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	James L. Holly, M.D.

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Letters - Medical Home News July 2013 Response to Alex Tolbert’s Top Three Obstacles to Better Primary Care

Medical Home News July, 2013
Response written on July 2, 2013
By James L. Holly, MD

I read with interest the article entitled “Top Three Obstacles to Better Primary Care,” by Alex Tolbert in the July, 2013 Medical Home News. I read it with enthusiasm because I am always looking for rational explanations for transformation of Primary Care Payment models. The attached article which was produced by the Commonwealth Fund is one which I find valuable. In my practice’s (Southeast Texas Medical Associates, LLP, SETMA, www.jameslhollymd.com) monthly provider training meeting, in March, 2013 we reviewed this article. We found it compelling partially because all of its recommendations are already being done by SETMA.

This is a link to the display of SETMA’s Accreditations which include PC-MH AAAHC and NCQA.

In the May/June Annals of Family Medicine an article appeared entitled, In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practice. The following is the link to the published article: http://www.annfammed.org/content/11/3/272.full The focus was not on finances but it did address the survival of primary care. Again, the lessons learned, were matched against the policies and practices of SETMA and we found that we are doing all of the things recommended. Our most recent innovation, The Automated Team, advances those ideas. The following is the link to the tutorial for The Automated Team which we deployed July 1, 2013.

Non-insurance-based Primary Care -- Concierge Medicine - The Euphemism of “Subscription-based model of healthcare financing”

The fundamental flaw to Mr. Tolbert’s plan is that most of SETMA’s patients cannot afford a $5 co-pay. How would they then afford a monthly payment of $60 or more. In fact, ten years ago we went to our major HMO and asked them to reduce the co-pay for primary care visits to zero for that very reason. Our analytics of outcomes measures by payer class shows that our Medicare Advantage patients who have no co-pay to see primary care have better outcomes that Fee-for-Service Medicare beneficiaries who have to pay their 20%. By implication, we think this largely has to be with the financial barrier to care.

To respond to the financial needs of our patients, in a patient-centric manner, the partners of SETMA formed the SETMA Foundation. In the past four years, the partners of SETMA have given $2,000,000 to the Foundation. This money has been used to pay for the care of our patients who cannot afford care. None of that money can profit SETMA but is used to pay co-pays and fees for our patients’ care from other providers who will not see them without being paid. The following link is to an article in which we discuss a patient who represents to us “the patient-centered medical home poster child.” SETMA's Medical Home Pilgrimage This patient’s life was saved by SETMA’s Foundation and that story can be repeated hundreds of times. This program is administered by SETMA’s Care Coordination Department with oversight by our CEO.

Healthcare Transformation

The proposal by Mr. Tolbert will work with patients who can afford their care, but it will not with our patients. SETMA employs four elements in transforming healthcare and we believe these elements are the core to any sustainable, affordable and acceptable healthcare transformation:

The Substance -- Evidence-based medicine and comprehensive health promotion
The Method -- Electronic Patient Management
The Organization -- Patient-centered Medical Home
The Funding -- Capitation with payment for quality outcomes

We believe that capitation will answer the problems of escalation of healthcare costs and that payment for quality outcomes will allow providers to be rewarded for their efforts at transformation. SETMA is confident that healthcare transformation, not reformation, will not be sustainable without these four elements being part of the solution. The following is a link to a description of SETMA’s Model of Care: SETMA's Model of Care Patient-Centered Medical Home: The Future of Healthcare Innovation and Change.

Concierge Medicine and Healthcare Provider Entrepreneurism

Healthcare should be a human right (a quote from Don Berwick). This is another way of expressing Senator Hubert Humphries, Moral Test of Government, which states: "The moral test of government is how it treats those who are in the dawn of life, children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped." A fuller discussion of SETMA’s ideas about entrepreneurism and concierge medicine are found in the following articles:

Mr. Tolbert makes the same mistake that others have in assuming that a personal financial relationship between a healthcare provider and a patient creates a patient-centric dynamic of care. It doesn’t. Here is the contrast.

	Medical Home	Concierge Medicine

Method	Transforming the practice to benefit all patients.	Artificially limiting the size of the practice to benefit the few.

Goal (Unique to the Model of care)	Collaborating with the patient to produce coordinated care	Improving patient convenience

Public Policy	Increasing access to care for all patients	Significantly deceasing or eliminating access to care for 80% of patients

	Deceasing cost of care	Increasing patient cost of care

	Eliminating Ethnic Disparities in care	Probably eliminating ethnic diversity in the practice

Dismissal from practice	No structural reason	Non-payment of franchise fee presumably

Treatment content	Evidenced-based medicine	Evidenced-based medicine

Record System	EHR with electronic patient management tools	EHR unclear how extensive

Transitions of Care	Plan of Care and Treatment Plan with care coordination	Undetermined

Barriers to Care	Evaluated and addressed	Presumably none exist due to patient selection on economic basis

Standards of Care	Published Quality Metrics	Undetermined

Endorsements available	Quality by NCQA, AAAHC, URAC	Corporate by claimed affiliation with Mayo, Cleveland Clinic and others

With a workforce shortage in primary care, MDVIP and Concierge physicians eliminate all but a small percentage of their former patients leaving the other patients without a “medical home.” With only 500 or so patients, all of whom by financial screening are middle or upper class, they tout themselves as the solution to healthcare quality in America. You cannot improve healthcare in American by excluding from your care all of those for whom there are financial barriers to care and/or those who need a great deal of care.
What happens to the others? I would like to see the following on MDVIP’s patient population:

Ethnic distribution of those whom they keep in their practice and of those whom they discharged from their practices.
Socio-economic distribution of those whom they keep in their practice and the same information for those whom they discharged from their practice.
The mean and standard deviation of the HCC/RxHCC coefficient aggregates for their patient populations which they keep in their concierge practice and the same information for those whom they discharged from their practice.
The education, gender, age and primary language of their population which they keep in their practices and the same for those whom they eliminated from their practices.
The number of patients dismissed from the MDVIP practice who could not find a new physician.

