when wood is king-- a ruler for my kingdom!

[Guest guest]

i sent this earlier today, but it never got there.i like that-- if we can't measure it, it doesn't exist.better yet, if it doesn't exist, we don't have to pay for it.even better, we determine what can and will be measured, and how to do so, so we'll never have to pay you.no wonder patients make their lexus payment before their deductible, they make this same calculation, and have discovered that we're priceless, i mean, worthless!mark my words, this is precisely the slippery slope of p4p. it will only be used to reduce our pay.thank you, ben, for helping to clarify this, it had really been bugging me, and now i know what to do-- it's time to get out of medicine, and into the measurement of it!on a more serious note, if we really are to be paid more, then we must clearly demonstrate our value and worth.if the "how's your health" indices are validated (are they based on the sf-36 quality of life index?), and if one

concurrently measured and therefore related various metrics, eg hba1c, peak flows, with "how's your health"/sf-36 quality of life index in general, for diabetes, asthma, ie, a validated combination of various metrics and one's perception of one's health and care, both in general and wrt to various disease states, that is something which could be worth a lot, and could clearly demonstrate the value of IMP-style practice. the metric data would/could be readily available with emr's with patient registries.we could become new-fangled bean counters; we could elevate bean counting to a whole new level!LLLLBen Brewer I

rather liked the $2 medical home piece, but I appreciate your comments. The total cost of providing a medical home and all associated visits emails and whatnot is obviously higher than $2-3 per person per month, but what would be a reasonable figure? $15? $25-30?Whatever your price point might be I would suggest it would probably seem low to those paying multiple hundreds in premiums for insurance. The bottom line in my opinion is that good primary care is not as expensive as many people have been led to believe. We are separated economically from the value we create. I wholeheartedly agree.Redefining Healthcare, a book by some Harvard

gurus (http://www.hbs. edu/rhc/index. html) talks quite a bit about the value cycle in healthcare and how the value created by primary care is largely invisible and difficult to account for. Their answer seems to be that we should measure many, many things like a factory does to prove our contribution to the value cycle. To do this would require the hospitals and our colleagues to price the global cost of care for each episode and agree amongst ourselves how we would split it based on performance metrics. Much of what they discussed seems logistically very, very difficult. It seems geared very much toward the pervasive idea that bigger healthcare entities are better because they have better metrics. What is the value of timely intervention for the patients Lawrence mentions, or the patient with critical CAD saved by recognition of some vague symptoms and timely evaluation? A heck of a lot more than a level 3 office visit, but proving is going to take some serious effort.The reality is we're saving people major trouble all the time but we're going to be judged on what our patient's A1c levels rather than how many dollars we saved the system. As long as we're stuck at the minutiae level of A1c measurement as a surrogate of our abilities instead of our total contribution to the patient's care we'll be struggling over the scraps of the healthcare dollar.One the preauthorization theme - I did do a piece on being rejected for Lantus insulin by Illinois Medicaid about 2 years ago. Ben Brewer M.D.

Looking for last minute shopping deals? Find them fast with Yahoo! Search.

[Guest guest]

We must question if what we're measuring really has any value.  For instance, here is the link to HEDIS data core quality measures on my practice as well as several others.  http://www.musc.edu/PPRNet/AQA/AQAMeasures.htm I think this is the first time that any practice has published their HEDIS data to the general public based on actual internally generated practice data.  One reaction I have after working with this for awhile is - Who Cares?  Down the line, I fear a never ending cycle of measuring more for the same pay.  I fear as soon as you emphasize one thing then they'll move the target and something you're not measuring will suffer.  This would be most helpful

to me if I was an employer of doctors at a big institution or a manager of an insurance network.  I would get doctors to compete on the measures and give me an objective way to say if they got a pay raise or not.None of these measurements would intuitively lead anyone to think we should pay doctors more.  Getting a good percentage on these P4P measures reflects a good system to capture documentation.  Even with a good emr, it under reports my efforts at getting people to quit smoking.  It gives no idea to anyone how many dollars I've saved (or cost) the system.  No insurance company wants to measure dollars saved by primary care because they'd have to triple our pay.  Instead they'll find ways to ding me if i didn't document the care I gave efficiently enough.It looks like I'll have to change my workflow to document differently if I want to buff up my numbers.  All this actually takes away from caring for people, returning some phone calls or email or reviewing lab results... and so on.  My patients don't really care about the metrics.  They know that I'll help them when they call and I know they'll generally pay the bill.  As a practical matter for a small practice that's enough and probably will be for the next 20 years of my career.Right now I'm doing this out of curiosity.  To write about the experience and find the trouble spots.The collection of this practice generated data was made possible by my investing heavily in my EMR, participating in a research project on colon cancer through PPRNET (a research network) and convincing

