1. Christine K. Cassel, MD, MACP President & CEO American Board of Internal Medicine The Leader’s Project April 24, 2008 What Physicians are Doing to Enhance Healthcare Value

3. What is Needed at the Physician Level  Coordination/integration of care  Meaningful and valid quality and cost information  Managing resources/controlling costs

4. Assets  Growing evidence base about what works  Well trained, motivated healthcare professionals  Models of excellence (Geisinger, Ford, Kaiser, and delivery systems overseas.)  Payers are seeking ways to reward more effective practitioners  Physicians want to fix a system they feel is broken and physician leaders are stepping up to the plate

5. Barriers at the Physician Level  Reimbursement based on volume of services, an approach which can undermine care coordination/ integration and care appropriateness  Fee-for-service payment does not support teams, practice infrastructure and alternative care delivery models  Prevalent payment models have fueled income disparity between generalists and specialists -- further reducing interest among residents and practitioners in primary care medicine  P4P programs are inadequate at best – most did not assess physicians in a multi-faceted, comprehensive way and many focus more on utilization than quality

6. Challenge Current system will not support a coordinated/comprehensive care approach.

7. Policy Approaches Support the Redesign of Systems in Which Physicians Work Increased coordination of care may reduce gaps in services, problems with care transitions, errors and quality shortcomings, as well as costs.  Medical home – Additional funding and enhanced practice infrastructure is projected to reduce overall use by the 10% to 20% of patients who use the most services – but need to focus on high need patients. Challenges: Not all primary care physicians trained/able to provide comprehensive coordinated care Need more primary care physicians – especially in rural and inner cities Require high bar for physician entry Accountability for quality and cost not yet clear, e.g., primary care’s relationship to specialists Other models: See Baron& Cassel, JAMA, 21st Century Primary Care

8. Policy Approaches Overhaul Physician Reimbursement Current system values utilization and specialization, not coordination, comprehensive care. Physicians need to understand that just distribution of finite resources is part of their professional responsibility. Challenges: Need to create accountability for highly compensated specialists, ie. No payment until report is received by the primary care physician Overhaul the RUC and RVRVS system – include consumers and other stakeholders, re-balance primary care specialists mix, move away from volume based payment and incorporate comparative effectiveness, Support physicians in their desire to provide comprehensive care: align incentives with things doctors value and are already doing e.g., certification (healthplans and BTE do this)

9. Policy Approaches Broaden Assessment and Improve Accountability The public and payers need to ensure that their physicians are comprehensively assessed and held to high standards, and that they deliver effective care. Challenges:  Most assessments at the physician level are too reliant on clinical measures – need patient experience, system, and assessment of knowledge, clinical judgment and diagnostic acumen  We have growing but limited experience at “getting it right” in terms of valid, reliable performance data at the physician level – science base needs to be enhanced  Physician organizations need more multi-stakeholder input into their processes so they better represent public needs and preferences

10. Questions?