RE: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]

February 10, 2009

Reference back to nice hx of govt sponsored universal health care someone else posted from New Yorker mag, was ALWAYS started during crisis, NEVER during "good times".

Will attach pdf copy, hope not to offend anyone's copywright?

Matt in Western PA

Re: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]To: Date: Monday, February 9, 2009, 6:36 AM

I believe the logic of how we are going about this in this country is fundamentally flawed.So if you believe this-Most other developed countries have at least as good health care and outcomes as the United States for substantially less money.Why?Because they have a strong primary care component to their health care system (70% primary care versus 30% primary care here)Then-The way to fix our system is to have 70% primary care rather than 30%.So-Why is this not being accomplished? (For the multitude of reasons we discussed on this listserv-insurance issues, payment issues, morale issues the list goes on)The first domino in the series is the establishment of a predominant, strong primary care system and the rest of the dominoes which include "quality" (including numbers and other criteria which are not able to be quantified)- will fall into place.Therefore-Asking primary care to prove that they should exist before being allowed to do so is fundamentally flawed.Lou>> After seeing this and the Senate hearing that Alan Falkoff posted, my> thoughts for today on PCMH and payment reform:> > 1. The messages being sent to Washington from medical professionals> appear terribly muddled. Everyone seems to have their own axe to> grind, and each supports their view with anecdotes and data that can't> logically support their conclusions. How can any coherent fix for> primary care payment come out of this?> > 2. It appears that there will be no appetite for payment reform until> a model "proves" that it can improve outcomes. My question is: What> will be accepted as acceptable outcomes? Some proxies for good care> such as HEDIS disease-specific markers, adoption of certified EMRs,> meeting NCQA criteria? The whole conversation needs to be shifted to> focus on the outcomes we need -- actually healthier, happier people.> But what measures do you offer Washington as proof that a model works?> Doctors are never going to agree to base this on patient-reported> measures.> > Don't you think, if the Grail of a REAL set of outcome measures that> could be applied to individual practices could be presented to the> power-brokers, then they could get out of the business of telling us> HOW to do our jobs and focus on the funding mechanism to pay those who> make it happen? Can't we leave some room for innovation, practice> differences, geographic differences? What are these measures?!> > Haresch>

February 10, 2009

Matt,

Thanks for the article; by the way you know what is really sad, Kaiser

Permanente, really developed, as a way to deliver PRIMARY CARE at the Kaiser

shipyards that were producing the Liberty Ships (that maintain the Atlantic

bridge to Britain during WW2), they improved productivity by given access to GP’s

at the yard, they discovered that simple health maintenance and early access to

doctors maintained a happier work force, that was more productive due to

decreased sick leave.

From there to now, I assume, they forgot the lesson.

José

From:

[mailto: ] On Behalf Of Dr Levin

Sent: Monday, February 09, 2009 7:04 PM

To:

Subject: Re: Re: [Fwd: NYTimes.com: UnitedHealth

and I.B.M. Test Health Care Plan]

Reference

back to nice hx of govt sponsored universal health care someone else posted

from New Yorker mag, was ALWAYS started during crisis, NEVER during " good

times " .

Will

attach pdf copy, hope not to offend anyone's copywright?

Matt

in Western PA

-----

Original Message -----

From: L. Gordon

To:

Sent: Monday, February 09,

2009 12:01 PM

Subject: RE:

Re: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test

Health Care Plan]

Yes.

A number of tools have been used to compare the US to other developed

countries. A lot of the work has been done by Barbara Starfield of s

Hopkins. She has published more than two decades of work demonstrating

the links between population access to primary care, quality, and cost.

When using

measures of population health we don’t measure up to other developed

countries – we’re number 23 – 35 in rank order on thinks like

infant mortality and a host of other markers.

A lot of

this is due to our willingness as a society to write off the poor and

disadvantaged – the outcome disparities based on income are shameful to

the extreme. Providing universal health care based on effective primary

care is what defines a high performing health system – something we

don’t have in the US.

We need to

keep hammering on the point that effective primary care is the solution to the US

health care crisis. When we are provided the resources we need and given

relief from the insane burden of work coming from “coding” and

“mother-may-I” health care denials we will be able to deliver on

the promise of effective primary care.