others that posting this data might be an interesting thing.Ben Brewer M.D.  a validated combination of various metrics and one's perception of one's health and care, both in general and wrt to various disease states, that is something which could be worth a lot, and could clearly demonstrate the value of IMP-style practice.  the metric data would/could be readily available with emr's with patient registries.we could become new-fangled bean counters; we could elevate bean counting to a whole new level!LLLL

Looking for last minute shopping deals? Find them fast with Yahoo! Search.

[Guest guest]

ok, so do we not measure anything?if that's the case, we cannot establish the value of what we do.no wonder the lexus payment comes before us, if we don't declare our value and others don't see our value, the lexus payment will continue to be paid before we do.i agree it's a shell game wrt payment to us by insurance companies, but that's only because they look at the dollars.the hedis data does look boring; i would go further, and ask, for each of these screenings, how many colon cancers, how many breast cancers were found at an early stage, thereby preventing morbidity and mortality, not to mention health care costs, loss of wages, loss of life, lost productivity, even insurance costs.let's connect the dots.i return to my original questions--is there any value in what we do?if there is, what is it?if we know what it is, let's clearly identify it, and see if it has value to others, to the extent that another would pay for it.if we

can't do the above, we've got a gigantic problem.no wonder patients angrily complain of "well, the doctor only spent five minutes with me".LLLLBen Brewer wrote: We must question if what we're measuring really has any value. For instance, here is the link to HEDIS data core quality measures on my practice as well as several others. http://www.musc.edu/PPRNet/AQA/AQAMeasures.htm I think this is the first time that any practice has published their HEDIS data to the general public based on actual internally generated practice data. One reaction I have after working

with this for awhile is - Who Cares? Down the line, I fear a never ending cycle of measuring more for the same pay. I fear as soon as you emphasize one thing then they'll move the target and something you're not measuring will suffer. This would be most helpful to me if I was an employer of doctors at a big institution or a manager of an insurance network. I would get doctors to compete on the measures and give me an objective way to say if they got a pay raise or not.None of these measurements would intuitively lead anyone to think we should pay doctors more. Getting

a good percentage on these P4P measures reflects a good system to capture documentation. Even with a good emr, it under reports my efforts at getting people to quit smoking. It gives no idea to anyone how many dollars I've saved (or cost) the system. No insurance company wants to measure dollars saved by primary care because they'd have to triple our pay. Instead they'll find ways to ding me if i didn't document the care I gave efficiently enough.It looks like I'll have to change my workflow to

document differently if I want to buff up my numbers. All this actually takes away from caring for people, returning some phone calls or email or reviewing lab results... and so on. My patients don't really care about the metrics. They know that I'll help them when they call and I know they'll generally pay the bill. As a practical matter for a small practice that's enough and probably will be for the next 20 years of my career.Right now I'm doing this out of curiosity. To write about the experience and find the trouble spots.The collection of this practice generated data was made possible by my investing heavily in my EMR, participating in a research project on colon cancer through PPRNET (a research network) and convincing others that posting this data might be an interesting thing.Ben Brewer M.D. a validated combination of various metrics and one's perception of one's health and care, both in general and wrt to various disease states, that is something which could be worth a lot, and could clearly demonstrate the value of IMP-style practice. the metric data would/could be readily available with emr's with patient registries.we could become new-fangled bean counters; we could elevate bean counting to a whole new level!LLLL Looking for last minute shopping deals? Find them fast with Yahoo! Search.

Never miss a thing. Make Yahoo your homepage.

[Guest guest]

That primary care can be judged on a hodgepodge of specific clinical

indicators is fundamentally flawed.

This keyhole peek into the medical home we create for our patients is a

poor representation of what we do to make that home a place where the

population we serve has a good experience of care and achieves the best

possible outcomes. Forcing us to drill holes through our walls to

create multiple peeks to me is just further absurdity that as Ben points

out actually degrades the value of our homes.

