Comments

(Our responses to comments in CAPS)

Meeting last week (with US Senate Staff X) went very well. I introduced the proposal which at first was received with initial "are you crazy" type response by Senate Staff X. But then several from the group chimed in favorably seeing the logic in it. Particularly when I mentioned your numbers of 350 per patient per year being a bargain compared to the usual 2000 that most are paying for concierge type service these days. There was concern of docs gaming the system and cherry picking healthy patients, but I told them that part of the deal would be to provide ongoing data regarding disease management, panel stats on severity of illness of patients etc. This annual fee could be adjusted for complexity of patients, size etc. We thought there should be some measure to reimburse for doing procedures, otherwise we would end up referring folks out to do minor derm etc. So a big base, plus some small percentage of fee for service, and other incentives. They were all in strong support of something like this ... I think they are getting the message that we are in crisis and need something revolutionary and not evolutionary. ALREADY SOME WORD IS GETTING TO POLICY MAKERS. THE GREATER THE NUMBER OF “FRONT LINE, GRASS ROOTS” PETITION SIGNERS, THE GREATER THE IMPACT COULD BE.

National health care policy is in flux. Policy makers have in conversation described their desire to make substantive and helpful changes but can only do so if there is a constituency for change. The usual players crowd the halls of power. This petition can break through the walls of lobbyists and find a receptive audience. Taking action now and encouraging others to participate has a real chance of moving national conversations beyond "the same old" and in the direction we need. WE AGREE. SEE THE COMMENT FROM AN ATTENDEE AT A RECENT SENATE STAFF MEETING ABOVE.

'As I understand it, this system is essentially "capitation" but at a national level. This was tried during the 1990's here in Minnesota, and in my opinion worked quite well. The system emphasized primary care and was able to bring down health care costs for the first time in decades. I made sure that referrals were appropriate and I coordinated the care of my patients and made sure the consultants provided good care. The problem was that patients began to see their primary care physician as a barrier to "specialists". Specialists, who were threatened by this system also joined in the fray and began to equate primary care as "bad care" for any number of conditions. This public outcry that equated managing care to denying care led to the gradual dissolution of the capitation approach towards fee for service. I think it will be key to figure out the "specialty" piece and how that relates to the provision of primary care. I don’t think your proposal does this as it does not address the relationship of the two levels of care. YOUR STORY OF PRIMARY CARE DURING THE “MANAGED CARE” WAS WIDELY EXPERIENCED. FOR THIS REASON THE PROPOSAL HAS TWO FINANCIAL STREAMS. PRIMARY CARE WILL NOT BE “FIGHTING FOR” THE SAME FINANCIAL STREAM SO BLAME OF PRIMARY CARE FOR COST ESCALATION ELSEWHERE WILL NOT BE A HIGHLY DEFENSIBLE POSITION. THE RELATIONSHIP BETWEEN THE TWO STREAMS WILL INVOLVE SPECIALISTS AND PRIMARY CARE AS PARTNERS. THE DETAILS OF THE RELATIONSHIP WILL EVOLVE OVER TIME.

'Great work!!'

'A dollar a day is the test and I believe it will work.'

' Please include APRN's as we are often the only primary care available in the rural and frontier areas. I have 28 years practice as an RN and 6 years as a FNP … 'Please include Nurse Practitioners in your plans and discussions. We have been very involved in primary care, and I think in the future, will be even more so.'…I am a Family Nurse Practitioner and recommend that you include NPs in the proposal. Whether independent or as part of the primary care team approach, NPs enrich the primary care system. Physician Assistants are presumed to be part of the system as they are traditionally supervised by physicians and regulated by boards of medicine but the NP role is too often neglected/rejected due to territorial issues. Given the Massachusetts experience, we will need all the physician PCPs and non-physician PCPs we can muster.

http://www.gao.gov/new.items/d08472t.pdf is a nice reference on current stats on physicians, PAs and NPs in primary care.' WE AGREE AND HAVE MADE CHANGES TO THE PROPOSAL WORDING.

I don't need $250 K for salary + benefits. This seems a bit high especially if administrative burdens of the job are reduced.

I have been under a capitated system before. I was penalized for having many female patients who got pregnant (child-bearing age). I was also penalized for having geriatric patients with multiple medical disorders (such as diabetes, hypertension, and hyperlipidemia). I am a relatively high utilizer due to these patients needing medications, as well as my patients who are on antidepressants. The coding can be onerous, so I hope the ICD-10 does not come to fruition. I don't want to be a gate-keeper. Most patients would rather see me once they understand that I can take care of much of their health-care needs (such as their rashes instead of seeing the dermatologist, and come to see me instead of waiting to go to the ER. hope this become a viable option.