Gordon

http://SavingPrimaryCare.org

Don’t

give in to apathy or hopelessness, sign up and be part of the solution!

From:

[mailto: ] On Behalf Of Lonna Larsh

Sent: Monday, February 09, 2009 8:39 AM

To:

Subject: Re: Re: [Fwd: NYTimes.com: UnitedHealth

and I.B.M. Test Health Care Plan]

Do

other countries (with better health statistics and more primary care docs)

use measures to monitor how primary care is doing?

From:

l_spikol

Subject: Re: [Fwd: NYTimes.com: UnitedHealth and

I.B.M. Test Health Care Plan]

To:

Date: Monday, February 9, 2009, 6:36 AM

I

believe the logic of how we are going about this in this country

is fundamentally flawed.

So if you believe this-

Most other developed countries have at least as good health care and

outcomes as the United States for substantially less money.

Why?

Because they have a strong primary care component to their health

care system (70% primary care versus 30% primary care here)

Then-

The way to fix our system is to have 70% primary care rather than

30%.

So-

Why is this not being accomplished? (For the multitude of reasons

we discussed on this listserv-insurance issues, payment issues,

morale issues the list goes on)

The first domino in the series is the establishment of a

predominant, strong primary care system and the rest of the dominoes

which include " quality " (including numbers and other criteria which

are not able to be quantified)- will fall into place.

Therefore-

Asking primary care to prove that they should exist before being

allowed to do so is fundamentally flawed.

Lou

>

> After seeing this and the Senate hearing that Alan Falkoff posted,

my

> thoughts for today on PCMH and payment reform:

>

> 1. The messages being sent to Washington from medical professionals

> appear terribly muddled. Everyone seems to have their own axe to

> grind, and each supports their view with anecdotes and data that

can't

> logically support their conclusions. How can any coherent fix for

> primary care payment come out of this?

>

> 2. It appears that there will be no appetite for payment reform

until

> a model " proves " that it can improve outcomes. My question is:

What

> will be accepted as acceptable outcomes? Some proxies for good care

> such as HEDIS disease-specific markers, adoption of certified EMRs,

> meeting NCQA criteria? The whole conversation needs to be shifted

to

> focus on the outcomes we need -- actually healthier, happier

people.

> But what measures do you offer Washington as proof that a model

works?

> Doctors are never going to agree to base this on patient-reported

> measures.

>

> Don't you think, if the Grail of a REAL set of outcome measures

that

> could be applied to individual practices could be presented to the

> power-brokers, then they could get out of the business of telling

us

> HOW to do our jobs and focus on the funding mechanism to pay those

who

> make it happen? Can't we leave some room for innovation, practice

> differences, geographic differences? What are these measures?!

>

> Haresch

>

February 10, 2009

Yes, Lou, agreed! But can you help me see a way that this (i.e.

pouring money into creating a real primary health care system as the

first step) could conceivably happen out of the current milieu?

Haresch

> >

> > After seeing this and the Senate hearing that Alan Falkoff posted,

> my

> > thoughts for today on PCMH and payment reform:

> >

> > 1. The messages being sent to Washington from medical professionals

> > appear terribly muddled. Everyone seems to have their own axe to

> > grind, and each supports their view with anecdotes and data that

> can't

> > logically support their conclusions. How can any coherent fix for

> > primary care payment come out of this?

> >

> > 2. It appears that there will be no appetite for payment reform

> until

> > a model " proves " that it can improve outcomes. My question is: What

> > will be accepted as acceptable outcomes? Some proxies for good care

> > such as HEDIS disease-specific markers, adoption of certified EMRs,

> > meeting NCQA criteria? The whole conversation needs to be shifted

> to

> > focus on the outcomes we need -- actually healthier, happier

> people.

> > But what measures do you offer Washington as proof that a model

> works?

> > Doctors are never going to agree to base this on patient-reported

> > measures.

> >

> > Don't you think, if the Grail of a REAL set of outcome measures

> that

> > could be applied to individual practices could be presented to the

> > power-brokers, then they could get out of the business of telling

> us

> > HOW to do our jobs and focus on the funding mechanism to pay those

> who

> > make it happen? Can't we leave some room for innovation, practice

> > differences, geographic differences? What are these measures?!