The parade of supporters behind this approach is wide, long, and loud,

but they are heading down the wrong road.

We can demonstrate the work we do in creating homes that give our

patients and excellent experience of care and clinical outcomes.

Validated patient-reported outcome measures help us here. Their

aggregate experience of care accurately represents our ability to

eliminate barriers to care through improved access, office efficiency,

continuity, how well we do in giving our patients the information they

need to manage their conditions, how good we are a helping them manage

their conditions (self-efficacy, a.k.a. " confidence " ).

Measuring A1c and pneumococcal vaccine administration is important to us

as we care for our patients. We need tools to find patients who

fail to follow through (reminder systems). Judge me on the presence

or absence of a reminder system. Judge me on how well I've

eliminated barriers to access, on how often my practice wastes patient

time (thus creating a barrier to follow through), on continuity.

These are fundamental qualities of the practice regardless of the

population served. These are qualities I control and for which I

can and should be held accountable. When the practice solves these

problems and can engage in patient-centered collaborative care, the

outcomes are much better. The improved experience of care means

that the patients want to contact us first - they see us as their medical

home. They are more likely to follow through on preventive care and

chronic conditions - so the population outcomes improve.

The IMPs are doing this work and find terrific professional satisfaction

in doing so. The efforts involved in data gathering and aggregation

and comparison are practically zilch - not the heavy lifting of HEDIS

minutia. With all the talk about funding medical homes, we're

eagerly anticipating the financial recognition that might even make

primary care a positive career choice again.

Gordon

At 11:18 AM 3/28/2008, you wrote:

We must question if what we're

measuring really has any value. For instance, here is the link to

HEDIS data core quality measures on my practice as well as several

others.

http://www.musc.edu/PPRNet/AQA/AQAMeasures.htm

I think this is the first time that any practice has published their

HEDIS data to the general public based on actual internally generated

practice data. One reaction I have after working with this for

awhile is - Who Cares? Down the line, I fear a never ending cycle

of measuring more for the same pay.

I fear as soon as you emphasize one thing then they'll move the target

and something you're not measuring will suffer. This would be most

helpful to me if I was an employer of doctors at a big institution or a

manager of an insurance network. I would get doctors to compete on

the measures and give me an objective way to say if they got a pay raise

or not.

None of these measurements would intuitively lead anyone to think we

should pay doctors more. Getting a good percentage on these P4P

measures reflects a good system to capture documentation. Even with

a good emr, it under reports my efforts at getting people to quit

smoking.

It gives no idea to anyone how many dollars I've saved (or cost) the

system.

No insurance company wants to measure dollars saved by primary care

because they'd have to triple our pay. Instead they'll find ways to

ding me if i didn't document the care I gave efficiently enough.

It looks like I'll have to change my workflow to document differently if

I want to buff up my numbers. All this actually takes away from

caring for people, returning some phone calls or email or reviewing lab

results... and so on. My patients don't really care about the

metrics. They know that I'll help them when they call and I know

they'll generally pay the bill. As a practical matter for a small

practice that's enough and probably will be for the next 20 years of my

career.

Right now I'm doing this out of curiosity. To write about the

experience and find the trouble spots.

The collection of this practice generated data was made possible by my

investing heavily in my EMR, participating in a research project on colon

cancer through PPRNET (a research network) and convincing others that

posting this data might be an interesting thing.

Ben Brewer M.D.

a validated combination of various metrics and one's perception of

one's health and care, both in general and wrt to various disease states,

that is something which could be worth a lot, and could clearly

demonstrate the value of IMP-style practice. the metric data

would/could be readily available with emr's with patient registries.

we could become new-fangled bean counters; we could elevate bean counting

to a whole new level!

LLLL

Looking for last minute shopping deals?

Find them fast with Yahoo! Search.

[Guest guest]

Gordon,

Sorry for my lack of memory here, but has

there been an article in Family Practice Management about this issue—why

P4P will not work—and the flip side-- what will work? It would be nice to

see your comments written down in an arena where all primary care docs can see

it. I think currently we have a lot of lemmings who don’t want to be left

behind, so they are following the herd. It would be nice to formally challenge

the process before we all end up heading off the cliff.

Re:

when wood is king-- a ruler for my kingdom!