The following are public records of SETMA’s patient population and performance::

Public Reporting - Reporting by Type -- public reporting by provider name of provider performance on over 300 quality metrics including HEDIS for 2009-2013.
EPM Tools - HCC/RxHCC Risk Tutorial -- patient HCC/RXHCC coefficient aggregate showing the chronicity and severity of illness of patients seen by SETMA.
Being Accountable For Good Preventive Care -- an article published by SETMA on good preventive care in a diverse population of over 40,000 patients.

SETMA’s data is based on all patients no matter whether they are insured or not, well educate or not, have adequate resources for their healthcare or not. When SETMA decided to become a Patient-Centered Medical Home in 2009, we did not exclude our sick patients. We included everyone and determined to improve the help of all patients. Rather than charge patients a premium to be a part of SETMA, the partners of SETMA founded The SETMA Foundation. When it is necessary for the patient to get care, we pay for our patients’ medications, transportation, surgeries, dental care, etc, as well as treat them at no charge at SETMA.

The greatest fraud of concierge medicine is the pretense of being patient-centric. The problem is they are patient-centric only for the patients left after they impose a tax on being a part of the concierge practice and after abandoning patients unable or unwilling to pay the tax, many of whom they have cared for years, because they could not or would not pay the tax. They contrasting of concierge medicine and medical home above indicates why NCQA, AAAHC, URAC and the Joint commission should not allow concierge practices to apply for PC-MH recognition or certification. If these organizations allow concierge practices to receive their approval, they will have abandoned any moral imperative they have as accrediting bodies. There is nothing in the mission of medical home, in the Triple Aim or in ACOs which allows for the exclusion of people who cannot afford a financial premium upon their care or for the exclusion of those who have complex, chronic health conditions. In addition if the Agency for Healthcare Quality and Research tacitly embraces concierge medicine as they currently do by listing one of the above two articles as “articles of interest,” they will do a disservice to the advancement of quality medicine.

SETMA received the following:

“The plaque arrived on April 23, 2013 and read: ‘Texas Physician Practice Award presented to Southeast Texas Medical Associates, LLP for Providing Exceptional Preventive Health Care Services using Health Information Technology.’ Awarded by The Texas Physician Practice Quality Improvement Award Committee, the committed is made up of the TMF Health Quality Institute (Texas’ CMS Quality Improvement Organization), the Texas Medical Association and the Texas Osteopathic Medical Association. Because our Nurse Practitioners are also included in the award, SETMA has recommended expanding the sponsoring organizations to include the Texas Nurses Association. The Committee commented further, ‘Congratulations on this significant accomplishment, which illustrates your commitment to delivering quality care to all patients. Your award demonstrates that SETMA has an exceptional team.’ ‘Quality care to all patients’ is one of the major goals of healthcare reform and one of the foundational principles of an ACO. This award is also an affirmation of SETMA’s decision in 2000 to begin tracking quality metrics performance and our 2009 decision to begin public reporting of performance by provider name. The results are now posted on SETMA’s website www.jameslhollymd.com under Pubic Reporting for 2009-2013.”

The above referenced concierge articles notes the following conclusion, “..the results from this retrospective chart review support our belief that the MDVIP primary care model providess (sic) more of the recommended preventive care services when compared to national health plans and delivers possibly better clinical outcomes. Further research is necessary to demonstrate that this personalized, preventive care model and increased physician contact time results in better health outcomes and ultimately lower healthcare costs.” The only thing the MDVIP journal’s data proves is that it is possible to select a subset of your patients for evaluation and prove that that subset has better preventive care than the whole. Unfortunately for SETMA is that we do not select a subset of patients but we audit all patients. Still the CMS study of SETMA’s care of Fee-for-service Medicare beneficiaries by RTI international proved that SETMA’s outcomes, coordination and costs were superior to similar practices. See Medical Home Feedback Report for SETMA II October 2011.pdf

Conclusion

Payment models need to be changed which pay primary care for the unique services they perform. However, the creating of a direct financial relationship between provider and patient which relationship is dependent upon the patient’s ability to pay a fee is not the solution to primary care providers being underpaid.

These problems acknowledged by this discuss are not solved, but the dialogue is good.

James (Larry) Holly, M.D.
C.E.O. SETMA
www.jameslhollymd.com

Adjunct Professor
Family & Community Medicine
University of Texas Health Science Center
San Antonio School of Medicine

Clinical Associate Professor
Department of Internal Medicine
School of Medicine
Texas A&M Health Science Center

Related Letters

	Alex Tolbert’s Reply to Dr. Holly's Response to Top Three Obstacles to Better Primary Medical Home News Barbara Turner, MD Response to Dr. Holly's Critique of Alex Tolbert's Top Three Obstacles to Better Primary Care Medical Home News Dr. Marvin Forland Response to Dr. Holly's Critique of Alex Tolbert's Top Three Obstacles to Better Primary Care Medical Home News Dr. Ronald Palang Response to Dr. Holly's Critique of Alex Tolbert's Top Three Obstacles to Better Primary Care Medical Home News July, 2013 Alex Tolbert’s Top Three Obstacles to Better Primary Care Response by YAI Chief of Mental Health Services NYC, NY July 3, 2013 to Dr. Holly’s Critique of Top Three Obstacles to Better Primary Care The Failure of Medicare and Market Forces The Flaw in Subscription Healthcare, James L. Holly, MD, Medical Home News, August, 2013 Tolbert's July 17th Response and Question to Dr. Holly

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