'I have just opened my ideal medical practice. I am able to take care of the sickest of patients at home and hospital for just $50 a month. Cutting out transactional costs for insurance is working for my patients and they are appreciative of the access.'

I live and work in rural Iowa. I provide obstetrical services and all of the local primary care doctors do hospital work. As this is more the norm in rural America, some adjustment to the 'specialty services' of hospital and/or obstetrics for rural doc would be nice.

'I love my job, I want to keep doing it, and I am struggling to pay my staff and my bills. And my own health insurance went up 17% this year, to over $900 a month for my family. The system is headed for collapse, and I would like to be able to at least build on something after it does.'

'I think a paradigm shift in how we finance primary care is the only way to increase access, reduce costs and move us in the direction of consistent evidence based care and adequate chronic disease management. I support the basic concepts of this proposal. '

'I think this is an excellent idea. Perhaps a pilot project could be run in such a way as to illustrate how it might draw more medical students into primary care.'

'In the meanwhile, you can support primary care immediately with medicare and other rules changes which do not need legislation.

1. equal reimbursment for primary care/specialist care, meaning parity of payment: no unnecessary specialist referral to make managment money.
2. reimburse medication use in primary care office at reasonable profit now to avoid ER referrals (I can not give an 80 year old a Rocephin injection and get paid for it even at cost.)
3. reimburse mental health office visits equally now, and avoid the pseudo illness of pschiatric patients.
4. make all levels of visit (2, 3 and 4) equal in reimbursment by the hour: 6 level 2s to equal 3 level 3s or 2 level 4s by reimbursment; avoid requirement of only level 2 visits imposed on primary care MDs in many groups. Stop the 7 minute visit requirement.
5. allow urgent care reimbursment in primary care offices at urgent care reimbursment now, saving referrals for real need for extra equipment.
6. Ban "bundling" to avoid managment sending patient to new MD in group the next day for treatment of extra known problem that can be treated here and now.
7. regulate that COBRA will cost the patient the same amount it used to cost his employer, not what the insurer charges individual clients. Some states do that now: make it universal.

'It is not really easy to find how to sign the petition. Might make it simple, or give directions on where to find the sign up part.' WE HAVE ADDED THE NAVIGATION BUTTONS!

'My practice is one of 36 "TransforMed" practices that have been under study with regards to transforming to a new model of care. The "TransforMed" National Demonstration Project conclusions are still pending, but one thing is clear: Substantive change in practice dynamics requires financial support. Without this support, attempts at such change will become one more "unfunded mandate" and run the risk of driving more primary care physicians out of business and out of their field of medicine. A clear paradigm shift with regards to funding health care in this country will be necessary to save the primary care base which keeps most Americans healthy.'

'Need payment reform supporting medical home now.'

'Nobody else has to call themselves "...practice". It\'s Internal Medicine, reproductive medicine, sports medicine, addiction medicine, etc.etc. There is no longer an American Board of Family Practice. It\'s now called the American Board of Family Medicine. Look it up. Yeah, I know it\'s a "PC" thing, but words matter, especially words that are said over and over again in public. SO please change the designation on the pick list. Thanks, rant over, thanks for all you do… 'We are done practicing, please use the term Family Medicine in your descriptions, my Boards do, thank you. PICK LIST CHANGED

'Please save our specialty!'

'Possibly the only hope for family practice.'

'Primary care providers increase or reduce healthcare costs and influence health outcomes by our "power of the pen". Cost controls like prescribing more generics, limiting high cost/low benefit imaging, and reducing unnecessary referrals MUST be part of the quality assessment or this proposal might increase rather than decrease costs. If it doesn't decrease costs, it will not work. Health outcomes must also improve, but that will take more time to measure. ' SOME PRIMARY CARE PHYSICIANS ARE ‘BIG SPENDERS’ AND OTHERS ARE NOT. VARIATION IN ADJUSTED COSTS WOULD BE ONE OF VALUE INDICATORS WITHIN THIS PROPOSAL. YET EVEN WITH THE VARIATION IN CURRENT COSTS AMONG PCPS, ACROSS NATIONS AND WITHIN THE UNITED STATES, THE GREATER THE USE OF PRIMARY CARE, THE LOWER THE COSTS.

'RBRVS is killing primary care and driving unnecessary cost. It is time for change!'

The best idea I've heard so far!

'The current model is broken and does not work for Primary Care MDs, society or the patient. We need to separate the blending of finances for primary care and the other components, which are built upon models that increase cost, not decrease it, all without evidence of better quality. '

'This is a very interesting plan as it gets primary care out from under the insurance companies. Doctors would be free to opt out and do concierge care on their own if they did not want to participate. '

'very difficult to survive in CA as a solo primary care doctor. Poor financial support, high legal fees, too many rules from all over that can strangle you'

Through Feb 14 Follow:

'Countries that support primary care see better health outcomes for all their citizens.'

