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Rumplestiltskin Planning in Health Care

Recently, on the Robert Wood Johnson Leadership Network LinkedIn site, Martha Somerville posted a link to a New York Times article by Robert Pear: “Medicare to Start Paying MDs Who Coordinate Needs of Chronically Ill Patients” (August 16, 2014).  The link, (http://www.nytimes.com/2014/08/17/us/medicare-to-start-paying-MDs-who-coordinate-needs-of-chronically-ill-patients.html) was contained in a post entitled “Chronic Disease Management.”  The article, about Medicare’s plan to pay for the coordination of care for chronically ill persons, says:

Under federal rules, these patients will have access to MDs or other health care providers on a MD’s staff 24 hours a day and seven days a week {my italics] to deal with “urgent chronic care needs….

 

As part of the new service, MDs will assess patients’ medical, psychological and social needs; check whether they are taking medications as prescribed; monitor the care provided by other MDs; and make arrangements to ensure a smooth transition when patients move from a hospital to their home or to a nursing home.

 

MDs can expect to receive about $42 a month for managing the care of a Medicare patient. Care management services can be provided only if patients agree in writing. Patients will pay about 20 percent of the $42 fee, the same proportion as for many other MD services.

Chronic disease management, coordinated care, integrated care and similarly named initiatives are being touted as innovations that will improve the quality and cost-efficiency of medical care.  And they might if properly resourced and implemented.  But I worry that a lot of magical thinking is going into the planning for interventions of this type.  Let’s take the plan described, hopefully not fully, by Pear.  Here is the list of the things “MDs” or their proxies will do under this plan according to Pear:

  1. assess patients’ medical needs
  2. assess patients’ psychological needs
  3. assess patient’s social needs;
  4. check whether patients are taking medications as prescribed;
  5.  monitor the care provided by other MDs; and
  6. make arrangements to ensure a smooth transition when patients move from a hospital to their home or to a nursing home.

Now if we are talking about people with multiple chronic conditions including disabling physical or mental ones, this is an imposing list and each of the items is only the tip of an iceberg.  But let’s assume that each of these items takes about 10 minutes to cover monthly – although this is probably an underestimate for some – and assumes no emergencies, so that a provider might need about an hour a month or more to cover this list.  Even if providers were equipped by training, experience and temperament to do these things, to what extent might $42 per patient per month cover them?

Well, Google tells me the average salary of a primary care MD these days is $221,000 per year.  Assuming that this covers 52 weeks a year, 40 hours a week, the average salary works out to be an hourly wage of a little more than $106 per hour.  So $42/month works out to 24 minutes per month – less than ½ of the needed hour.

And how would that one hour compare with what MDs are now spending?  According to a very nice article by Tai-Seale, McGuire and Zhang (2007) the average primary care office visit is only 15.7 minutes, covering a median of six topics, about 5 minutes were spent on the longest topic whereas the remaining each received 1.1minutes.  So we would be asking providers to increase the time they spend with patients by a factor of 4.

So this new Medicare initiative probably is not providing enough money to cover the costs of the care that it is proposing and it is assuming that providers can spend about 4 times as much time with patients as MDs now do.

Where do policy makers and planners come up with these numbers???  Did they actually estimate the times required for and the costs of the services they would like to see provided?  Did they run simulations and sensitivity analyses to estimate how these resource requirements might change as a function of different assumptions and as they impacted service utilization and outcomes?  Maybe they did and if so, I’d like to see the details.  Can anyone point me to these?

Methods and tools like PBN Free (http://model.planningbythenumbers.org/) have been developed in operations research and related fields for this type of planning, but I doubt they are much used.  (I’ve actually been working on expanding PBN Free to cover integrated care.).

Without careful databased planning we may be engaging in “Rumplestiltskin planning,” asking health care providers and systems to “spin straw (inadequate resources) into gold (higher quality, cost-efficient quality of care).”

As Tai-Seale and her colleagues conclude:

Efforts to improve the quality of care need to recognize the time pressure on both patients and physicians, the effects of financial incentives, and the time costs of improving patient–physician interactions (Tai-Seale, McGuire, & Zhang, 2007).

Reference

Tai-Seale, M., McGuire, T. G., & Zhang, W. (2007). Time allocation in primary care office visits. Health Serv Res, 42(5), 1871-1894. doi: HESR689 [pii] 10.1111/j.1475-6773.2006.00689.x

 

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