Harold D. Miller: Improving Quality, Reducing Costs, and Increasing Physician Satisfaction

The physician's foundation says this will be a watershed year for the US health care system. At the end of 2012, they released a survey showing the top concerns of doctors for 2013. One of the best people to address these various concerns is Harold D. Miller, executive director of the Center for Healthcare Quality and Payment Reform. He also is president and CEO of the Network for Regional Healthcare Improvement and a recognized expert on health care payment and delivery reform. CardioSource WorldNews Executive Editor Rick McGuire talked with Mr. Miller at the ACC's Cardiovascular Summit in Las Vegas in January.

Rick McGuire: You presented the keynote address here at the "Cardiovascular Summit: Solutions for Thriving in a Time of Change." A recent Physician's Foundation survey shows a lot of worried practitioners wondering how the changes to health care are going to play out. What's your message?

Harold D. Miller: They are correct—2013 is a pivotal year and not just because of the Affordable Care Act. It is also related to the federal deficit and we have this situation where every year, doctors are facing a 25-30% pay cut. There is no other industry in America where the key professionals get told every year, "You might have your salary cut by 30%, regardless of whether you're doing a good job." And that's got to get fixed.

You say that 2013 is pivotal for many reasons. Do you think the great concern over the Affordable Care Act is misplaced?
There is inherent uncertainty about how it's going to play out because it is a major change. With millions of Americans suddenly getting health insurance for the first time, how do health insurance exchanges play out? How are health plans going to change? What does that mean in terms of physician contracting, et cetera? There is huge uncertainty, so it's not misplaced at all.

In terms of the Affordable Care Act, what it has done in terms of coverage is going to be positive for physicians. There will be more patients who have health insurance and have the ability to pay for preventive care and good physician care rather than showing up at the emergency room with a late-stage problem that is much more difficult and much more expensive to treat.

Who's in Charge?

Yes, how millions of new patients are going to be treated is also a top concern of doctors. Loss of autonomy is another.
Loss of autonomy is also dependent on who's in charge. One of the big problems is that this is being done in a top-down fashion from Washington. We need to do more in terms of a bottom-up approach with physicians all over the country stepping forward and saying: "How can we improve care? How do we reduce costs? And how do we need to be paid in order to support that?"

If you put health plans and hospitals in charge, they are going to want to subject doctors to their control. If physicians can step forward and take control, then they maintain their autonomy. But today you can't have autonomy without accountability and physicians need to be willing to take accountability not just for the quality of care, but also for the cost of care.

How can we improve care and cut costs?
There are many ways cost of care can be reduced without hurting patients. Somewhere between 5% and 17% of hospitalizations in this country are preventable. We have three preventable errors in medicine every minute in America that cost billions of dollars. Also, when we look around, we see in many cases that there are people delivering care at a much lower cost than others.

Also, we can control or reduce health care costs dramatically without affecting physician pay at all because physician pay represents only about 8% of total medical spending. It's the other 92% that's really what counts and if physicians can start having payment models that enable them to actually control the rest of the cost, they could do that in ways that would improve their pay; they could get reasonable pay without facing threats of 30% pay cuts, be able to help solve the federal deficit, and make the Medicare program solvent. That's really the kind of power that physicians hold in their hands if they can exercise it.

Improving Quality of Care

Only a small percentage of providers have taken advantage of the Physician Quality Reporting System (PQRS) incentives and those incentives will soon turn into penalties. A recent study finds fewer than one in five doctors hitting PQRS goals and getting bonuses. What's the problem?
Your question is a particularly complicated one because part of the reason they are not hitting the bonuses is because of the way the program is being administered which makes it very difficult to do that. But the other issue is that it's not really related to patient care. I mean, reporting information to Medicare just to be able to get a 1% or 2% payment difference is really not what physicians are all about. They didn't go to medical school to write up quality measures and send them to CMS, they went to medical school to take care of patients. The issue is how do physicians change care?

Why I got involved in payment reform issues in the beginning was that it's very difficult, and impossible in some cases, for physicians to actually improve the quality of care given the current payment system because they don't get paid for things that actually improve quality of care. If you have a payment system that doesn't give doctors flexibility or reward them for higher quality, then simply submitting quality measures to CMS is not going to solve it.

Physicians want to spend more time with patients rather than fill out forms, but when all that paperwork is required, what's the answer? As you said, accountability is mandatory. Improving quality and reducing costs is a train; either you get on it or you'll get run over.
Part of the answer is physicians should spend more time with some patients in the office and less time with other patients. Other patients could be managed over the phone, by email, et cetera. But we have a payment system right now that basically says, "Everybody's the same. You're all going to come in and get your 15-minute visit whether your need it or not."

One physician I know who runs a physician IPA and a health plan says that their goal is to not have physicians waking up in the morning worrying about whether their schedule is full but rather waking up in the morning and worrying about whether patients are getting good quality care. And physicians who operate under more flexible payment systems do that. They are able to prioritize patients; they are able to focus more resources on the patients who really need them as opposed to dragging patients into the office just for a blood pressure check.

So, less time with low-risk patients and more time for more complicated cases; like the patient with comorbidities who need extra attention?
That's exactly right. Or hiring a nurse care manager to work with some of those patients and help them understand how to take their medications and help them overcome barriers to adherence. But again, Medicare and most health plans don't pay for care managers for cardiologists, even though it's been shown in study after study after study that the simple addition of a nurse to work with some of those patients who need more help can dramatically reduce the rate of ER visits, hospitalizations, and rehospitalizations, saving a huge amount of money—far beyond the cost of a nurse.

It's a tumultuous time and a lot of doctors are very frustrated. Any final words of encouragement?
The good news is if you talk to physicians who are operating under different payment models, it's not just that they're improving quality and reducing cost, their satisfaction as physicians goes up. In one study, the most dramatic result was the number of physicians who had been planning to retire changed their minds and said, this is the way I wanted to practice medicine and I want to stay with it because this is the opportunity I've been waiting for for decades. That opportunity exists for physicians across the board; to be able to be paid appropriately for delivery of good quality care and to have the flexibility to make sure that their patients get the right care at the right time in the right way.

Keywords: Physicians, Health Insurance Exchanges, Motivation, Patient Care, Delivery of Health Care, Schools, Medical, Personal Satisfaction, Comorbidity, Health Care Costs, Medicare, Patient Protection and Affordable Care Act, Hospitalization

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