“DELIVERING VALUE-BASED TRANSFORMATION IN PRIMARY CARE”-Government incentive, Solution by title, Deception between the lines…!

Healthcare in America is in turmoil. Medical practice is taking another turn on a steep winding road paved with the political cobblestone by the hands of bureaucrats who repeatedly fail to see the concept of health and the healthcare as they flounder to comprehend the rationale of the 21st-century medical practice. Bureaucrats take shortcuts without appreciating the established solutions at their fingertips, as they even use buzzword like “patient empowerment” in the title of their citations when the entire paragraph under fails to describe its virtue.

Within the context of current healthcare solutions, there seems to be a significant discrepancy between what is cause and effect, hence overwhelming the physician community when ought to reward them. Or, it jeopardizes the quality of care, when the true objective is maximizing values. Imbalanced mandates increase the unnecessary burden despite shouting out the ambiguous slogan “patient and physician empowerment”. Political solutions pose the mission to drive for value-based reimbursement models at the outlay of pushbacks to devalue the physician's role, while wasting Medicare funds in between, such as Comprehensive Outpatient Rehabilitation Facilities (CORF), and federally qualified health center solution (FQHC).

The healthcare turmoil is on murky water of those on the fishing trip of profiteering, monopoly, and chaos of what the role of a physician is!

Within the terms of the proposed policy expanding the scope of the physician practice under the title of primary care means opening the door to hidden political agenda by reducing costs for the establishment at the expense of the individual physician weigh down.

On April 22nd, 2019 U.S. Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) under the respective leaderships of Secretary Alex Azar and Administrator Seema Verma announced a joint initiative. The citation outlines a fresh set of payment models by the department of HHS that would “transform primary care” to deliver “better value” for patients throughout the healthcare system“. Accordingly, “The new models would represent the biggest step ever taken by the administrations toward vision of primary care focused healthcare delivery with the patient-centered approach”.

My take:

1.    The citation has the inclination to Profile physician, nurse practitioners, internists, gynecologists based on a distinctly profiled assignment (primary care) irrespective of their independent skills and qualifications.

2.    It assigns a non-clinical representation of Primary care as a subspecialty where in fact is nothing but particularization responsibility.

3.    It infers lean value-based billing practice is, in fact, the quality medical practice

4.    It’s the rationale of quality care and value of service is not only vague but also irrelevant.

5.    It promotes the selective lower administrative burden as the reward in compensation for increased end value of rendered collective care

6.    The proposal assumes Empowering primary care practice is as equitable as empowering the physician within a particular system.

7.    It focuses on defined patient Empowerment with utter disregard of physician commitment.

8.    The policy is portraying chronic complex medical problems under the spectrum of general medical practice.

9.    It blunders to describe the veracious definition of quality and value of delivered medical service.

10.  It fails to observe the individual determinants of the quality and value in lone patient care.

Let’s expand

Prior to reaching the end of the statement, there was an element to the content of HHS report that worth the mention, i.e. the matter of “primary care”. Between the lines, as I was reading through the content, the notion of “Primary care” appeared as being merely about the “practice of primary care” as there was no reference made to a subject that would make me be certain of that the physician interest in any shape or form was to be ascribed.

This illustrates in fact, the choice of words can be quite deceiving to the public eye, hence confusing to the medical community. Yet, let’s go over definitions before we dive into the details!

What is primary care?

In general, Primary care medical practice contributes to the day-to-day medical care provided by a physician or an alternate specialty. Under the managed care health delivery system physician providing this care acts as the first contact and principal point of continuing to care for the patient within the organization and coordinates patient care with another specialist. This is by far the most realistic definition of the primary care medicine and primary care physician. The recent definitions have been frequently swayed in many ways. Under Primary care delivery protocols, Patients receive medical care from a general internist or family practice physician, a nurse practitioner adult Obstetrics & Gynecology nurse practitioner, family nurse practitioner, or pediatric nurse practitioner, or a physician assistant.

What are value and quality?

Value, quality of medical care and value-based reimbursement has been among the most recent buzzwords of healthcare dialogues. It has been used by the current secretary of the health and human services “Alex Azar” and administrator of the Center for Medicare and Medicaid services “Seema Verma” quite often in the aforementioned report.