'FFS medicine is wasteful and inflationary - but many will work harder/longer/more efficiently if they receive more for doing more, so a blended payment system may be more effective. But no more idiotic "3 from column A and 10 from column B" coding idiocy, please Also, implementing a single, standard EHR system, of which the VA\'s VISTA would make the most sense since the software itself is free and quite scalable, would offer the best chance for actually lowering costs and improving quality through HIT and should be considered as an essential part of primary care/health care reform.'

'Has the AMA and the RUC weighed in on the content of this petition and the position taken? What would happen to their over reaching influence in setting fee scales for procedures and EMS in a system such as proposed in the petition? As I am sure you are aware, there are powerful forces that work within the RUC acting not for the benefit of those patients being served but seemingly serving more the interests of the specialty care services that dominate their ranks.' MANY LARGE ORGANIZATIONS HAVE MANY CONFLICTING INTERESTS. THIS BOTTOM UP PETITION IS INTENDED TO BRING ANOTHER IDEA TO THE TABLE THAT IS SUPPORTED BY THOSE WHO ACTUALLY DELIVER THE CARE AND HAVE TO DEAL WITH THE CRAZY QUILT CREATED, OFTEN AS UNINTEDED CONSEQUENCES, BY THE BIGGER ORGANIZATIONS.

I am concerned about the salary concept. Doctors seem happier and enjoy their patients more when they are rewarded for giving good care. I don't think I would enjoy my work as much if I were just being paid to show up. There have to be some rewards/recognition, ideally financial, for providing the best, not necessarily the most, care. HENCE THE FOCUS ON A SIMPLE METRIC FOR WORK…PATIENT-REPORTED QUALITY. MUCH MORE THAN “SHOWING UP.’

'I am in strong agreement regarding the role of primary care and the need to develop the primary care pipeline'

'I appreciate your work. Significant reform is necessary in the realm of reimbursement for primary care physicians. This proposal makes a dramatic effort at moving our health care system toward a more sustainable future.'

'I consider myself to be primary care for a lot of women's issues but feel that they would be better served to have comprehensive rather than just gyn based care. This proposal would require better reimbursement for the rural primary care providers in our area and might attract more to practice here to help fill the needs.'

'I have worked in the Canadian system many years. It is very good quality. A health care system based on family physicians and generalists is the only way to organize an efficient, quality system. Family doctors have the broadest training.'

'I will not be practicing much longer with the current impossible constraints placed on me as a Family Doctor. '

'Keep up the fight! The primary care system in this country is a disgrace. There is no excuse for a lack of access and poor reiimbursement in the "Land of The Free and Home of The Brave." The ER is not a family practice office and provides very poor continuity of care for people :). '

'legislating portability/compatibility is absolutely essential if electronic records are to deliver any benefit to either patients or their doctors.' WE WILL BE OFFEREING A FREE PORTABLE HEALTH RECORD FOR THIS PURPOSE DURING THE SPRING.

'Of note, I would take this all back even one step further to the actual education process and cost to all physicians. Having some students coming out of medical school with enormous loans/debt before they are married/have families/ and even jobs in some cases is driving people into specialty care where salaries are higher and some would argue better quality of life with less call etc. That coupled with what occurs on the other end...low salaries for work load, administrative paperwork which contributes little to patient care, medication changes at the whim of insurance companies is making primary care a fairly unattractive career to pursue. Those of us that have done it for some time know that there are many meaningful and long lasting relationships and excellent care given that simply can not be measured by some quality-metric system and that is the reason many of us chose the profession to begin with.' ACTUALLY, MANY ARE EASILY MEASURABLE BUT YOUR UNDERLYING POINT ABOUT RELATIONSHIPS IS VERY IMPORTANT NOT TO TRY TO REDUCE ONLY TO “METRICS.”

'Primary care as it is now is unsustainable. '

'teach in family medicine residency and have half time family medicine full spectrum practice. Support for family medicine training financially and with quality instructors is in serious jeopardy'

'Thank you for embarking on this very important, critical work!'

'We are definitely in crisis mode in our practice and constantly overwhelmed by administrative and managed care requirements. It is impossible to attract new physicians into this environment and those who are left are burning out.'

'While I generally support a single payer "Medicare for all" system, the system described by this petition is workable. Changing payment to support work done besides office visits and getting away from the ICD 9- generated need for over-documenting are key components to making primary care an attractive field.'

'Would not use the term "capitation" at all...a "Primary care fee", or "Care Management fee" would be perhaps better received. Strongly agree with budgeting for primary care first...give everyone first line access. Would add some component of FFS on top of management fee to reward face to face care on top of desk top medicine.' GOOD POINT. WE WILL CONSIDER ADJUSTING THE WORDING.