Primary care providers are on the frontlines of patient care and often are the first practitioners to feel and be counted on to execute changes in how care is delivered.
The Commonwealth Fund and the Kaiser Family Foundation (PDF, 442 KB) asked more than 2,000 primary care doctors, nurse practitioners and physician assistants what they thought of what's happening and how that's affecting the care they provide. See results in call-out below.
Most of the more than 2,000 primary care providers surveyed by the Commonwealth Fund and Kaiser Family Foundation say new care delivery models are having a positive impact on the quality of care they deliver to their patients. Yet, many remain unconvinced, suggesting that the proponents of the new care delivery models need to do more to enable those new models to work for both patients and providers.
Proving The New Model
We asked McKesson's resident chief medical officers to weigh-in on why physicians may be skeptical about changes in the medical practice and what it will take to get them on board with new care delivery models.
Q: What factors make physicians bullish on the changes in medical practice and care delivery?
Jonathan Niloff, M.D.: Physicians pride themselves on providing great quality care to their patients. Transforming their practice model to a patient centered medical home with a team-based approach to coordinated care helps them accomplish that goal. When done right it also improves their professional satisfaction as they can spend more time devoted to the high value cognitive activities that they were trained for.
Michael Blackman, M.D.: Increased quality of care and shifting payment models are two factors that are driving physician interest. However, changing the overall model will present challenges along the way.
Q: What factors make physicians skeptical about the changes in medical practice and care delivery?
Niloff: Fundamental to the new primary care model is delivery of care by a team. This is, of course, difficult to operationalize without the requisite revenue to support additional staff. The physician's challenge, especially early in the transition process when revenue to support this approach is only available for a small proportion of a practice's patients, is how to fund this incremental staff.
Blackman: The transition from pay for service to paying for value. There is concern that the new models will become a method simply to decrease reimbursement coupled with increased reporting requirements.
Q: Physician views are mixed on whether new care delivery models like ACOs and PCMHs improve care. What do they need to see or experience to give them a favorable opinion of new care delivery models?
Niloff: Many physicians don't really understand what the PCMH model really is. With a superficial understanding they believe that they have been practicing patient centered care for years. Education will go a long way towards addressing any misconceptions and help physicians embrace new care models.
Blackman: We need to see the outcomes from delivery models, such as ACOs, outside of closed systems. Organizations such as Kaiser, and others like them, have done a great job, but they control all aspects of the patient's care including the payments. Dividing bundled payments between an acute care facility and the follow up care in independent practices is going to be challenging.
Q: Physicians may be skeptical on the use of quality metrics and financial penalties to improve care. What do they need to see or experience to give them a favorable opinion of the carrot-and-stick approach to care improvement?
Niloff: There are two challenges with quality metrics. First is the metrics themselves. There is a common belief among physicians that many of the quality metrics used today do not really measure quality in a meaningful way. Specifically, they don't reflect important patient outcomes. The second concern is the accuracy of measurement. Which providers should be responsible for which metrics? Individual or shared responsibility among providers? And there are challenges with the data with small denominator population - all of which raise concerns among physicians about the validity of quality metrics.
Blackman: This feeling tends to come when the measures are not structured in a way that makes clinical sense. Often there is a disconnect between what can be measured and what truly has an impact on patient outcomes. A focus on measuring those things which are proven to effect outcomes will help.
Q: What can stakeholders do to get physicians on board with the changes reshaping how they practice medicine?
Niloff: These are the key things stakeholders can do to help accelerate the adoption of new care models: Education. Physicians need to understand these new practice reimbursement models and why they are good for them and for their patients. Alignment. There needs to be alignment among all constituents with a common message. This is often challenging early in transition when FFS and VBR are coexisting. Reimbursement. Physician reimbursement needs to be aligned with the new model with rewards commensurate with the required resources and efforts. Process. Requisite IT and related processes with the needed resources need to be in place. Engagement. Practices need support to help them transform how they provide care. This transformation needs to recognize the importance of the team so the physician is not put in the position of doing incremental work but is supported by an engaged collaborative team.
Blackman: Create team based care with the appropriate composition. To truly focus on all of a patient's needs, especially for a complicated patient, requires a team which includes physicians, nurses, case managers, dietitians, and others as appropriate. The appropriate team members need to have enough time to work with patients to truly understand their issues and barriers so all of them can be addressed. They are not only medical, in many cases the social issues are the larger challenge. Government can help with standards and consistent rules. While things are improving quality measures vary by location and, commonly, payer. A standard set of reporting requirements and attention to how that data will be used. Reporting for reporting sake does not make sense. We should focus on how the collected data will either directly improve patient care or be used to advance the body of knowledge. Additionally, there should be a review of the total regulatory burden from various programs (HITECH / Meaningful Use, PQRS, ICD-10 for example) to both address alignment and the timelines. Healthcare priorities need to be aligned. Vendors can continue to improve decision support and make it easier to do what we know works. However, none of the tools should restrict the user and always allow them to do what is appropriate for any given patient.
Q: What will it take for physicians to be satisfied with the changes reshaping how they practice medicine?
Niloff: I don't think that there is any question that they will be very satisfied. In talking with PCPs that have successfully transformed their practices, especially when they are in supportive environments, they are very happy. They are enjoying doing more of what they were trained to do and are pleased to see the improved outcomes and better experience of care among their patients.
Blackman: Physicians, and other clinicians, genuinely want to care for patients. If the changes can result in letting people focus on patients with a reduced administrative burden attitudes will shift. Perhaps, paying for outcomes will decrease the focus on coding and allow documentation to be refocused on its use as a communication rather than a billing tool.
Source: Commonwealth Fund, Kaiser Family Foundation (PDF, 442 KB)