Money, primary care, and IMPs

[Guest guest]

Just catching up on this terrific thread. Thanks for kicking it off

Larry!

Larry, Egly and Larry's MD partner & I had dinner in Chicago a

week ago. Larry has a sweet little office in a nice part of

town. Chicago is an expensive place so his rent is higher than it

is for some. Malpractice is rapacious in Illinois (full time FP

without OB is 30K, is that right Larry?).

In spite of that, he's bringing home $150k for which he should be

justifiably proud. He has two staff and 1.5 providers. Is he

an IMP?

I vote Yes.

He has eliminated the delay for appointments and gotten out of the

Mother-may-I triage by " urgency " game

He sees people on time

His continuity of care is fabulous

Advancing along the developmental curve he's taking on improvement of

chronic conditions in his practice

Is the money enough? Not really - Larry lives in a very expensive

part of the country and has kids going to college.His second year into

IMP he's moving into the developmental stage of raising the bar on

chronic care.

We've learned anecdotally on the listserv that different parts of the

country have huge variation in the big drivers of finances.

Malpractice, reimbursement, rent are the biggest external

drivers.

Please remember these basic principles:

Take-home income is that money left over after you pay your

expenses. The IMP model is not solo-solo, but a sustainable practice capable of

delivering patient centered collaborative care (PCCC)

Low overhead practices are more likely to be sustainable than high

overhead practices.

There are some parts of the country where - due to the unfortunate

mix of reimbursement and expense - no practice can survive without

subsidy.

Our country elects to treat certain citizens as second rate and to

create systems of payment and eligibility that give them third-world

level care

It is theoretically possible to deliver PCCC in a high flow practice,

and we eagerly await the practice that can demonstrate the capability.

We have demonstrated PCCC in very low flow practices AND in moderate

flow practices like Larry's

We have to work together to continue to push for fundamental and

substantial changes to the way we pay for health care

That payment ought to focus on rewarding the behaviors that lead to

PCCC

From the IMP project we now have tools that can quickly tell us how well

a practice performs (read this article: Wasson JH, DJ,

R, , J, MacKenzie TA. Patients Report Positive

Impacts of Collaborative Care, Journal of Ambulatory Care Management Vol

29, No 3, pp. 201-208).

We're demonstrating so far that IMPs are the best in the nation at

delivering patient centered collaborative care (see attached, please

excuse the typo about 2007, should be 2006). The public has no

interest in doctors asking for more money when the care we deliver is

demonstrably second rate or worse (McGlynn, E: New England Journal of

Medicine. 348(26):2635-45, 2003 Jun 26). We have a place at the

national table when we have put our houses in order.

The good news is that through demonstration of our good work, we have

captured the attention of some very important people and

organizations. Our guest speaker at the IMP convocation is

Webber, the CEO of the National Business Coalition on Health. He

and his organization are eager partners as we engage the nation in a

discussion of solutions to our growing crisis in health care.

Gordon

At 12:12 PM 9/15/2006, you wrote:

,

I agree with what you are saying, but

therein lies the problem. Most of us made the leap to this form of

practice to provide higher quality care and have more professional

satisfaction, and hoped the money would flow in as well. Insurances pay

for quantity and so this has not been entirely the case, and as we add

and see more patients, the time spent with each patient declines and at

some point (I don’t know where) the doctor-patient relationship begins to

falter and the quality begins to drop. At the same time, increasing chaos

in the office (from more employees, more phone calls, etc) further

destroys quality. So, following this line of thought, the only way to

provide high quality medicine is to not accept insurances, which then

alienates us from the majority of people who don’t want to pay privately.

So, in our lovely society, in order to financially make ends meet we have

to lower our standards, increasing our risk of getting sued and

increasing our overhead further. So, the insurances have really become

the force driving poor quality. Ironically, then the same companies send

letters saying that they are enrolling your diabetics in special case

manager classes to ensure quality. It really sucks!

Sorry for being disgruntled, but having

“climbed the mountain and looked down into the promised land,” I hate

that others might not join us in the journey. Maybe something will change

somewhere…..