" payments for hospital and immediate post-hospital care, which would provide an incentive to minimize readmissions, and the banding together of doctors, hospitals, clinics, imaging centers, diagnostic labs, etc., into "accountable care organizations" that would get to share in any savings accruing to the Medicare program.
To gain such savings, the organizations would have to keep patients healthy. That, in turn, would require health-care workers to perform services generally not done by doctors (or done only occasionally), such as home visits, medication monitoring, dietary counseling and intensive patient education.
The iron laws of economics suggest that only large organizations (or contractual arrangements among smaller ones) will be able to offer this kind of soup-to-nuts care. At the moment, fewer than 20 percent of clinicians are in practices with 11 or more doctors. It is clear that lots of doctors are going to have to change their work arrangements before the "accountable care" model becomes the norm -- if it ever does.Better information
Doctors already have incentives to report quality-related measures to Medicare. The new law will penalize doctors who don't make such reports, starting in 2015. In the future, physicians participating in the Physician Quality Reporting Initiative will receive reports about how their performance compares to others'.
There is also money for the creation and dissemination of "patient decision aids" -- handouts, videos, computer programs, etc. -- that will help patients understand their treatment options. That is part of the law's general intent to make medical care more patient-centered.
In one of its more controversial parts, the law establishes a Patient-Centered Outcomes Research Institute to underwrite and direct "comparative-effectiveness research" seeking to determine the best and most economical treatment for common diseases. While the law specifically says that comparative-effectiveness findings can't become mandates that tell doctors how to practice, many champions of reform think that such research is essential to improving care.
"Three key steps -- wise standardization, meaningful measurement and respectful reporting -- have transformed other industries, and we believe they can help health care as well," 12 of them wrote in the New England Journal of Medicine in January.
Get the full story: This article is adapted from Landmark: The Inside Story of America's New Health-Care Law and What It Means for Us All by the staff of The Washington Post. Now available at bookstores and online (www.landmarkbook.com).