In Atul Gawande's latest piece in The New Yorker, the physician-author compares the current pilot-project approach to reforming healthcare with efforts in the early 1900s to improve agricultural production. Farmers at the time were struggling with analogous problems—spiraling costs, a lack of "comparative effectiveness research," poor quality rating mechanisms, and industry fragmentation—and only began to see improvements after government-initiated pilot programs spurred innovation.
Gawande, who was named one of HealthLeaders' 20 People Who Make Healthcare Better this year, offers long-term and clear-eyed hope amidst a lot of short-term nay saying and pessimism about the future of healthcare.
But his analogy may not be very reassuring to one segment of physicians. A consequence of agricultural progress that Gawande briefly glosses over is the near extinction of the small family farmer. If healthcare follows a similar path, does the solo or small physician practice face the same fate?
Before the transformation of agriculture, the industry presented a similar economic challenge as healthcare does today. Forty percent of a family's income went to paying for food and almost half the American workforce worked in agriculture, many on small farms. Scientific and technological advancements, as well as evidence-based efficiencies, cut spending to 24% of income and 20% of the workforce by 1930, Gawande explains. Today it only accounts for 8% of income and 2% of the labor force.
Consolidation of farms and the rise of big agribusiness played a major role in that. Small farmers increasingly had trouble purchasing necessary new equipment and keeping up with productivity gains made by larger operations with more capital to invest.
Sound familiar?
It's no secret that, even with the reimbursement bonuses in the HITECH Act, solo and small physician practices face a steeper climb when purchasing and implementing electronic health records than larger groups.
A new study published in the Journal of the American Medical Association highlights yet another small-practice struggle: Nearly 65% of primary-care physicians work in practices that are too small to draw meaningful conclusions about the quality of care they provide based on Medicare data. Even aggregating data over a 3-year period for each physician group failed to produce large enough sample sizes for half of the groups with fewer than six physicians.
Don Berwick, MD, MPP, president and CEO of the Institute for Healthcare Improvement, offered some suggestions to improve data collection without compromising the size and autonomy of practices, such as pooling data from all payers and surveying patients about their experiences.
But measuring small-practice quality will become a more significant change if one of these payment pilot projects evolves into a full-fledged quality-based reimbursement system.
Given the general direction healthcare is heading and the financial pressures physicians face, it's likely that the proportion of doctors in small practices will continue to drop over the next couple of decades.
There are some options for the little guys, though. An independent practice can have a managed service organization run by a hospital or other entity handle human resources and administrative tasks, or a physician-hospital organization, where money matters are handled jointly. Some physicians may also look at limited or divisional mergers, where a small practice retains its individual identity but joins other practices to form a corporation.
To stay small, many practices will have to find help, and perhaps give up some of their autonomy. But that may be the only way to resist the tide of consolidation.
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A survey conducted by the American Association of Clinical Endocrinologists indicates that the Centers for Medicare & Medicaid Services decision to eliminate consultation codes will force four out of five endocrinologists to reduce the number of Medicare patients seen in their practices. The CMS decision, which will go into effect in January 2010, will no longer allow endocrinologists and other specialists to bill for consultations provided for patients referred to them by primary care physicians and written reports will no longer have to be provided to referring physicians, according to the AACE.
Senior Senate Democrats reached tentative agreement to abandon the government-run insurance plan in their health-overhaul bill and to expand Medicare coverage to some people ages 55 to 64. The American Medical Association said it opposes expanding Medicare because doctors face steep pay cuts under the program and many Medicare patients are struggling to find a doctor.
Senate Democrats largely embraced a compromise that dropped a "public option" from healthcare legislation, setting aside their concerns about aspects of the consensus plan in the hopes that the deal would serve as a rallying point in their push for the passage of reforms, the Washington Post reports. But industry groups representing doctors and hospitals attacked one of the alternatives in the deal, designed to take the place of a proposed government-run insurance program. They argued that a plan to allow uninsured individuals as young as 55 to buy into Medicare would be financially untenable and would jeopardize access to healthcare services for millions of Americans.
