Tag Archives: Primary care

Seeking Primary Care Elsewhere

Patients who can’t get in to see their primary care physicians on a timely basis–or when it’s convenient for them–seem to be increasingly voting with their feet, seeking care at retail clinics or after-hours urgent care centers.  And that seems to be one factor that’s expected to drive down the cost of health care next year, says PriceWaterhouseCoopers.

Image Courtesy CVS Caremark

The accounting and consulting behemoth released its annual “Behind the Numbers” report on health cost trends. Health spending has been lower than expected for the last three years and will likely stay low, rising by about 7.5% in 2013, according to the report.

PwC found that one of the slowest areas of growth is physician spending. From 2007-2012, spending on physician services by private health plans grew only 5.4%–compared to 8% growth for inpatient care and 10% for outpatient hospital care.  They slowdown in doctor spending “is expected to continue in 2013 as consumers choose alternatives to the traditional doctor’s office visit,” said the report. Those alternatives include “lower-cost options such as workplace and retail health clinics, telemedicine, and mobile health tools,” which are viewed by employers and consumers “as cost effective and convenient.”

In 2010, about 17% of consumers said they had sought care at a retail clinic; by 2011, that had risen to 24%, according to a PwC survey conducted each year to help flesh out the medical spending picture.

It’s no secret that use of retail clinics and urgent care centers has skyrocketed. Last fall, the RAND Corp. reported that there was a ten-fold increase in use of those retail clinics between 2007 and 2009. Using data from a commercially-insured population of 13.3 million, RAND determined that 3.8 million made at least one clinic visit between 2007 and 2009. Monthly visits jumped from 0.6 per 1,000 in January 2007 to 6.5 per 1,000 in December 2009.

Interestingly, availability of primary care physicians did not seem to be a factor in determining use. Those who went to retail clinics tended to be in good health, between 18 and 44, and have a higher income.

In other words, those are paying customers who are choosing to spend their money elsewhere for their care. PriceWaterhouseCoopers advises physicians to make their pricing “defensible” to help stem the tide of patient outflow to these clinics.

One reason why consumers may be going to a lower-priced environment: because employers are increasingly asking workers to shoulder more of the costs of their care. And that is expected to continue.

“We’re seeing long-term trends that could keep cost increases in check,” said Michael Thompson, principal, human resource services at PwC in a press release.  “As employers shift expenses to their employees, for example, these workers are pursuing lower-cost alternatives. Even as the economy strengthens, changes in behavior by employers and consumers may help limit medical growth.”

Alicia Ault

1 Comment

Filed under Family Medicine, Internal Medicine, Practice Trends, Primary care

Criticism of the AMA’s RUC Grows

Tom Scully, the outspoken former head of Medicare, recently said that one of the biggest mistakes policymakers made when redesigning the physician payment system in the early 1990s was giving the American Medical Association control over the Relative Value Scale Update Committee or the RUC.

The RUC, which is as controversial as it is unknown, is a 29-member panel that makes recommendations on how to value of thousands of physician services under Medicare. While Medicare officials are under no obligation to accept the panel’s decisions, most of the time that’s exactly what they do.

Courtesy Wikimedia Commons/ Public Domain.

Mr. Scully told members of the Senate Finance Committee that the current RUC structure, as run by the AMA, isn’t objective enough. There’s a lot on the line since the RUC’s decisions impact about $80 billion in Medicare spending each year, he said. As lawmakers consider how to reform the physician payment system, he urged them to also think about ways to make the RUC less political and more independent.

The comments in the Senate hearing room were just a sampling of the criticism that the AMA and the RUC have received recently. Over the past year or so, the RUC has been under near constant attack from a small group of primary care physicians who are suing the Centers for Medicare and Medicaid Services with the goal of getting the agency to dump the RUC. Their contention is that the RUC is biased toward subspecialists and that the panel’s recommendations have contributed to a significant gap between primary care and specialty pay.

The AMA has continued to support the RUC process, arguing that a group of physicians is best positioned to determine the value of medical services and that the panel has often championed payment increases for primary care services.

— Mary Ellen Schneider

Leave a comment

Filed under Health Policy, IMNG, Litigation, Physician Reimbursement, Practice Trends, Primary care

Health Officials to Docs: Help Save ACA

Health officials are encouraging doctors who support the health law to help save it. By telling patients about how the Affordable Care Act will benefit them and the entire system, physicians can help garner support for the ACA, said Kathleen Sebelius, secretary of Health and Human Services.

“The notion that [you] are going to share factual information and have people share that information with friends and neighbors and patients on websites, in blogs, and church groups, and at [parent/teacher organization meetings], that’s really what makes a huge impact,” Ms. Sebelius said while addressing primary care and specialist physicians at the annual conference of Doctors for America. She added that doctors should not only spread the news, but become a part of the process as well.

“Your comments, certainly, about what is happening in rulemaking is helpful … but more than that is participating in some of the new models of care,” Ms. Sebelius said.