> >

> > Haresch

> >

>

February 10, 2009

With respect to the statement " ...employers, insurance and other interested parties want proof that their money is being well spent... " What proof do they have that their money is currently being well spent? Are they asking the proceduralists to prove their worth? Is anyone asking them to provide metrics and measurements that what they are costing the system TODAY is money well spent?

I do not have a beef against the proceduralists, but I do have a beef that we in thought-based medicine are repeatedly asked to provide metrics/data/numbers/pilot studies/insurance pilot projects-all generally without payment for our efforts-- in order to SOMEDAY maybe, possibly start getting paid for the job we were trained to do in the first place.

As Gordon repeatedly points out, the data that basing a health care system on a viable, robust primary care system costs less and provides better outcomes is basically irrefutable, and plenty of solid research already completed and validated supports this.

I do not mind participating in projects to become accountable for my care and outcomes. I like improving my care and outcomes. What is getting so very old is being punished for providing quality and watching the situation for primary care continue to worsen to the point of extinction while insurance companies and the folks we have abdicated authority for payment come up with more " pilot projects " to string us along.

What has happened with the pilot project Eads was involved with for paying email visits (or maybe it was phone visits, I can't quite remember)? I have not suddenly seen an outgrowth of realization that paying for these kinds of services is good. What I have seen is lots of pilot projects that get us exactly nowhere with respect to sustainability when doing the right thing.

How long do we have to wait for " the powers that be " to deem us worthy? "

I know I am preaching to the choir here, but this thread is incredibly important to understanding why we are all so frustrated with the current and worsening status quo.

The answers seem to already be available, but no one in power is listening.

We do need to continue to try and rally patients and physician support with true understanding of what got us here and what it will take to dig our health care non-system out of the muck.

Durango, CO

Yes, Lou, agreed! But can you help me see a way that this (i.e.pouring money into creating a real primary health care system as thefirst step) could conceivably happen out of the current milieu? Haresch

> >> > After seeing this and the Senate hearing that Alan Falkoff posted, > my> > thoughts for today on PCMH and payment reform:> > > > 1. The messages being sent to Washington from medical professionals

> > appear terribly muddled. Everyone seems to have their own axe to> > grind, and each supports their view with anecdotes and data that > can't> > logically support their conclusions. How can any coherent fix for

> > primary care payment come out of this?> > > > 2. It appears that there will be no appetite for payment reform > until> > a model " proves " that it can improve outcomes. My question is: What

> > will be accepted as acceptable outcomes? Some proxies for good care> > such as HEDIS disease-specific markers, adoption of certified EMRs,> > meeting NCQA criteria? The whole conversation needs to be shifted

> to> > focus on the outcomes we need -- actually healthier, happier > people.> > But what measures do you offer Washington as proof that a model > works?> > Doctors are never going to agree to base this on patient-reported

> > measures.> > > > Don't you think, if the Grail of a REAL set of outcome measures > that> > could be applied to individual practices could be presented to the> > power-brokers, then they could get out of the business of telling

> us> > HOW to do our jobs and focus on the funding mechanism to pay those > who> > make it happen? Can't we leave some room for innovation, practice> > differences, geographic differences? What are these measures?!

> > > > Haresch> >>

February 10, 2009

I can't take credit for finding this, was on another listserv

Re: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]To: Date: Monday, February 9, 2009, 6:36 AM

