What Physicians are Doing to
Enhance Healthcare Value
Christine K. Cassel, MD, MACP
President & CEO
American Board of Internal Medicine
The Leader’s Project
April 24, 2008
What is Needed at the Physician Level
 Coordination/integration of care
 Meaningful and valid quality and cost
information
 Managing resources/controlling costs
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
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
Challenge
Current system will not support a
coordinated/comprehensive
care approach.
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
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)
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
Questions?