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The AAFP and Payment Reform — They’re Screwing It Up, Again, Part 5 – Population Health Management

March 6, 2017
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In the AAFP’s Advanced Primary Care Alternative Payment Model document, the concept of population health management is a little more muddled, but it keeps rearing its head in different places in the document with different descriptors. From the definition of the primary care medical home, the phrase Planned Care and Population Health is used. Later in the document, it proposes a complicated 4-step pecking order for attributing patients to physicians. How can a population be managed if no one knows which patients the family physicians are supposedly responsible for? Still later in the document, “manage populations of patients” is listed as a goal.

Then, a supposedly risk-stratified care management fee is promised to lead to a “payment model [that] empowers medical homes to manage patients efficiently, manage health care costs, and dedicate the time for adequate screening, preventive care, patient education, robust care coordination, and social services that contribute to cost-effective care that improves both the patient experience and the health of the population (i.e. the Triple Aim).” As readers of American HealthScare know, this sentence includes goals in contradiction with one another. More screening and preventive care increases costs. Higher patient satisfaction scores are associated with higher mortality rates. No Triple Aim achieved in these cases.

Also, notice what’s missing. There is nothing in this sentence that suggests family physicians should provide a comprehensive basket of cognitive and procedural services. Apparently the complex patients are to be coordinated out of the presence of the family physician. There are lots of other missing features more important than the quoted list. More on that in a future post.

There are many problems with the assumption that family physicians should “manage” a population of patients or their health. It implies that ultimately the physicians will be responsible for the populations’ outcomes. The word “accountability” is sprinkled throughout the document. This is patently absurd. This problem goes to misused quality measures and they contradict the very nature of family medicine. I’ll have a lot more to say on this issue in the next post. With what the authors propose, they are trying to create incentives for family physicians to over-diagnose chronic diseases and dump the most complex vulnerable patients from their practices — the exact opposite of the incentives that should be put into place. Family physicians should be rewarded for continuing to care for patients who have unstable lives and multiple challenges to achieving goals the books say they should, not incentivized to dump complex patients back to the never ending cycle of ER and specialist visits.

This might at first sound like trivial semantics, but I’ll give the authors credit for presenting the word population. They just tied it to the wrong noun. Family physicians should not manage the population’s health, but its discomforts and fears. Too many factors are way out of our control, and no one has developed good risk stratification tools, for family physicians to be paid based on population outcome differences, which is a huge mistake in this document.

But family physicians’ ability to make judgment call after judgment call can be better put into action, and respected, and paid for. The cardiologist and ER doc will treat just about every case of chest pain the same. In their world, algorithms are thought to result in the best care. “Everybody with chest pain gets an EKG, troponins, chest CT, overnight stay in the hospital” and so on. There is the misapplied worship of standardization that is corrupting generalism. Most family physicians view this chest pain example as a horrid waste of limited medical resources for low-risk patients. Therefore the trick is to take the patient or population fear/concern of chest pain out of the cardiologists and ER doctors’ hands. Family physicians should be the first ones to hear that concern and then apply different diagnostic and treatment approaches to the myriad of presenting symptoms and risk levels, not a cookie cutter approach to a “population.”

But to do this would require a large army of family physicians, and there is not a large army because family physicians are not paid for the valuable judgment calls we make every day, so medical students stay away from family medicine in droves. The AAFP APM will not make this situation better.

 

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