Medicare has initiated their quality payment program for 2017 and beyond, which is their attempt at reeling in healthcare costs, waste and changing non productive referral habits most medical providers have developed over the years.
Yesterday, I sat down with a representative from NJIT (New Jersey Innovation Institute) who was hired to help doctors work within the new guidelines that CMS (Centers for Medicare and Medicaid services) succeed at this new initiative. Their goal as stated is to make sure care is coordinated and managed based on medical diagnosis as well as patients unique needs using up to date evidence-based interventions. They believe that by labeling patients as low risk (healthy with no significant risk factors), moderate risk (One or more risk factors with one or more chronic diseases but stable clinically) or severe (multiple late state diseases) they can better manage these patients at a lower cost. While this applies more to primary care than to a specialty like ours, it is understandable that our system with its many moving parts often throws costs and specialties at problems without managing their utilization well.
As someone who works in the primary care of musculoskeletal problems, I expressed my frustration with how few medical providers refer to us first, even though we have shown again and again that we solve the problems people experience after seeing multiple providers which is wasteful. The truth is, when you visit your primary care provider who has very little training in anything that is problematic with the musculoskeletal system, they either begin by ruling out problems by running tests, ordering MRI’s or making referrals to orthopedic surgeons, who then filter through whomever are candidates for their procedures, and then refer the rest to rehabilitation of the part, with very mixed results. The other truth is that many symptoms of the stomach and pains in the chest are not life threatening, and are musculoskeletal in nature, yet, most primary doctors are ill equipped to adequately evaluate those patients musculoskeletal and instead run tests for disease processes that could be avoided altogether if they did an adequate musculoskeletal workup while talking to the patient, taking their vitals and examining their lungs and other systems. Most of us are unaware that statistically, 95% of those visiting an ER for chest pain are not having a heart attack, and the pain is emanating from the musculoskeletal system. Unfortunately, a large part of the problem is the under reimbursement at the primary care level which financially is harmful to your doctor if they spend too much time doing a proper exam, and the general lack of training in how to properly evaluate problems in these systems in an integrated fashion..
Most diagnostic tracts for back or neck pain are suggesting conservative care first, with chiropractic showing the most promise, yet, due to referral habits or physician bias, few of these referrals show up in chiropractic offices, and most of these patients are referred after the typical medical approaches fail.
I had suggested that part of the problem is that the primary doctors have very little time to evaluate and few tools to use since their training in the musculoskeletal realm is cursory at best. We have been meeting with providers for years attempting to help them with certain clinical pearls they can use help them triage these patients better.
The reality is that most patients with back, neck and even chest pain would do better if they visited a chiropractor first, so why doesn’t CMS force doctors as has happened in a couple of states to visit a chiropractor first? Believe it or not, she says that this is probably coming soon, so there is help for what is wrong with healthcare; too many tests that come back negative, and I cannot find any info on what percentage of these tests can be skipped when used for screening. While we are looking for disease states, the truth is that most patients with back, neck, knee, shoulder and other musculoskeletal problems rarely have any diseases related to why they hurt, so why are these tests done on this subset of patients?
In the case of our office, we were asked by the representative about many of the things on her list we do on a regular basis. The questions were clearly geared toward primary care, their level of service to their clients, their cost profiles, and how the consumer perceives them. We do almost all of what she asked us about on a regular basis, and our patients by and large are quite happy with their experiences and the thoroughness of our care. Apparently, according to the representative, this is not true of most medical offices that not only require coaching and remedial help in customer service, but also tend to test and refer too much to providers who drive costs into the system which aren’t necessary or helpful for that matter. There are also too many medications being ordered, and the Opioid problem is simply a failure to manage. The truth is the musculoskeletal system overlaps everything, from hormones, to how we walk and move and must be part of what primary care is capable of triaging.
Where will this lead us?
CMS’s approach is to financially starve providers who cost too much and use the savings to financially reward the providers who improve their referral patterns and reduce costs; a kind of Robin hood approach to healthcare costs. Those who are able to drive costs down will be rewarded up to 9 percent and those who are not able to change their ways of doing things will be docked a similar amount.
Can primary care doctors do this successfully when their reimbursement levels are already too low in many cases?; we shall see. Is this truly a great idea or approach, or is this just another complicated set of policies that will get doctors angry, while they try to do this jobs in 10 minutes or less? Can years of training that is myopic toward diseases, the use of drugs, an overreliance to procedures, specialists and the general ignorance of 55% of the human body which is the musculoskeletal system be overridden by a program designed to financially manipulate them into doing things differently?
The important thing to watch is do the insurance companies after seeing how this approach works use this wisely, or do they do what they always have done; financially squeeze the providers while paying larger amounts to fragmented hospital systems and for drugs that are often priced much higher than they were 10 years ago, which is a growing trend and problem. CMS’s new program will also affect hospitals as well, and many hospitals are moving toward population health, which may be just a big corporate way of managing an over specialized profession that at times, seems to be tone deaf to its own deficiencies and costs.
While talking to her shows that fragmentation is the number one cost driver that feeds unnecessary testing and increasing healthcare costs. There are simply too many referrals and errors in management even with electronic health records and some central data bases. Do people really require all that healthcare management as they age, or is there a better way. One part of this problem that is glaringly evident is the CMS program wants to reform the systems, yet the lack of a holistic approach to care is clearly a cost driver, as is the over reliance on the disease model and symptom model?
As you can see, primary care is the tip of the iceberg, yet primary care has been trained to look at your pain, classify problems or first consider your problems as being disease related, when a simple musculoskeletal evaluation may eliminate many tests and inappropriate referrals. Years of mismanagement and poor information later results in chronic pain, damaged joints and a host of interventions that could have been prevented had we had a better way of seeing things.
Is this new CMS program a step in the right direction or just a very complicated solution when the real solution is to retrain the way doctors think and proceed? I hope so, especially if our country finally decides that one insurer, or a Medicare for all method of coverage makes the most sense, allows simplicity and reduces provider frustration while they are trying to control costs.
There is indeed a greater role for chiropractic in the healthcare system, even though the profession does not currently have prescriptive rights. When you do not have access to pharmaceuticals, you find other ways that are maybe healthier. Perhaps this is why chiropractors work with nutraceuticals which are often more effective than many medications, without the side effects. Chiropractors should be the front line choice for most musculoskeletal complaints, especially of the neck, back, arms and the extremities. The inconvenient truth is that the body is a series of interconnected systems that must be looked at holistically. The other inconvenient truth is that the CMS plan is trying to pull on the financial strings of a profession that sees the body as a series of different organs and joints that just go bad, and are often indifferent to how they are connected.
Moving the health care system from non holistic, fragmented, too expensive and too drug centered to a healthier holistic model is a herculean task. There are many professions that can help the system move into a better mode of practice. Even functional medicine, as practiced by most naturopaths deserves a look since they often solve problem that are systemic in nature. Knowing all of this, should we redefine or reconsider who does primary care and maybe, should chiropractors and primary care doctors be working more closely with each other. Should doctors of Osteopathy with their additional hours of musculoskeletal training get additional training to improve how they can evaluate a back, a knee, or foot pain?
Clearly, the CMS approach is a start, but unless many of these relationships are forced to happen, it is likely that the health care system will be put on a diet, but it may not change if we do not remove some of the many moving parts that only serve to swell costs, while over complicating care which can result in many errors in patient management.
Clearly, primary care needs to change. So does who is doing primary care, how they approach health and the disease based models that result in too many costs, poor outcomes and too many of us taking drugs we see on television. Clearly, there is a better way. Good luck CMS.