I have outlines the significance of the quality and value of delivered medical care in my past articles. The Value, quality, and value-based reimbursement are the subject of an eccentric political controversy, but one could realistically elucidate healthcare quality as the approval and appropriation of care that matches the patient and the physician’s point of view based on their abilities given the available options at any specific point of time, and The value of healthcare is the measure of quality of the medical service furnished to the patient by the physician solely stand on their unique mutual association by taking into consideration every aspect of the individual patients determinants, together within the social, emotional, physical, financial, environmental, familial, genetic, mental, ideological and personal.

Payment model or the terms by which a physician is compensated for his or her contribution to the well-being of the particular patient is thus solely based on those divulged qualities, and values hence called value-based reimbursement.

The subjects of quality and value have become to some degree the subject of contention. Even though, intriguing, nonetheless intrinsic interpretation and the enticements of the quality and values handed-down by the system have weakened its mitigation. Let’s linger by emphasizing, quality in medicine is a subjective attribute, therefore by utilizing a limited knowledge-based approach that in turn exploits the inflexible selected objective determinants and excluding subjective perception of a particular medical visit will deter the unadulterated explication of the quality, hence stirring the value of the care delivered, which may or may not be admissible to patient or the tending physician.

The empowering physician must be on the assumption mobilizing them with the necessary tools, resources, strategies and initiatives that are consistent with his or her distinct professional and personal vision as well as mission. This crafts a medium that will help funnel the unrivaled of the physician’s qualification to the patient, hence expanding the quality and value of the medical care. Empowering the patient is to provide the means through education, personalization, autonomy, and choice to build a stronger bond with the physician.

The Center for Medicare and Medicaid Innovation Center is an organization based on the vision that allows the Medicare and Medicaid programs to test models that improve care, lower costs, and better align payment systems to support patient-centered practices, which has been the focus of discussion as described under “DELIVERING VALUE-BASED TRANSFORMATION IN PRIMARY CARE”

The CMS Primary Cares Initiative to Empower Patients and Providers to Drive Better Value and Results

The notion of empowerment in this piece deserves close acknowledgment. Therefore, as we reach the inference, we will be able to understand what the CMS citation is implying to!

My subjective impression- within the context of admin’s decision the patient and physician empowerment fits more in the definition of “motivation” than empowerment in which government provisions the incitement of the practice in general vs. primary physician as the “sole provider”. In its plan governed through the Centers for Medicare & Medicaid Services (CMS) Innovation Center, the CMS Primary Cares Initiative claimed it would offer primary care practices and other providers with five new payment model options under two paths hence, Primary Care First and Direct Contracting.

The big picture!

Although promising, then again the considerable segment of this solution is worth shedding light on, as we will be able to see clearly as to how the solution fails to discuss the issues of physician burnout and the value of physician service delivered.

The main focus of this overture is about fostering incentives that will increase the scope of the primary care practice responsibilities under the contingency of increase reimbursement and or reduced administrative workload, which reflects the fact that under this scenario physician or healthcare provider is subordinate to the “primary care practice”. It will empower the medical practice and reimbursement but burden the physician.

The Role of the HHS and CMS as the governing branches of the U.S. healthcare system is to enhance the health and well-being of the Americans, by providing effective health and human services and by fostering sound, sustained advances in the sciences' underlying medicine, public health, and social services as well as providing coverage through reimbursement programs that are funded by citizens and federally managed. The scope of administrative oversight is to preserve patient sovereignty and sound physician clinical judgment. but, in contrary, what we experience are the transformed administrative mantle into the overzealous micromanagement which has been shaped into an inflexible mandates, arm twisting protocols and a redefined vague version of what is called optimal quality of medical care, or how much a physician's time is worth or what is the patient's allowable treatment time and cost for a specific medical visit.

Incentivizing the physician practices without allocating for the necessary logistics, policies and the contraption to enhance their journey would be inevitably counterproductive. Promoting quality must also parallel preventing physician burnout.