That primary care can be judged on a hodgepodge of specific clinical

indicators is fundamentally flawed.

This keyhole peek into the medical home we create for our patients is a poor

representation of what we do to make that home a place where the population we

serve has a good experience of care and achieves the best possible

outcomes. Forcing us to drill holes through our walls to create multiple

peeks to me is just further absurdity that as Ben points out actually degrades

the value of our homes.

The parade of supporters behind this approach is wide, long, and loud, but they

are heading down the wrong road.

We can demonstrate the work we do in creating homes that give our patients and

excellent experience of care and clinical outcomes. Validated patient-reported

outcome measures help us here. Their aggregate experience of care

accurately represents our ability to eliminate barriers to care through

improved access, office efficiency, continuity, how well we do in giving our

patients the information they need to manage their conditions, how good we are

a helping them manage their conditions (self-efficacy, a.k.a.

" confidence " ).

Measuring A1c and pneumococcal vaccine administration is important to us as we

care for our patients. We need tools to find patients who fail to follow

through (reminder systems). Judge me on the presence or absence of a

reminder system. Judge me on how well I've eliminated barriers to access,

on how often my practice wastes patient time (thus creating a barrier to follow

through), on continuity.

These are fundamental qualities of the practice regardless of the population

served. These are qualities I control and for which I can and should be

held accountable. When the practice solves these problems and can engage

in patient-centered collaborative care, the outcomes are much better. The

improved experience of care means that the patients want to contact us first -

they see us as their medical home. They are more likely to follow through

on preventive care and chronic conditions - so the population outcomes improve.

The IMPs are doing this work and find terrific professional satisfaction in

doing so. The efforts involved in data gathering and aggregation and

comparison are practically zilch - not the heavy lifting of HEDIS

minutia. With all the talk about funding medical homes, we're eagerly

anticipating the financial recognition that might even make primary care a

positive career choice again.

Gordon

At 11:18 AM 3/28/2008, you wrote:

We must question if what we're measuring really has

any value. For instance, here is the link to HEDIS data core quality

measures on my practice as well as several others.

http://www.musc.edu/PPRNet/AQA/AQAMeasures.htm

I think this is the first time that any practice has published their HEDIS data

to the general public based on actual internally generated practice data.

One reaction I have after working with this for awhile is - Who Cares?

Down the line, I fear a never ending cycle of measuring more for the same

pay.

I fear as soon as you emphasize one thing then they'll move the target and

something you're not measuring will suffer. This would be most helpful to

me if I was an employer of doctors at a big institution or a manager of an

insurance network. I would get doctors to compete on the measures and

give me an objective way to say if they got a pay raise or not.

None of these measurements would intuitively lead anyone to think we should pay

doctors more. Getting a good percentage on these P4P measures reflects a

good system to capture documentation. Even with a good emr, it under

reports my efforts at getting people to quit smoking.

It gives no idea to anyone how many dollars I've saved (or cost) the system.

No insurance company wants to measure dollars saved by primary care because

they'd have to triple our pay. Instead they'll find ways to ding me if i

didn't document the care I gave efficiently enough.

It looks like I'll have to change my workflow to document differently if I want

to buff up my numbers. All this actually takes away from caring for

people, returning some phone calls or email or reviewing lab results... and so

on. My patients don't really care about the metrics. They know that

I'll help them when they call and I know they'll generally pay the bill.

As a practical matter for a small practice that's enough and probably will be

for the next 20 years of my career.

Right now I'm doing this out of curiosity. To write about the experience

and find the trouble spots.

The collection of this practice generated data was made possible by my

investing heavily in my EMR, participating in a research project on colon

cancer through PPRNET (a research network) and convincing others that posting

this data might be an interesting thing.

Ben Brewer M.D.

a validated combination of various metrics and one's perception of one's

health and care, both in general and wrt to various disease states, that is

something which could be worth a lot, and could clearly demonstrate the value

of IMP-style practice. the metric data would/could be readily available

with emr's with patient registries.

we could become new-fangled bean counters; we could elevate bean counting to a

whole new level!

LLLL

Looking for last minute shopping deals? Find

them fast with Yahoo! Search.

[Guest guest]

Gordon,

I would like to very loudly second 's request.