President Barack Obama endorsed a Senate Democratic compromise that backed away from a big government-run health plan, calling the idea a "creative framework" that could propel a health bill to passage, the Wall Street Journal reports. Obama said senators had "made critical progress" with a compromise that would "help pave the way for final passage." He added, "I support this effort, especially since it's aimed at increasing choice and competition and lowering cost."
Sen. Chuck Grassley (R-IA), the ranking Republican on the Senate Finance Committee, is pushing for legislation that would require public reporting by drug- and device-makers on an annual basis. Grassley and Sen. Herb Kohl (D-WI) say their bipartisan Physician Payments Sunshine Act would require annual reporting "by drug, device, and biologic manufacturers of payments made to physicians nationwide."
Executives from some of Massachusetts' leading health insurance companies refused to answer key questions from state regulators about why some hospitals and doctors are paid up to three times as much as others for the same services. But some of the company officials acknowledged that provider payments are based on fierce competition among hospitals and doctors in some areas of the state, as well as employers' insistence that a particular hospital or physicians' group be included in their plan. The testimony was part of a probe by the state Department of Insurance into the reasons for soaring increases in insurance costs overall.
The busy emergency room at Aria Health's Frankford campus in Philadelphia was on "divert" status for 121 hours last month. For an average of four hours a day, things were so tight that ambulances were advised to take patients elsewhere, the Philadelphia Inquirer reports. It is unclear whether high volume at the hospital played any role in the death of Joaquin Rivera, whose watch was later stolen, while he waited for care Nov. 28. But healthcare experts and one state official say there is clearly a crunch at the facility—due in part to the closing of nearby Northeastern Hospital, which used to see at least 45,000 emergency patients a year, the Inquirer reports.
Healthcare companies greeted a Senate healthcare bill compromise warily and were worried that a proposed expansion of Medicare would raise costs and result in greater government control of parts of the industry, the Wall Street Journal reports. Insurance companies expressed concern that the lower rates Medicare pays doctors and a requirement forcing the companies to pay out 90% of their premium income on medical benefits for policyholders could drive up costs. For drug companies, additional Medicare enrollees could mean that they would be paid at lower rates by the government than what private insurers pay for medicines, the Journal reports.
The Center for Medicare & Medicaid Services (CMS) recently released chapters 1, 3, and 5 and appendices A through H of the new Resident Assessment Instrument (RAI) User's Manual for the Minimum Data Set (MDS) 3.0, giving long-term care providers insight into how to code the new assessment tool.
There are many changes included in the already released chapters of the new RAI User's Manual, such as modified language, different item labeling, and changes to coding instructions for the MDS 3.0, which will be implemented in October 2010.
"There are some hidden nuggets in these chapters that, on first reading, may go over people's heads," says Rena R. Shephard, MHA, RN, RAC-MT, C-NE, founding chair and executive editor of the American Association of Nurse Assessment Coordinators and president of RRS Healthcare Consulting Services in San Diego. "For example, you can use preadmission information when coding ADLs [activities of daily living] on the MDS 2.0, but this will not be true with the MDS 3.0. There are only a few sections on the new assessment in which you can look back into the preadmission period and there is not a big red flag that says ‘Notice this' but it does say this on p. 3-3 of the new manual."
ADL coding is an area of high interest in long-term care and although the methodology won't really change under the MDS 3.0, the manual contains some significant changes to some of the details of ADL coding. "For example, facilities will only be able to use the information collected by staff, not family or visitors," Shephard says. "There is an ADL coding flow diagram on p. G-6, and it will be very important for people to use this because it will help them code ADLs more accurately on the MDS 3.0."
Another notable change included in the new RAI User's Manual is that, under the MDS 3.0, facilities will only have 14 days to transmit the assessment, rather than the 31 days allowed under the MDS 2.0.
Chapters 2, 4, and 6, and Appendix C of the new RAI User's Manual are scheduled to be released this month.
"I think it is good that CMS released the manual in sections because it gives people time to digest the item-by-item coding of each section before trying to wrap their heads around the changes included in other chapters," Shephard says. "There will be enough changes to Chapters 2, 4, and 6, in terms of timing and scheduling of assessments, Care Area Assessments, and Resource Utilization Group–Version IV, and releasing chapters at different dates helps to not overwhelm everyone with all the changes at once."