Between the lines

On the memo, the administrations have proposed two payment model options under Primary Care:

1.    Primary Care First (PCF) which is for General population

2.     Primary Care First – High Need Populations.

The three payment model options under Direct Contracting which include:

1.    Direct Contracting (DC) – Global

2.    Direct Contracting – Professional 3. Direct Contracting – Geographic

“As it is stated within the frame of reference, “Primary care is central to the high-functioning health care system and thus, an urgent need to preserve and strengthen primary care as well as a need for support of complex, chronic, and serious illness care services for Medicare beneficiaries. PCF also addresses these needs by creating a seamless continuum of care and as a result, accommodating a continuum of interested providers at many stages of readiness to assume accountability for patient outcomes”.

With reference to above recite, it’s domineering to point out to the value of the physician's independent contribution within its unique context, as every physician's aptitude and adeptness is unique in its own modus operandi regardless of their affiliation to a specific specialty. The department of HHS along with CMS is on the fast track to implementing policies that devalue the role of Internists, family physicians, and other specialties, by painting their responsibility under the bureaucratic umbrella of primary care medicine. By redefining physician's contributes to healthcare, the administration has established a swamp that rewards the participating “practices” if in fact doctors work harder and see more debilitated patients in order to be supplementary reimbursement, something that is lawfully theirs, to begin with!

The denomination of primary care is not the representation of a physician's skill or specialty, in fact, is the functional dub given by the healthcare administration architects to rationalize devaluing and over utilizing a class of physicians who otherwise prefer to treat common diseases with common treatment options.

The CMS’s claims of the scope of primary care practice by no means imply to “supporting complex, chronic, and serious illnesses”. In fact, the idea of primary care is a politically sustained terminology which makes particular medical disciplines equal and junkyard for the insurance companies and managed care Systems as an alternative route to save money.

“In Primary Care First Payment Model choice, CMS tests, whether delivery of progressive primary care can reduce total cost of care and focuses on foremost primary care practices ready to assume the financial risk in exchange for reduced administrative burden and performance-based payments. The PCF model choice also introduces new, higher payments for practices that care for complex, chronically ill patients”-HHS

The issues with the above statement:

First- the criteria’s and determinants of the quality which motivates HHS to make physicians of selected backgrounds function as primary doctors are very vague. It sways an impression as the administration stipulates that it would be more costly to utilize physicians whose skills are more in line with the complexity of the diseases. The policy as an alternative transfers the responsibility to the physician groups who have a wider scope of practice but care for patients with less complex problems. Does it mean under such circumstances they have to follow a certain protocol written by in the administration, resulting in further loss of independence?! Or is it a hypothetical presumption?!

Second- what makes the administrative workload any less, as I fail to appreciate the logic behind, more workload would translate into fewer administrative labor.

Third- What determines the quality of performance?

Fourth- it is a controversial assumption that would undoubtedly raise the red flag to any reader.

“Primary Care First – High Need Populations Payment Model choice is ought to encourage primary care practices, including practices whose clinicians are enrolled in Medicare and typically provide hospice or palliative care services, to take responsibility for high need, seriously ill beneficiaries who now lack a primary care practitioner and/or effective care coordination”-HHS

Those physicians who have taken care of the “gravely Ill” population would concur, caring for those patients is time-consuming and resource dependent. Application of such an overwhelming responsibility, and clinical workload through expansion of the scope of primary care practice and advocating attendance for more complex issues under the presumption that it would reduce costs, is not only subject to slip but also penalizes the physicians with a new set of burdens, as such policy will (if any practical) shift the workload from administrative to clinical.

“Direct Contracting (DC) is defined as a set of three voluntary payment model options aimed at reducing expenditures and preserving or enhancing the quality of care for beneficiaries in Medicare fee-for-service (FFS)” -HHS

It is out of the scope of this discussion to cover the details of the HHS report. yet, the point of the article clearly outlines the Administration's mission to make the participating physician practices the wastebasket for mandates by subjecting them to experimentation for the quality care that is determined by bureaucrats in exchange for a reimbursement that is physician's well-earned right in the first place.

This policy is the healthcare version of the federal tax policy and tax break were depending on selected criteria and meaningful action physicians earned values are repaid according to predefined incentives. It represents the kind of policies that the citizen must work even harder in order to be rewarded by partial refund of their own money.