P4P may drive me back to urgent care, where nobody measures anything but wait times..... I truly feel this will be the straw that breaks this camel's back!

-- Durango, CO

Gordon,

Sorry for my lack of memory here, but has there been an article in Family Practice Management about this issue—why P4P will not work—and the flip side-- what will work? It would be nice to see your comments written down in an arena where all primary care docs can see it. I think currently we have a lot of lemmings who don't want to be left behind, so they are following the herd. It would be nice to formally challenge the process before we all end up heading off the cliff.

Re: when wood is king-- a ruler for my kingdom!

That primary care can be judged on a hodgepodge of specific clinical indicators is fundamentally flawed. This keyhole peek into the medical home we create for our patients is a poor representation of what we do to make that home a place where the population we serve has a good experience of care and achieves the best possible outcomes. Forcing us to drill holes through our walls to create multiple peeks to me is just further absurdity that as Ben points out actually degrades the value of our homes.

The parade of supporters behind this approach is wide, long, and loud, but they are heading down the wrong road. We can demonstrate the work we do in creating homes that give our patients and excellent experience of care and clinical outcomes. Validated patient-reported outcome measures help us here. Their aggregate experience of care accurately represents our ability to eliminate barriers to care through improved access, office efficiency, continuity, how well we do in giving our patients the information they need to manage their conditions, how good we are a helping them manage their conditions (self-efficacy, a.k.a. " confidence " ).

Measuring A1c and pneumococcal vaccine administration is important to us as we care for our patients. We need tools to find patients who fail to follow through (reminder systems). Judge me on the presence or absence of a reminder system. Judge me on how well I've eliminated barriers to access, on how often my practice wastes patient time (thus creating a barrier to follow through), on continuity.

These are fundamental qualities of the practice regardless of the population served. These are qualities I control and for which I can and should be held accountable. When the practice solves these problems and can engage in patient-centered collaborative care, the outcomes are much better. The improved experience of care means that the patients want to contact us first - they see us as their medical home. They are more likely to follow through on preventive care and chronic conditions - so the population outcomes improve.

The IMPs are doing this work and find terrific professional satisfaction in doing so. The efforts involved in data gathering and aggregation and comparison are practically zilch - not the heavy lifting of HEDIS minutia. With all the talk about funding medical homes, we're eagerly anticipating the financial recognition that might even make primary care a positive career choice again.

GordonAt 11:18 AM 3/28/2008, you wrote:

We must question if what we're measuring really has any value. For instance, here is the link to HEDIS data core quality measures on my practice as well as several others.

http://www.musc.edu/PPRNet/AQA/AQAMeasures.htm I think this is the first time that any practice has published their HEDIS data to the general public based on actual internally generated practice data. One reaction I have after working with this for awhile is - Who Cares? Down the line, I fear a never ending cycle of measuring more for the same pay.

I fear as soon as you emphasize one thing then they'll move the target and something you're not measuring will suffer. This would be most helpful to me if I was an employer of doctors at a big institution or a manager of an insurance network. I would get doctors to compete on the measures and give me an objective way to say if they got a pay raise or not.

None of these measurements would intuitively lead anyone to think we should pay doctors more. Getting a good percentage on these P4P measures reflects a good system to capture documentation. Even with a good emr, it under reports my efforts at getting people to quit smoking.

It gives no idea to anyone how many dollars I've saved (or cost) the system. No insurance company wants to measure dollars saved by primary care because they'd have to triple our pay. Instead they'll find ways to ding me if i didn't document the care I gave efficiently enough.

It looks like I'll have to change my workflow to document differently if I want to buff up my numbers. All this actually takes away from caring for people, returning some phone calls or email or reviewing lab results... and so on. My patients don't really care about the metrics. They know that I'll help them when they call and I know they'll generally pay the bill. As a practical matter for a small practice that's enough and probably will be for the next 20 years of my career.

Right now I'm doing this out of curiosity. To write about the experience and find the trouble spots.The collection of this practice generated data was made possible by my investing heavily in my EMR, participating in a research project on colon cancer through PPRNET (a research network) and convincing others that posting this data might be an interesting thing.

Ben Brewer M.D. a validated combination of various metrics and one's perception of one's health and care, both in general and wrt to various disease states, that is something which could be worth a lot, and could clearly demonstrate the value of IMP-style practice. the metric data would/could be readily available with emr's with patient registries.

we could become new-fangled bean counters; we could elevate bean counting to a whole new level!LLLLLooking for last minute shopping deals? Find them fast with Yahoo! Search.