I believe the logic of how we are going about this in this country is fundamentally flawed.So if you believe this-Most other developed countries have at least as good health care and outcomes as the United States for substantially less money.Why?Because they have a strong primary care component to their health care system (70% primary care versus 30% primary care here)Then-The way to fix our system is to have 70% primary care rather than 30%.So-Why is this not being accomplished? (For the multitude of reasons we discussed on this listserv-insurance issues, payment issues, morale issues the list goes on)The first domino in the series is the establishment of a predominant, strong primary care system and the rest of the dominoes which include "quality" (including numbers and other criteria which are not able to be quantified)- will fall into place.Therefore-Asking primary care to prove that they should exist before being allowed to do so is fundamentally flawed.Lou>> After seeing this and the Senate hearing that Alan Falkoff posted, my> thoughts for today on PCMH and payment reform:> > 1. The messages being sent to Washington from medical professionals> appear terribly muddled. Everyone seems to have their own axe to> grind, and each supports their view with anecdotes and data that can't> logically support their conclusions. How can any coherent fix for> primary care payment come out of this?> > 2. It appears that there will be no appetite for payment reform until> a model "proves" that it can improve outcomes. My question is: What> will be accepted as acceptable outcomes? Some proxies for good care> such as HEDIS disease-specific markers, adoption of certified EMRs,> meeting NCQA criteria? The whole conversation needs to be shifted to> focus on the outcomes we need -- actually healthier, happier people.> But what measures do you offer Washington as proof that a model works?> Doctors are never going to agree to base this on patient-reported> measures.> > Don't you think, if the Grail of a REAL set of outcome measures that> could be applied to individual practices could be presented to the> power-brokers, then they could get out of the business of telling us> HOW to do our jobs and focus on the funding mechanism to pay those who> make it happen? Can't we leave some room for innovation, practice> differences, geographic differences? What are these measures?!> > Haresch>

February 10, 2009

Really, really good point -- what evidence is there that the current methods are

working as desired or are high-value/cost-effective?I'm adding the sentiment

to my armamentarium.TimOn

Mon, February 9, 2009 10:03 pm EST, wrote:

With respect to the statement " ...employers, insurance and other

interested parties want proof that their money is being well spent... " What

proof do they have that their money is currently being well spent? Are they asking

the proceduralists to prove their worth? Is anyone asking them to provide metrics

and measurements that what they are costing the system TODAY is money well spent?

I do not have a beef against the proceduralists, but I do have a beef that we

in thought-based medicine are repeatedly asked to provide metrics/data/numbers/pilot

studies/insurance pilot projects-all generally without payment for our efforts-- in

order to SOMEDAY maybe, possibly start getting paid for the job we were trained to

do in the first place.

As Gordon repeatedly points out, the data that basing a health care system on a

viable, robust primary care system costs less and provides better outcomes is

basically irrefutable, and plenty of solid research already completed and validated

supports this.

I do not mind participating in projects to become accountable for my care and

outcomes. I like improving my care and outcomes. What is getting so very old is

being punished for providing quality and watching the situation for primary care

continue to worsen to the point of extinction while insurance companies and the

folks we have abdicated authority for payment come up with more " pilot

projects " to string us along.

What has happened with the pilot project Eads was involved with for paying

email visits (or maybe it was phone visits, I can't quite remember)? I have not

suddenly seen an outgrowth of realization that paying for these kinds of services is

good. What I have seen is lots of pilot projects that get us exactly nowhere with

respect to sustainability when doing the right thing.

How long do we have to wait for " the powers that be " to deem us

worthy? "

I know I am preaching to the choir here, but this thread is incredibly

important to understanding why we are all so frustrated with the current and

worsening status quo.

The answers seem to already be available, but no one in power is listening.

We do need to continue to try and rally patients and physician support with

true understanding of what got us here and what it will take to dig our health care

non-system out of the muck.

Durango, CO

Yes, Lou, agreed! But can you help me see a way that this (i.e.pouring

money into creating a real primary health care system as thefirst step) could

conceivably happen out of the current milieu? Haresch---

In ,

" l_spikol " wrote:

>> I believe the logic of how we are going

about this in this country > is fundamentally flawed.> >

So if you believe this-> > Most other developed countries have at

least as good health care and > outcomes as the United States for

substantially less money.> > Why?> > Because

they have a strong primary care component to their health > care system

(70% primary care versus 30% primary care here)> > Then->

> The way to fix our system is to have 70% primary care rather than > 30%.> > So-> > Why is this not being

accomplished? (For the multitude of reasons > we discussed on this

listserv-insurance issues, payment issues, > morale issues the list goes

on)> > The first domino in the series is the establishment of a

> predominant, strong primary care system and the rest of the dominoes > which include " quality " (including numbers and other criteria which

> are not able to be quantified)-will fall into place.> >

Therefore-> > Asking primary care to prove that they should exist

before being > allowed to do so is fundamentally flawed.> > Lou> > > > > > >> > After

seeing this and the Senate hearing that Alan Falkoff posted, > my>

> thoughts for today on PCMH and payment reform:> > > >

1. The messages being sent to Washington from medical professionals> >

appear terribly muddled. Everyone seems to have their own axe to> >

grind, and each supports their view with anecdotes and data that > can't> > logically support their conclusions. How can any coherent fix for> > primary care payment come out of this?> > > > 2.

