Primary care physicians acknowledge over-utilization and blame it on the lawyers.

Catching up on some reading, I came across this article in Medical News Today, describing the results of survey research conducted by Brenda E. Sirovich, MD, MS, and colleagues from the VA Outcomes Group (White River Junction, Vermont), and the Dartmouth Institute for Health Policy and Clinical Practice.   They surveyed primary care physicians and published their results in the Archives of internal Medicine.  They documented that primary care physicians acknowledge over-utilizationof services received by their patients.

Their #1 theory of causation?  “It’s because of malpractice lawyers!” That is not surprising to me, and is consistent with many conversations with both front line PCPs and leaders of primary care physician organizations.

However, I personally believe that this is really the #1 rationalization of the over-utilization.  I feel that there are two main causes:

  1. Low fee-for-service reimbursement, creating the need for many short visits each day to generate enough revenue to make a good living (i.e. the “hamster wheel”).  When visits need to be short, prescriptions and referrals are important to make the patient feel satisfied that their problem is really being addressed.
  2. Lack of effective clinical leadership or even peer interaction over the actual clinical decision-making (i.e. “care-planning”) done on a day-to-day basis by the vast majority of primary care physicians

Beyond the medical school and residency stage, physicians’ care planning occurs all alone, with no-one looking over their shoulder — at least no one with sufficient quantity and quality of information to make any real assessment of clinical decision-making.  Health plans have tried to do so with utilization management programs, but the poor quality of information and the relationship distance between the physician and the health plan are too great to generate much more than antipathy.

If you eliminated malpractice worries and paid primary care physicians a monthly per-capita fixed fee, would wasteful over-utilization go down without also providing deeper clinical leadership and peer review enabled by better care planning data?  Perhaps.  But I would worry that, in that scenario, physicians would still stick with their old habits of hitting the order & referral button out of habit to please the patients who have been habituated to think of “lots of orders and referrals” as good primary care.

The “mindfulness” thing in the invited commentary by Calvin Chou, MD, PhD, from the University of California, San Francisco, is a bit much — trying too hard to coin a term.  I’ve heard that presented before, and I categorized it with “stages of change,” “empowerment,” “self-actualization,” “motivational interviewing,” and “patient activation.”   I’m not saying that such popular psychological/sociological concepts have no merit.  I’m just a Mid-Westerner who starts with more conventional theories of behavior.

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Mayo and Cleveland Clinic are becoming franchisers. Maybe they should focus on primary care.

As described in a recent article in American Medical News, the Mayo Clinic and the Cleveland Clinic are both independently offering medium to large groups of specialist physicians an opportunity to use their esteemed brand names and a variety of other resources formerly only available to employed physicians.  In return, the group has to pay a fee and agree to meet clinical criteria.

That’s a franchise model, although Mayo and Cleveland don’t use that terminology. Perhaps they are worried that the term “franchise” may conjure up unflattering comparisons to fast food chains.  But, as I’ve described in a previous blog post, the franchise model is not frivolous.  It is a serious, time-tested business structure appropriate for a business that his a mix of large scale and small scale requirements. Large scale requirements are things like infrastructure for research and development, volume purchasing, specialized management disciplines, and branding.  Small scale requirements include top local talent that is highly motivated to develop relationships and attend to the details that determine the quality of local operations.  A large, conventionally-structured company can certainly have “field” employees spread out in many local areas.  But, they may not be able to attract and retain the best local talent.  And those field employees won’t be as motivated as franchisees that are, by definition, entrepreneurial business owners.

It has to be real to avoid being cheap

Mayo Clinic and Cleveland Clinic are well aware that they have strong, valuable international brands.  They take their brands very seriously, both in local markets for care delivery and on a national and international scale when they have ventured into publishing and internet-based businesses.  So, I know they must be keenly focused on picking franchisees that won’t sully their names. The worst thing for them would be for their franchisees to deliver poor care under their logos, creating confusion in the market about what their brand stands for.  Franchisers know they need to assure that their standards are maintained consistently.  This consistent adherence to standards is one of the most essential sources of value to consumers.

But why not focus on primary care?

The fact that both Mayo and Cleveland are focused on “single specialty groups” implies to me that they are directing this franchise model on specialists rather than primary care-based organizations. But, perhaps it is the primary care providers that could benefit the most from getting access to resources that are too costly for them to develop themselves.  Things like advanced analytics, health care information technology, lean coaches, care management training, call centers, contracting professionals, and sophisticated advertising.  These are the capabilities that serve as the foundation for successful primary care-based accountable care organizations (ACOs) or to achieve favorable performance in episode-based, bundled payment for chronic diseases.  To a primary care franchisee, the brand name recognition may actually be less important than the opportunity to have world class infrastructure and management support, while still allowing the participating primary care physicians to maintain a degree of independence.

The following tongue-in-cheek video illustrates the idea.

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