The Bigger Picture: Better Quality, More Money. Right Now.

February 1, 2009

Yes, there is a way to make more money; by providing better care - and you needn’t wait for some P4P program or “medical home” experiment to get started.


It just started using software to actively recall patients behind in their care. For this 180-physician group in Green Bay, Wisc., that meant 7,758 existing patients called in for preventive and follow-up care that they probably would not have otherwise received, according to hospitalist Ashok Rai, the multispecialty group’s chief medical officer.

In other words, Prevea made money by improving quality. Its physicians took better care of patients, and the practice saw more revenue as a result.

We’ve been hearing a lot lately about the idea of paying primary-care physicians extra to provide preventive services more comprehensively. Medicare’s flawed pay-for-performance program is one example. The “medical home” concept promoted by several professional associations is another. But Prevea’s experience begs a question: Do you really need to wait around for such programs to develop in order to start getting paid more to do better?

Rai doesn’t think so. “We consider we have all the aspects of a medical home already, and we are rewarded for that without remuneration from the medical home [demonstration project],” he says.

And the pay-for-performance programs offered by Medicare and other payers are not necessarily the answer, either. Most physicians already give fine care, Rai argues. The challenge is getting patients who need care in front of good physicians in the first place, he says, not marking off codes to show that physicians provided it.

Not everyone would agree, certainly, with Rai’s assumption about how great every physician is. There is abundant evidence that care quality varies wildly and essential services often don’t get done. The only question is whether poor care happens because individual physicians mess up or whether it’s actually the result of our payment systems. Physicians rushing from exam room to exam room will miss things. Those looking to help patients will put just about any diagnosis code on a claim form to work the system. Of course it’s that claims data that gets used to measure quality down the road.

But here’s the thing about what Rai - and others here and there around the country - are doing: We can stop arguing about the cause. Physicians can just start doing better within the system. These practices don’t need to wait for someone else - CMS or the AAFP - to save the day. They just start doing, and doing in ways that pay off.

I recently heard a keynote speech from Jay Kaplan, an emergency medicine physician turned public speaker. He encouraged the audience to turn from a renter’s mentality to an owner’s mentality. If you rent a house, you wait for the landlord to show up and fix things. If you own, you find a way to fix them yourself. That’s the possibility I see here. Fixing the system yourself, from the inside out, is revolutionary.

It’s not all flowers and bird song, obviously. If your practice starts recalling patients who need care, you’ll see a big upswing in volume, creating access challenges for most busy practices. Prevea reacted by directing patients who required acute, simple care to nonphysician practitioners, yet the practice may still need to add more providers.

Practices also will need to professionalize billing, capturing every service, sending clean claims, understanding what to appeal, and so on. While a meaty visit can yield more than a lean one, the margins still are not huge, and efficient and fast billing is essential.

Still, over time, physicians in groups focused on prevention will begin to spend a good part of their day on in-depth care instead of runny noses. There will be time for higher-revenue, higher-happiness visits, not just churn.

And it doesn’t take some major shift in the U.S. healthcare system to make it happen.

Not only are physicians more satisfied, so are patients - especially in these economic times. “The healthier we can keep our patients, the less out of pocket costs they’ll see,” Rai says. “We get thank-you notes for our reminders from patients.”

Isn’t that the way it should be?

Is this all just a pipe dream? Tell it like it is by responding at forum.physicianspractice.com.

Pamela Moore, is director of content and strategy for Physicians Practice. Moore has been writing for physicians on practice management issues for 10 years, and she is a recognized speaker and commentator on healthcare management. She can be reached at pam.moore@cmpmedica.com.

This article originally appeared in the February 2009 issue of Physicians Practice.