It appears that there will be no appetite for payment reform > until> > a model " proves " that it can improve outcomes. My question is:

What> > will be accepted as acceptable outcomes? Some proxies for good

care> > such as HEDIS disease-specific markers, adoption of certified

EMRs,> > meeting NCQA criteria? The whole conversation needs to be

shifted > to> > focus on the outcomes we need -- actually

healthier, happier > people.> > But what measures do you offer

Washington as proof that a model > works?> > Doctors are never

going to agree to base this on patient-reported> > measures.>

> > > Don't you think, if the Grail of a REAL set of outcome measures

> that> > could be applied to individual practices could be

presented to the> > power-brokers, then they could get out of the

business of telling > us> > HOW to do our jobs and focus on the

funding mechanism to pay those > who> > make it happen? Can't

we leave some room for innovation, practice> > differences, geographic

differences? What are these measures?!> > > >

Haresch> >>

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February 10, 2009

I hope you don't think I agree with the money bags driving physician evaluation, . You may or may not recall that I left my large group practice about 18 months ago and have a cash only practice for just those reasons that you get on your soap box about. I was just thinking, as we try to influence the conversation about health care, that if we point out that countries (with better health outcomes) DON'T force their primary care docs to prove themselves, that might be useful information to include. I don't know if this is accurate or not though, as I have no idea if other countries make their docs/providers jump through the hoops that ours does.Lonna

Yes, Lou, agreed! But can you help me see a way that this (i.e.pouring money into creating a real primary health care system as thefirst step) could conceivably happen out of the current milieu? Haresch

> >> > After seeing this and the Senate hearing that Alan Falkoff posted, > my> > thoughts for today on PCMH and payment reform:> > > > 1. The messages being sent to Washington from medical professionals

> > appear terribly muddled. Everyone seems to have their own axe to> > grind, and each supports their view with anecdotes and data that > can't> > logically support their conclusions. How can any coherent fix for

> > primary care payment come out of this?> > > > 2. It appears that there will be no appetite for payment reform > until> > a model "proves" that it can improve outcomes. My question is: What

> > will be accepted as acceptable outcomes? Some proxies for good care> > such as HEDIS disease-specific markers, adoption of certified EMRs,> > meeting NCQA criteria? The whole conversation needs to be shifted

> to> > focus on the outcomes we need -- actually healthier, happier > people.> > But what measures do you offer Washington as proof that a model > works?> > Doctors are never going to agree to base this on patient-reported

> > measures.> > > > Don't you think, if the Grail of a REAL set of outcome measures > that> > could be applied to individual practices could be presented to the> > power-brokers, then they could get out of the business of telling

> us> > HOW to do our jobs and focus on the funding mechanism to pay those > who> > make it happen? Can't we leave some room for innovation, practice> > differences, geographic differences? What are these measures?!

> > > > Haresch> >>

February 10, 2009

I asked Graham Chiu in New Zealand about this a while ago and I think he said( and I am sure he is listending and will jump in) that NO there were not a lot of these measurements going on in NZ in primary care.

JEan

Do other countries (with better health statistics and more primary care docs) use measures to monitor how primary care is doing?

Subject: Re: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]

To: Date: Monday, February 9, 2009, 6:36 AM

I believe the logic of how we are going about this in this country is fundamentally flawed.So if you believe this-Most other developed countries have at least as good health care and outcomes as the United States for substantially less money.