Many physicians are skeptical about the ACA according to some surveys. However, Doctors for America is among those who support of the law. It remains to be seen whether there’s enough agreement among doctors to make a difference.  What do you think? Tell us in the comments section.

—Frances Correa (@FMCReporting on Twitter)

1 Comment

Filed under health reform, IMNG, Practice Trends, Uncategorized

Innovation Center Seeks to Renovate Medicare

Government officials have stood before doctors many times and talked about the need to change the perverse incentives that pay them more for caring for sick patients than for keeping people healthy to start. Dr. Richard Gilfillan, who runs the new Center for Medicare and Medicaid Innovation, had a similar pitch when he talked to more than 1,000 people who recently convened at a Washington, D.C. hotel for a day-long summit on health care innovation. The difference is, Dr. Gilfillan has some leverage.

Under the Affordable Care Act, his new center is charged with rapidly testing alternative payment and health care delivery models. If those pilot projects are proven to both improve the quality of care and bring down health care costs, the Secretary of Health and Human Services can roll out the program nationally. There’s a little more paperwork involved, but that’s the general idea.

Dr. Richard Gilfillan (R), with HHS Secretary Kathleen Sebelius and former head of the Centers for Medicare and Medicaid Services, Dr. Don Berwick, in November. HHS Photo by Chris Smith.

What that means is that in a relatively short amount of time, Medicare could fundamentally change the way it pays doctors. That is, if the pilot projects sponsored by the Innovation Center are successful.

Dr. Gilfillan offered an example: Let’s say the Innovation Center launches a project where it pays primary care physicians an extra $10 per patient per month to coordinate care. If officials at the Innovation Center can prove that the project improves outcomes and reduces costs, HHS can publish regulations to roll it out to primary care physicians around the country. “As you can see, this is a powerful tool for changing the way we deliver care,” Dr. Gilfillan said at the summit.

The Innovation Center has been around for about a year and officials there have been busy putting together a set of pilot projects that look at new ways to deliver primary care and home-based care. They are also testing other concepts like bundled payments and accountable care organizations. Check out the Innovation Center’s report on its first year for descriptions of all the projects.

One thing they are trying to do in each of the projects, Dr. Gilfillan said, is to work closely with private payers. The goal, he said, is to make life a little simpler for doctors by ensuring that when they find new payment mechanisms that work, all the payers, both public and private, will adopt it in the same way.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

Leave a comment

Filed under Family Medicine, Health Policy, health reform, IMNG, Internal Medicine, Pediatrics, Physician Reimbursement, Practice Trends, Primary care

New Questions on Lung Cancer Screening

Would you allow patients to self-refer for a CT lung cancer screening? Would you screen a never-smoker? What size nodule would trigger a follow-up exam? What is your lower age limit and lower pack-year limit for screening?

These are just a few of the questions tackled during an interactive lung cancer screening session at the recent Radiological Society of North America meeting, and that highlight the uncharted waters physicians face in the wake of the pivotal National Lung Screening Trial.

The NLST demonstrated a 20% reduction in lung cancer mortality when low-dose CT screening was used, compared to chest X-ray, among 53,000 asymptomatic current or former heavy smokers. However, CT produced more than three times the number of positive results and a higher false-positive rate than radiography.

Without a clear plan to manage abnormal findings or a firm handle on cost, policymakers and payors are hesitant to back reimbursement for widespread lung cancer screening. Results of the ongoing NLST cost-effectiveness analysis are expected early next year. Based on already published data, however, a crude back-of-the-envelope estimate puts the incremental cost-effectiveness ratio at $38,000 per life-year gained, NLST investigator Dr. William Black told attendees.

“That actually is a pretty good deal compared to a lot of things we do in medicine, and in fact most people would put the threshold for acceptability somewhere between $50,000 to $100,000 per life-year gained,” he said. “So it certainly is feasible”

Dr. Black pointed out that low-dose CT saved one lung cancer death per 346 persons screened in NLST, which again is very favorable compared to the rate of 1 per 2,000 patients for mammography.

Although the session provided just a small snapshot in time, audience responses suggest there is much work ahead. A full 77% of attendees were not using low-dose CT to screen for lung cancer and 72% reported not being familiar with the recently published National Comprehensive Cancer Network guidelines for lung cancer screening.

One-quarter of the audience had no lower age limit for screening, and 34% said they did not provide either decision support or obtain informed consent.

Dr. Caroline Chiles. Image by Patrice Wendling/Elsevier Global Medical News

Radiologist and NLST collaborator Dr. Caroline Chiles said informed consent in NLST helped prepare patients for the potential risks of a screen, the likelihood of a positive result and that a positive result didn’t mean they had lung cancer.

“It made a huge difference once they got that letter saying they had a positive screen, because at that point you don’t want everyone rushing out to a surgeon to get that nodule resected,” she added.

What attendees and panelists could agree on is the need for smoking cessation to be included in any future lung cancer CT screening program, with 60% of attendees saying they already do so.