[Guest guest]

Perhaps what we really need is for our professional societies, AAFP, ACP or some other reasonably trusted entity like the Wood Foundation to assemble a team of actuaries, economists and statistics experts working on this value cycle aspect of things. The downward spiraling business model of primary care needs more of our collective attention than Transformed projects, future of family medicine opinion studies, medical home pilot programs and the like. This is an economic modeling problem fit for someone's PhD at least.  We could go through all the complex math of those innumerable variables or, alternatively we could throw off the shackles of the  insurance monopoly and our price fixing government and let the free market and the patients paying the bills decide.  That way, the only metrics we need to worry about are those that guide us in making our patients healthy and happy.Ben Brewer M.D. Re: when wood is king-- a ruler for my kingdom!

ok, so do we not measure anything?if that's the case, we cannot establish the value of what we do.no wonder the lexus payment comes before us, if we don't declare our value and others don't see our value, the lexus payment will continue to be paid before we do.i agree it's a shell game wrt payment to us by insurance companies, but that's only because they look at the dollars.the hedis data does look boring; i would go further, and ask, for each of these screenings, how many colon cancers, how many breast cancers were found at an early stage, thereby preventing morbidity and mortality, not to mention health care costs, loss of wages, loss of life, lost productivity, even insurance costs.let's connect the dots.i return to my original questions--is there any value in what we do?if there is, what is it?if we know what it is, let's clearly identify it, and see if it has value to others, to the extent that

another would pay for it.if we

can't do the above, we've got a gigantic problem.no wonder patients angrily complain of "well, the doctor only spent five minutes with me".LLLLBen Brewer <brewermd98yahoo (DOT) com> wrote: We must question if what we're measuring really has any value.  For instance, here is the link to HEDIS data core quality measures on my practice as well as several others.  http://www.musc. edu/PPRNet/ AQA/AQAMeasures. htm I think this is the first time that any practice has published their HEDIS data to the general public based on actual internally generated practice data.  One reaction I have after working

with this for awhile is - Who Cares?  Down the line, I fear a never ending cycle of measuring more for the same pay.  I fear as soon as you emphasize one thing then they'll move the target and something you're not measuring will suffer.  This would be most helpful to me if I was an employer of doctors at a big institution or a manager of an insurance network.  I would get doctors to compete on the measures and give me an objective way to say if they got a pay raise or not.None of these measurements would intuitively lead anyone to think we should pay doctors more.  Getting

a good percentage on these P4P measures reflects a good system to capture documentation.  Even with a good emr, it under reports my efforts at getting people to quit smoking.  It gives no idea to anyone how many dollars I've saved (or cost) the system.  No insurance company wants to measure dollars saved by primary care because they'd have to triple our pay.  Instead they'll find ways to ding me if i didn't document the care I gave efficiently enough.It looks like I'll have to change my workflow to

document differently if I want to buff up my numbers.  All this actually takes away from caring for people, returning some phone calls or email or reviewing lab results... and so on.  My patients don't really care about the metrics.  They know that I'll help them when they call and I know they'll generally pay the bill.  As a practical matter for a small practice that's enough and probably will be for the next 20 years of my career.Right now I'm doing this out of curiosity.  To write about the experience and find the trouble spots.The collection of this practice generated data was made possible by my investing heavily in my EMR, participating in a research project on colon cancer through PPRNET (a research network) and convincing others that posting this data might be an interesting thing.Ben Brewer M.D.  a validated combination of various metrics and one's perception of one's health and care, both in general and wrt to various disease states, that is something which could be worth a lot, and could clearly demonstrate the value of IMP-style practice.  the metric data would/could be readily available with emr's with patient registries.we could become new-fangled bean counters; we could elevate bean counting to a whole new level!LLLL Looking for last minute shopping deals? Find them fast with Yahoo! Search. Never miss a thing. Make Yahoo your homepage.

Looking for last minute shopping deals? Find them fast with Yahoo! Search.

[Guest guest]

Be

careful Ben. That kind of talk can start a revolution. J

Re:

when wood is king-- a ruler for my kingdom!