Why?Because they have a strong primary care component to their health care system (70% primary care versus 30% primary care here)Then-The way to fix our system is to have 70% primary care rather than

30%.So-Why is this not being accomplished? (For the multitude of reasons we discussed on this listserv-insurance issues, payment issues, morale issues the list goes on)The first domino in the series is the establishment of a

predominant, strong primary care system and the rest of the dominoes which include " quality " (including numbers and other criteria which are not able to be quantified)- will fall into

place.Therefore-Asking primary care to prove that they should exist before being allowed to do so is fundamentally flawed.Lou>> After seeing this and the Senate hearing that Alan Falkoff posted, my> thoughts for today on PCMH and payment reform:> > 1. The messages being sent to Washington from medical professionals

> appear terribly muddled. Everyone seems to have their own axe to> grind, and each supports their view with anecdotes and data that can't> logically support their conclusions. How can any coherent fix for

> primary care payment come out of this?> > 2. It appears that there will be no appetite for payment reform until> a model " proves "

that it can improve outcomes. My question is: What> will be accepted as acceptable outcomes? Some proxies for good care> such as HEDIS disease-specific markers, adoption of certified EMRs,> meeting NCQA criteria? The whole conversation needs to be shifted

to> focus on the outcomes we need -- actually healthier, happier people.> But what measures do you offer Washington as proof that a model works?> Doctors are never going to agree to base this on patient-reported

> measures.> > Don't you think, if the Grail of a REAL set of outcome measures that> could be applied to individual practices could be presented to the> power-brokers, then they could get out of the business of telling

us> HOW to do our jobs and focus on the funding mechanism to pay those who> make it happen? Can't we leave some room for innovation, practice> differences,

geographic differences? What are these measures?!> > Haresch>

-- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD

ph fax impcenter.org

February 10, 2009

I can speak for Canada. The measure there is a letter from gov't with your stats on it. You do what you want with it. there is no P4P. Majority of docs are in fee for service private practice. Much less bureaucracy much less stress, better pay. Any other Canadians out there? can you confirm that this is still happening? Also there is no re cert exams. Oh how I miss my practice in Canada

What I meant was - do other countries monitor the " performance " of their primary care docs, such as with HEDIS measures, P4P programs, or other such devices.

From: l_spikol < lspikolptd (DOT) net >Subject: [Practiceimprovemen t1] Re: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]To: Practiceimprovement 1yahoogroups (DOT) com

Date: Monday, February 9, 2009, 6:36 AM

I believe the logic of how we are going about this in this country is fundamentally flawed.So if you believe this-Most other developed countries have at least as good health care and

outcomes as the United States for substantially less money.Why?Because they have a strong primary care component to their health care system (70% primary care versus 30% primary care here)Then-

The way to fix our system is to have 70% primary care rather than 30%.So-Why is this not being accomplished? (For the multitude of reasons we discussed on this listserv-insurance issues, payment issues,

morale issues the list goes on)The first domino in the series is the establishment of a predominant, strong primary care system and the rest of the dominoes which include " quality " (including numbers and other criteria which

are not able to be quantified)- will fall into place.Therefore-Asking primary care to prove that they should exist before being allowed to do so is fundamentally flawed.Lou>> After seeing this and the Senate hearing that Alan Falkoff posted, my> thoughts for today on PCMH and payment reform:> > 1. The messages being sent to Washington from medical professionals

> appear terribly muddled. Everyone seems to have their own axe to> grind, and each supports their view with anecdotes and data that can't> logically support their conclusions. How can any coherent fix for

> primary care payment come out of this?> > 2. It appears that there will be no appetite for payment reform until> a model " proves " that it can improve outcomes. My question is: What

> will be accepted as acceptable outcomes? Some proxies for good care> such as HEDIS disease-specific markers, adoption of certified EMRs,> meeting NCQA criteria? The whole conversation needs to be shifted

to> focus on the outcomes we need -- actually healthier, happier people.> But what measures do you offer Washington as proof that a model works?> Doctors are never going to agree to base this on patient-reported

> measures.> > Don't you think, if the Grail of a REAL set of outcome measures that> could be applied to individual practices could be presented to the> power-brokers, then they could get out of the business of telling

us> HOW to do our jobs and focus on the funding mechanism to pay those who> make it happen? Can't we leave some room for innovation, practice> differences, geographic differences? What are these measures?!