Dr. Chiles pointed out that 16.6% of participants in the NELSON lung screening trial quit smoking compared with 3%-7% in the general public, but that participants were less likely to stay non-smokers. She also cited a recent MMWR that found 70% of adult smokers want to quit smoking, but only about half had been advised by a health professional to quit.

“We really have to think of lung cancer screening as being a teachable moment,” she said.

She suggested physicians visit www.smokefree.gov for help in guiding their patients. Dr. Black also noted that the NLST team is working on a lung cancer screening fact sheet for physicians and patients that will be ready in a few weeks and made available on the Internet.

—Patrice Wendling

Leave a comment

Filed under Cardiovascular Medicine, Family Medicine, Health Policy, IMNG, Internal Medicine, Oncology, Physician Reimbursement, Practice Trends, Pulmonary Diseases and Sleep Medicine, Radiology, Surgery, Thoracic Surgery

Walmart Downplays Its Designs on Primary Care

As Wednesday dawned, many media outlets were atwitter over the report from Kaiser Health News and NPR that Walmart was seeking to build a gargantuan network of primary care clinics.

Courtesy Wikimedia Commons/RemiOo/Creative Commons License

But by late afternoon it wasn’t so clear exactly what Walmart was up to, as it issued what sounded like a “don’t pay attention to the man behind the curtain” non-denial denial.

The initial NPR report linked to a confidential 14-page “request for information” from Walmart to potential partners in this apparently new business venture.  A Walmart spokeswoman confirmed the existence of the RFI to Kaiser and to the Wall Street Journal. But in the WSJ story, the spokeswoman “downplayed” the importance of the RFI.

NPR later updated its web story with an addendum — that is, the non-denial denial.

“The RFI statement of intent is overwritten and incorrect. We are not building a national, integrated, low-cost primary care health care platform,” John Agwunobi, Senior Vice President & President of Walmart U.S. Health & Wellness, said in a statement.

But it seems hard to believe that a corporation run seemingly as tightly as Walmart would put out a request with a Nov. 22 response date and a Jan. 13 “final vendor selection” date as a big old trial balloon.

The RFI states that “Walmart will use its retail and multi-channel footprint to offer the lowest cost primary healthcare services and products in the nation.”

That may be overly ambitious, but I doubt it was overwritten.

—Alicia Ault (on Twitter @aliciaault)

Leave a comment

Filed under Family Medicine, Health Policy, health reform, IMNG, Internal Medicine, Practice Trends

Help Is on the Way for Primary Care Doctors (Wink, Wink)

Help is on the way “very soon” for family physicians, internists, and pediatricians in the form of a final rule for accountable care organizations (ACOs).

Based on extensive feedback on the proposed ACO rule, changes are coming that primary care physicians are going to like, Dr. Nancy Nielsen said.

The preliminary  rule  “was met with – how shall I say? – an underwhelming response by the medical community,” said Dr. Nielsen, Senior Advisor of the Center for Medicare & Medicaid Innovation established as part of Centers for Medicare and Medicaid Services (CMS) by the Affordable Care Act.

“We have a few code words we have to work out here so I don’t get into trouble, but you get what I am trying to say,” Dr. Nielsen said at the American Academy of Family Physicians Congress of Delegates. For example, if I tell you ‘it has been suggested to us,’ that is REALLY important and it may be coming out, but I can’t announce anything yet,” said Dr. Nielsen, an internist and former president of the American Medical Association.

Regarding ACOs, Dr. Nielsen said, “Very soon the final rule will come out. Very soon. CMS has listened to the feedback:”

“It has been suggested to us that 65 quality measures are way too many.”

“It has been suggested to us that the mechanism for the shared savings ought to be done differently.”

“And it clearly has been suggested to us that hospitals have the ability to come up with the capital to start an ACO, but it’s really tough for doctors. So it has been suggested to us that we give advanced payment. I am here to say that very soon you will see that, and very soon you will like what you see.”

Although doctors have always been accountable for the care of patients, now they also will be accountable for resource expenditures, and the Center for Medicare & Medicaid Innovation plans to help, Dr. Nielsen said. There will be new expectations and new tools given to primary care physicians. “I will tell you that never once in my 23 years of practice did I see data showing me what it cost when I ordered an x-ray. Do you know what it costs when you write a prescription for an antibiotic? Do you get that data? No, you have never seen that.”

“But you must help us achieve this … when the [internal] warfare within the house of medicine begins,” Dr. Nielsen said. “I have a pet peeve. It really makes me crazy when people talk about people who do primary care as ‘primary care physicians’ and all the other docs as ‘specialists.’” She said that family physicians, internists, and pediatricians should stand together and say ‘We are specialists, just like you are specialists. We have a critical role to play and we need to have the tools to help us play that role.”

“Stay tuned. A lot of things you are going to, like, have been suggested to us.”

Dr. Nielsen’s comments were streamed live on the Internet during the congress and are available as archived video.

–Damian McNamara

@MedReporter on Twitter

Leave a comment

Filed under Blognosis, Family Medicine, IMNG, Internal Medicine, Pediatrics, Physician Reimbursement, Practice Trends