Perhaps what we really need is for

our professional societies, AAFP, ACP or some other reasonably trusted entity

like the Wood Foundation to assemble a team of actuaries,

economists and statistics experts working on this value cycle aspect of

things.

The downward spiraling business

model of primary care needs more of our collective attention than Transformed

projects, future of family medicine opinion studies, medical home pilot

programs and the like. This is an economic modeling problem fit for someone's

PhD at least.

We could go through all the complex

math of those innumerable variables or, alternatively we could throw off the

shackles of the insurance monopoly and our price fixing government and

let the free market and the patients paying the bills decide. That way,

the only metrics we need to worry about are those that guide us in making our

patients healthy and happy.

Ben Brewer M.D.

Re: when wood is king-- a ruler for my

kingdom!

ok, so do we not measure anything?

if that's the case, we cannot establish the value of what we do.

no wonder the lexus payment comes before us, if we don't declare our value and

others don't see our value, the lexus payment will continue to be paid before

we do.

i agree it's a shell game wrt payment to us by insurance companies, but that's

only because they look at the dollars.

the hedis data does look boring; i would go further, and ask, for each of these

screenings, how many colon cancers, how many breast cancers were found at an

early stage, thereby preventing morbidity and mortality, not to mention health

care costs, loss of wages, loss of life, lost productivity, even insurance

costs.

let's connect the dots.

i return to my original questions--

is there any value in what we do?

if there is, what is it?

if we know what it is, let's clearly identify it, and see if it has value to others,

to the extent that another would pay for it.

if we can't do the above, we've got a gigantic problem.

no wonder patients angrily complain of " well, the doctor only spent five

minutes with me " .

LLLL

Ben Brewer

<brewermd98yahoo (DOT) com> wrote:

We must question if what we're

measuring really has any value. For instance, here is the link to HEDIS

data core quality measures on my practice as well as several others.

http://www.musc. edu/PPRNet/ AQA/AQAMeasures. htm

I think this is the first time

that any practice has published their HEDIS data to the general public based on

actual internally generated practice data. One reaction I have after

working with this for awhile is - Who Cares? Down the line, I fear a

never ending cycle of measuring more for the same pay.

I fear as soon as you emphasize one

thing then they'll move the target and something you're not measuring will

suffer. This would be most helpful to me if I was an employer of doctors

at a big institution or a manager of an insurance network. I would get

doctors to compete on the measures and give me an objective way to say if they

got a pay raise or not.

None of these measurements would

intuitively lead anyone to think we should pay doctors more. Getting a

good percentage on these P4P measures reflects a good system to capture

documentation. Even with a good emr, it under reports my efforts at

getting people to quit smoking.

It gives no idea to anyone how many

dollars I've saved (or cost) the system.

No insurance company wants to

measure dollars saved by primary care because they'd have to triple our pay.

Instead they'll find ways to ding me if i didn't document the care I gave

efficiently enough.

It looks like I'll have to change my

workflow to document differently if I want to buff up my numbers. All

this actually takes away from caring for people, returning some phone calls or

email or reviewing lab results... and so on. My patients don't really care

about the metrics. They know that I'll help them when they call and I

know they'll generally pay the bill. As a practical matter for a small

practice that's enough and probably will be for the next 20 years of my career.

Right now I'm doing this out of

curiosity. To write about the experience and find the trouble spots.

The collection of this practice

generated data was made possible by my investing heavily in my EMR,

participating in a research project on colon cancer through PPRNET (a research

network) and convincing others that posting this data might be an interesting

thing.

Ben Brewer M.D.

a validated combination of various metrics and

one's perception of one's health and care, both in general and wrt to various

disease states, that is something which could be worth a lot, and could clearly

demonstrate the value of IMP-style practice. the metric data would/could

be readily available with emr's with patient registries.

we could become new-fangled bean counters; we could elevate bean counting to a

whole new level!

LLLL

Looking for last minute shopping deals? Find them fast with Yahoo! Search.

Never miss a thing. Make Yahoo your homepage.

Looking for last minute shopping deals? Find

them fast with Yahoo! Search.