> > Haresch>

-- M.D.www.elainemd.comOffice: Go in the directions of your dreams and live the life you've imagined.

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February 10, 2009

ElaineCan you give a few more details, what is included in your 'stats'?LynnTo: From: elaine2md@...Date: Tue, 10 Feb 2009 07:05:12 -0800Subject: Re: Re: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]

I can speak for Canada. The measure there is a letter from gov't with your stats on it. You do what you want with it. there is no P4P. Majority of docs are in fee for service private practice. Much less bureaucracy much less stress, better pay. Any other Canadians out there? can you confirm that this is still happening? Also there is no re cert exams. Oh how I miss my practice in Canada

On Mon, Feb 9, 2009 at 9:16 AM, Lonna Larsh <larshlonna> wrote:

What I meant was - do other countries monitor the "performance" of their primary care docs, such as with HEDIS measures, P4P programs, or other such devices.

From: l_spikol < lspikolptd (DOT) net >Subject: [Practiceimprovemen t1] Re: [Fwd: NYTimes.com: UnitedHealth and I.B.M. Test Health Care Plan]To: Practiceimprovement 1yahoogroups (DOT) com

Date: Monday, February 9, 2009, 6:36 AM

I believe the logic of how we are going about this in this country is fundamentally flawed.So if you believe this-Most other developed countries have at least as good health care and

outcomes as the United States for substantially less money.Why?Because they have a strong primary care component to their health care system (70% primary care versus 30% primary care here)Then-

The way to fix our system is to have 70% primary care rather than 30%.So-Why is this not being accomplished? (For the multitude of reasons we discussed on this listserv-insurance issues, payment issues,

morale issues the list goes on)The first domino in the series is the establishment of a predominant, strong primary care system and the rest of the dominoes which include "quality" (including numbers and other criteria which

are not able to be quantified)- will fall into place.Therefore-Asking primary care to prove that they should exist before being allowed to do so is fundamentally flawed.Lou>> After seeing this and the Senate hearing that Alan Falkoff posted, my> thoughts for today on PCMH and payment reform:> > 1. The messages being sent to Washington from medical professionals

> appear terribly muddled. Everyone seems to have their own axe to> grind, and each supports their view with anecdotes and data that can't> logically support their conclusions. How can any coherent fix for

> primary care payment come out of this?> > 2. It appears that there will be no appetite for payment reform until> a model "proves" that it can improve outcomes. My question is: What

> will be accepted as acceptable outcomes? Some proxies for good care> such as HEDIS disease-specific markers, adoption of certified EMRs,> meeting NCQA criteria? The whole conversation needs to be shifted

to> focus on the outcomes we need -- actually healthier, happier people.> But what measures do you offer Washington as proof that a model works?> Doctors are never going to agree to base this on patient-reported

> measures.> > Don't you think, if the Grail of a REAL set of outcome measures that> could be applied to individual practices could be presented to the> power-brokers, then they could get out of the business of telling

us> HOW to do our jobs and focus on the funding mechanism to pay those who> make it happen? Can't we leave some room for innovation, practice> differences, geographic differences? What are these measures?!

> > Haresch>

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February 10, 2009

Yes, yes, yes. All good points. But when you have AAFP, ABIM, AMA, ad

nauseum standing up in Washington saying we're not doing well enough

and if you'll dribble some money our way we'll fix everything with

PCMH and lots of reporting, and the AMA with all the proceduralists

and other assorted money-makers aggressively defending their funding

turf, what is possibly going to get legislators to invest in a

functional primary care system? The voices of small groups of PCPs

advocating AGAINST their national organizations on a new direction

aren't going to get very far. If the current appetite for change is to

be utilized, it seems to me that the CURRENT movement needs to be

turned toward the good. That's why I am thinking that, if there were

relatively simple, easily testable, and MEANINGFUL measure(s) that

could be substituted when the NCQA benchmarks fail to bring about

anything useful, the current shifting sands could just maybe be

directed somewhere good.

But these are just my loose synapses (mis)firing. Thanks for your

indulgence.