“As we seek to unleash innovation in our healthcare system, we recognize that the road to value must have as many lanes as possible,”- Administrator Seema Verma

I respectfully disagree with administrator Seema Varma’s comment- Innovation is supposed to improve quality of life and drive its users competitive, but not serve as the segregating factor through shortcuts at the expense of doctors who authentically believe in the Hippocratic oath, in contrary to some other disciplines whom form unions and establish political affiliation with the mission to protect their financial interest. Physicians lay down patient interest ahead of their own. Innovation is ought to offer the necessary tools compatible to use case of physician and the patient, primarily focusing on improving patient care and clinical outcome. A medical Practice neither equates to billing practice and reimbursement nor relates to the execution of efficient ICD-10 coding practice.

The concept of “DELIVERING VALUE-BASED TRANSFORMATION IN PRIMARY CARE by CMS” is nothing but interference with physicians clinical judgment, doctor-patient relationship and most of all the individual right.

Patient empowerment cannot be without physician empowerment

“Empirical evidence shows that strengthening primary care is associated with higher quality, better outcomes, and lower costs within and across major population subgroups. Despite this evidence, primary care spending accounts for a small part of the total cost of care, and is even lower for patients with complex, chronic conditions” – HHS report Quotes

With the assumption that strengthening the primary care can be achieved at a fraction of the cost, is recalling the transfer of the bulk of the workload to the individual physician. Even though the costs may be low but absolute values must raise parallel to the mounting quality and efforts in the delivery of care.

If we assume primary care service signifying a project, we should be able to apply the Project Management Triangle, which outlines that the quality of medical service is constrained by the project's budget, deadlines, and scope. Changes in one constraint need changes in others to compensate, or quality will suffer. The typical person managing the deliverable has to trade between the three constraints, yet physicians due to the nature of their profession typically struggle to upkeep the balance of constraints to support quality by absorbing the limitations.

The unilateral patient empowerment with the top-down strategic methodology to quality assurance would inherently turn a blind eye on the significance of the physician contribution to patient care. A fruitful stratagem will have to integrate empowering and easing up the burden on the individual physician.

The narrative of the editorial controverts what frontrunners of the two branches of the healthcare administrations are trying to convey in their heading about how and what government contributes to the solution.

Nobel Prize-winning economist- Milton Friedman once wrote:

“Medical price inflation since 1965 has been caused by the rising demand for health-care coupled with restricted supply (Friedman 1992)”

Robert Alford explained in 1975 the minority as:

 "The market reformers wish to preserve the control of the individual physician over his practice, over the hospital, and over his fees, and they wish to open up the medical schools to meet the demand for doctors, to give patients more choice among doctors, clinics, and hospitals, and to make that choice a real one by public subsidies for medical bills"

The majority of policymakers support either monopolization and /or nationalization by trying to convince the citizens through populist oratory that physician supply can create its own demand, which means increasing the supply of doctors and hospitals will motivate them to convince passive consumers to order more unnecessary and expensive tests.

Assumption of primary physicians' shortage within a certain geographic location for the perseverance of particular medical problem and implementing a firm legislative action, through bureaucratic mandates and encouragement-based reimbursement models will not only result in Direct and /or indirect interference with the clinical judgment but also will further overthrow the physician practice. Be that as it may, adversely contribute to be the already shaky medical specialties and services distribution.

Quality and government involvement

Quality of care is an independent outcome of medical service delivered at the grass root of the healthcare delivery system, thus the clinic encounter. In contrast, Quality of care delivered through the administrative-bureaucratic top-down procedures is destined to neglect certain values that are inherent to that particular individual medical encounter.

Any such policies or solutions comparable to what is being offered under the DELIVERING VALUE-BASED TRANSFORMATION, whether through negotiation or rigid mandates with private clinics about quality of patient care is flawed and is destined to interfere with the physician's clinical judgment and sidetracking the standard of medical care. Government’s dive into elements of medical practice will leave out the most vital healthcare issues unaddressed.

Value is indeed unique and personal, where Individual determinants of quality are it’s the fundamental influencers. The valid social determinants of quality care are those within the immediate perimeter round of every individual.

Motivating is not Empowerment

Logistics, Technology, strategy and collaborative effort are vital to lowering costs while upholding the quality and efficiency. It is every administration's duty to circumvent dictating the practice of medicine, as is simpler, cheaper, Safer, worthier to support the personalization of the medical practice, in the path to create a healthcare without borders devoid of bureaucracy and micro management.