[Guest guest]

I think that was the basis of the HYH article - as it started out discussing what should be measured in a practice. Gordon,Sorry for my lack of memory here, but has there been an article in Family Practice Management about this issue—why P4P will not work—and the flip side-- what will work? It would be nice to see your comments written down in an arena where all primary care docs can see it. I think currently we have a lot of lemmings who don’t want to be left behind, so they are following the herd. It would be nice to formally challenge the process before we all end up heading off the cliff.  Re: when wood is king-- a ruler for my kingdom! That primary care can be judged on a hodgepodge of specific clinical indicators is fundamentally flawed.  This keyhole peek into the medical home we create for our patients is a poor representation of what we do to make that home a place where the population we serve has a good experience of care and achieves the best possible outcomes.  Forcing us to drill holes through our walls to create multiple peeks to me is just further absurdity that as Ben points out actually degrades the value of our homes.The parade of supporters behind this approach is wide, long, and loud, but they are heading down the wrong road.  We can demonstrate the work we do in creating homes that give our patients and excellent experience of care and clinical outcomes.  Validated patient-reported outcome measures help us here.  Their aggregate experience of care accurately represents our ability to eliminate barriers to care through improved access, office efficiency, continuity, how well we do in giving our patients the information they need to manage their conditions, how good we are a helping them manage their conditions (self-efficacy, a.k.a. "confidence").Measuring A1c and pneumococcal vaccine administration is important to us as we care for our patients.  We need tools to find patients who fail to follow through (reminder systems).  Judge me on the presence or absence of a reminder system.  Judge me on how well I've eliminated barriers to access, on how often my practice wastes patient time (thus creating a barrier to follow through), on continuity.These are fundamental qualities of the practice regardless of the population served.  These are qualities I control and for which I can and should be held accountable.  When the practice solves these problems and can engage in patient-centered collaborative care, the outcomes are much better.  The improved experience of care means that the patients want to contact us first - they see us as their medical home.  They are more likely to follow through on preventive care and chronic conditions - so the population outcomes improve.The IMPs are doing this work and find terrific professional satisfaction in doing so.  The efforts involved in data gathering and aggregation and comparison are practically zilch - not the heavy lifting of HEDIS minutia.  With all the talk about funding medical homes, we're eagerly anticipating the financial recognition that might even make primary care a positive career choice again. GordonAt 11:18 AM 3/28/2008, you wrote:We must question if what we're measuring really has any value.  For instance, here is the link to HEDIS data core quality measures on my practice as well as several others.  http://www.musc.edu/PPRNet/AQA/AQAMeasures.htm I think this is the first time that any practice has published their HEDIS data to the general public based on actual internally generated practice data.  One reaction I have after working with this for awhile is - Who Cares?  Down the line, I fear a never ending cycle of measuring more for the same pay.  I fear as soon as you emphasize one thing then they'll move the target and something you're not measuring will suffer.  This would be most helpful to me if I was an employer of doctors at a big institution or a manager of an insurance network.  I would get doctors to compete on the measures and give me an objective way to say if they got a pay raise or not.None of these measurements would intuitively lead anyone to think we should pay doctors more.  Getting a good percentage on these P4P measures reflects a good system to capture documentation.  Even with a good emr, it under reports my efforts at getting people to quit smoking.  It gives no idea to anyone how many dollars I've saved (or cost) the system.  No insurance company wants to measure dollars saved by primary care because they'd have to triple our pay.  Instead they'll find ways to ding me if i didn't document the care I gave efficiently enough.It looks like I'll have to change my workflow to document differently if I want to buff up my numbers.  All this actually takes away from caring for people, returning some phone calls or email or reviewing lab results... and so on.  My patients don't really care about the metrics.  They know that I'll help them when they call and I know they'll generally pay the bill.  As a practical matter for a small practice that's enough and probably will be for the next 20 years of my career.Right now I'm doing this out of curiosity.  To write about the experience and find the trouble spots.The collection of this practice generated data was made possible by my investing heavily in my EMR, participating in a research project on colon cancer through PPRNET (a research network) and convincing others that posting this data might be an interesting thing.Ben Brewer M.D.  a validated combination of various metrics and one's perception of one's health and care, both in general and wrt to various disease states, that is something which could be worth a lot, and could clearly demonstrate the value of IMP-style practice.  the metric data would/could be readily available with emr's with patient registries.we could become new-fangled bean counters; we could elevate bean counting to a whole new level!LLLLLooking for last minute shopping deals? Find them fast with Yahoo! Search.