Haresch

>

> Really, really good point -- what evidence is there that the current

methods are

> working as desired or are high-value/cost-effective?

> I'm adding the sentiment

> to my armamentarium.

> Tim

February 10, 2009

Lonna,

I am so sorry for even implicating you as any part of the problem....no no no. You are a " good guy " and I did not mean to imply otherwise. Your statement just made me think for the first time that no one is asking the current costly part of our non system to prove their worth, but those of us facing extinction are told to hang on and if we can just prove our worth, they just might send us a rickety life boat.

In my worst nightmares I do not dream that you agree with any money bags. So sorry, Lonna.

Snowed in at her office in Durango, CO

I hope you don't think I agree with the money bags driving physician evaluation, . You may or may not recall that I left my large group practice about 18 months ago and have a cash only practice for just those reasons that you get on your soap box about. I was just thinking, as we try to influence the conversation about health care, that if we point out that countries (with better health outcomes) DON'T force their primary care docs to prove themselves, that might be useful information to include. I don't know if this is accurate or not though, as I have no idea if other countries make their docs/providers jump through the hoops that ours does.

Lonna

Yes, Lou, agreed! But can you help me see a way that this (i.e.pouring money into creating a real primary health care system as thefirst step) could conceivably happen out of the current milieu?

Haresch> >> > After seeing this and the Senate hearing that Alan Falkoff posted, > my> > thoughts for today on PCMH and payment reform:> >

> > 1. The messages being sent to Washington from medical professionals> > appear terribly muddled. Everyone seems to have their own axe to> > grind, and each supports their view with anecdotes and data that

> can't> > logically support their conclusions. How can any coherent fix for> > primary care payment come out of this?> > > > 2. It appears that there will be no appetite for payment reform

> until> > a model " proves " that it can improve outcomes. My question is: What> > will be accepted as acceptable outcomes? Some proxies for good care> > such as HEDIS disease-specific markers, adoption of certified EMRs,

> > meeting NCQA criteria? The whole conversation needs to be shifted > to> > focus on the outcomes we need -- actually healthier, happier > people.> > But what measures do you offer Washington as proof that a model

> works?> > Doctors are never going to agree to base this on patient-reported> > measures.> > > > Don't you think, if the Grail of a REAL set of outcome measures > that

> > could be applied to individual practices could be presented to the> > power-brokers, then they could get out of the business of telling > us> > HOW to do our jobs and focus on the funding mechanism to pay those

> who> > make it happen? Can't we leave some room for innovation, practice> > differences, geographic differences? What are these measures?!> > > > Haresch> >

>

February 10, 2009

Talking about Primary care systems:

In case someone is interested in a system that seems to work,

Sweden, they run primary care as a fee for service (private or county operated

as private for the most part) system paid by a centralized single payer system

with a, relatively, high deductible. To put it in perspective primary care

visit are 100 to 150 SEK, hospital stay is 80 SEK per day. Deductible was 900

SEK per calendar year in 2007 (the calendar year runs starting to count the day

of the first service for that year) and medication deductible was 1800 SEK.

It seems to work and health care expenditure is around 9% GDP,

stable since 1980. They are only 9,000,000 Swedes (less than NYC).

My experience with them, sorry but I have to tell the story: I

see a lot of patients from the United Nations; someone told them that I was

good and cheap (compared to the Park Avenue people, I guess). I see several Swedes

that don’t question paying me, seems natural for them to pay for the service;

all they ask is for a receipt (same for meds and labs) that describes the level

of service as they would get reimbursed by the Swedish Health Care System. Try

to get reimbursed here for services rendered abroad!

Below is a link to the 2007 Swedish government Primary Care pdf

report, may be an example to strive for.

http://www.sweden.se/upload/Sweden_se/english/factsheets/SI/SI_FS76z_Swedish_Health_Care/FS76z%20FINAL_Low.pdf

José

From:

[mailto: ] On Behalf Of Haresch

Sent: Tuesday, February 10, 2009 12:03 PM

To:

Subject: Re: [Fwd: NYTimes.com: UnitedHealth and

I.B.M. Test Health Care Plan]

Yes, yes, yes. All good points. But when you

have AAFP, ABIM, AMA, ad