By Richard Young, M.D.
Ms. M was a 68-year-old Hispanic female who had not seen Dr. Smith (not his real name) in nearly a year. She had run out of her diabetes, high blood pressure, and cholesterol medications months before.
Ms. M had other concerns in addition to these three chronic diseases and the practical difficulties she faced filling her prescriptions. She asked Dr. Smith to help her with her foot pain and knee pain. She was told by another doctor at an ER that she had visited for a non-urgent problem a few months prior that her blood potassium level was low. She expected Dr. Smith to address her heartburn, recent weight gain, bad teeth, and an additional but distinctly different abdominal pain. She wanted a test for her kidney function, for which Dr. Smith had to spend a couple of minutes trying to figure out why she was concerned about her kidneys in the first place and the results of blood tests at other facilities such as her recent ER visit. Dr. Smith also spent several minutes explaining the need and importance of osteoporosis screening, which she ultimately declined.
This was not a fictitious case. I observed this clinical encounter as part of my work for the CMS Innovation Advisor Program. I was the only person in Texas selected for this program.
Twelve prescriptions later and Dr. Smith asking Ms. M to obtain the lab results and other records from the recent ER visit, so as to avoid unnecessary duplicate blood tests, the visit was finished. Dr. Smith ordered no lab work or imaging and billed a CPT code 99214 plus the injection administration fees for the flu and pneumonia vaccines. He broke even on the cost of the vaccine vials to his office. For this work, it took about 45 minutes of his time with additional time spent by his staff. CMS paid him about $153 for his work. In this amount of time, a Medicare-participating ophthalmologist could perform two cataract surgeries with lens implants and receive from CMS $1,488 for the professional fee (not including the cost of the artificial lens or operating room time). The existing payment rules are clearly broken.
Cost-effectiveness of family physicians
How should family physicians be paid for their services? I and my colleagues in the Residency Research Network of Texas have conducted research on issues related to this important question, which were funded in part by the TAFP Foundation. What follows are findings of two of those studies.
We interviewed 38 family physicians across Texas and asked them one over-arching question: “We all know about the Barbara Starfield-type evidence that places with more family physicians have better health at a lower cost. Why is this? Tell us stories from your daily practice that you think explain this.”
Our family physician subjects told us many great stories of exercising prudent judgment in patients who knew them well and trusted them deeply. As the research team, we organized the major themes of their stories and concluded that the family physician’s personal attitudes and characteristics, combined with their long-term relationships with their patients, were the foundations of more cost-effective care than the disjointed multi-ologist model (my term from my book, American HealthScare). These traits include a comfort with uncertainty, an ability to apply probabilities to individual patients, a mastery of complexity, and even a comfort with death. None of these important factors are mentioned in the PCMH documents. These characteristics lead to fewer tests, more targeted testing when ordered, fewer ER visits, and fewer hospitalizations, because sick patients are seen and cared for in clinics and not these more expensive facilities.
Problems with the current documentation, coding, and billing rules
In a separate project, we interviewed 32 family physicians across Texas and asked them what they liked and did not like about the existing evaluation and management rules. As you might imagine, they didn’t like much of it (manuscript accepted for publication, but not published yet). Other than the basic SOAP format, most family physicians wanted to scrap the existing rules and work under new guidelines that are less bureaucratic and onerous and more intuitive. They are tired of counting bullet points that add nothing to the quality of care. They are fed up with taking care of multiple issues in one clinic visit but only being paid for two of them. They feel bad when they tell a patient to come back for what is actually a needless extra visit just to be paid something for their ability to provide comprehensive patient care services.
A better way to value the work of family physicians
To sum up the findings of these two research projects, we found that family physicians deliver better care at a lower cost because of who they are as people: their unique perspectives on what defines high-quality health care that is different from all other doctors, delivered in the presence of a long-term trusting relationship with their patients. But we also found a huge mismatch between these characteristics and the aspects of medical practice that are incentivized in the existing payment rules.
I had the honor of being chosen to be in the first, and probably only, class of CMS Innovation Advisors in 2012. My project was to create a brand new way for family physicians to document, code, and bill for their work. I based my proposals on the results of these two research projects and later investigations. My full proposals are over 100 pages long. I’m happy to share them with anyone who is interested. There are a lot of details in this work, but the summary is that there are three major reforms:
- The number of issues addressed in a primary care clinic visit are additive. A patient with one simple problem will be seen quickly and the visit will generate a smaller allowable fee than existing rules. In contrast, a patient with six problems to be addressed will have all of those issues addressed, and that visit will generate a bill which is larger than the existing rules allow.
- Pay primary care providers for non-face-to-face care such as phone consultations and email-based clinical encounters.
- Incentivize a series of seven physician and practice characteristics that add value to the greater health care system.
These are listed in this table.
There are other reasonable proposals in the public discussion for family physician payment reform, but it is beyond the scope of this article to compare and contrast those proposals to mine. Whatever position the AAFP decides to support—and hopefully it supports several possible options—the fact is that the existing documentation, coding, and billing rules do not incentivize the strengths of family physicians to provide high-quality cost-effective primary care. In fact, they financially punish family physicians for practicing like family physicians. As a result, our current economy and our children’s future are bleaker than they should be. Let’s all keep fighting to change the current realities for a better tomorrow for our patients and our country. We can start by not believing that we are stuck with the status quo.