A Conversation With David A. Fleming, MD: Medical Practices Struggle With Change

New regulations, EMRs, maintenance of certification, and concern about cost are burdens for physicians, but things will improve, says this year’s president of the American College of Physicians

John Marcille

Imagine that your physician believes that your hip pain could be helped by an injection from an orthopedist. He enters the order into your electronic medical record, and a box pops up advising him of what it will cost you. ‘That is the ideal,’ says David A. Fleming, MD, president of the American College of Physicians.

‘The patient and I could look at that, and we could plan out what’s going to happen. We could discuss what the expectations are for the patient and what the expectations are of me in terms of how I can help navigate the health care system and the insurance plan.’

That scenario is a long way away from reality, he acknowledges, but as technology advances, physicians are also moving forward. They must become more adept at discussing the financial aspects of health care with their patients, deal with the ramifications of the Affordable Care Act, and redesign their practices to meet emerging payment structures and new regulations, Fleming notes.

Importantly, these changes also have to become a part of training programs for physicians and other health care professionals. ‘There’s a lot of shifting sand out there,’ he says.

Although Fleming practiced in a small, rural community in north-central Missouri for almost 20 years, he is now chairman of the department of internal medicine at the University of Missouri School of Medicine, where he also is director of the Center for Health Ethics. He has written or co-written more than 60 peer-reviewed journal articles and book chapters, and he wrote the book Care of the Dying Patient.

He has held many leadership positions, including governorship of the Missouri chapter, within the ACP, which as the nation’s largest medical-specialty organization, represents internists. He previously was an associate professor of medicine at Georgetown University.

Fleming earned his bachelor’s degree and his medical degree from the University of Missouri, where he also completed his internship and residency. He completed a fellowship in primary care with a focus on bioethics at Georgetown University. He spoke recently with Managed Care editor John Marcille.

Managed Care: The American College of Physicians has been an advocate of the Affordable Care Act. What’s behind your support?

David A. Fleming, MD: The ACP has always been in favor of broadening access to health care by enabling universal access to insurance. One of our top priorities is to encourage the continued rollout of the ACA at the state level, where much of the resistance is in terms of its deployment. States have put up some barriers, but the health insurance exchanges are working. Ten to 12 million individuals have health insurance now that did not have health insurance prior to the ACA being implemented.

MC: How has the law affected internists?

Fleming: It has been both positive and negative. More people can get to health care clinicians, but it is starting to strain health care systems to care for all of them. We are concerned that we are not going to have enough physicians to take care of everyone. Another downside is that this was a well-balanced plan for trying to control costs but also continuing to pay physicians appropriately. In states where Medicaid expansion is not occurring, though, disproportionate share funding is still going down and some health systems are struggling.

MC: Is the ACP advocating any specific amendments?

Fleming: We are advocating that all states embrace Medicaid expansion. That is critically important. The issue of whether federal subsidies can be used for federally run health insurance exchanges is new, and it could have a big impact. If those subsidies won’t be there to support people in their efforts to get health insurance, they will be back where they were before, and it may even be worse.

MC: Sometimes on the managed care side, we get the idea that physicians like fee-for-service payment and that other kinds of payment mechanisms are a problem. But the ACP supports transitions to value-based payment. Can you explain what the hope is?

Fleming: Fee-for-service is a long, rich culture. It is like taking a pacifier away from a child. It’s hard to wean ourselves away from it and look at alternative payment models. But in the long run, those alternatives will probably be quite effective and actually serve to sustain reasonable reimbursement for care. We’re talking about team-based care, where we’re being given an incentive to optimize quality, to ensure that we have good and evidence-based clinical outcomes, and to control costs. That is quite reasonable; it is the payment form of the future.

MC: What is the primary care model of the future?

Fleming: Primary care is going to be through patient-centered medical homes. It is going to be patient-centric, where multiple disciplines are involved in the care of patients, where chronic disease management and prevention are the focal points, and where care is provided in the ambulatory setting more than in the inpatient setting. There are many patients out there with multiple chronic comorbidities who are a hairsbreadth from qualifying for admission to a hospital because of the acute exacerbations that can occur. We are hoping to have systems in place where multiple disciplines are communicating effectively with each other across specialties and are sharing in the responsibility of keeping them out of the hospital.

MC: Doesn’t such a system imply the existence of large, multidisciplinary groups rather than small groups? A study from the Commonwealth Fund recently found that small primary care physician practices have low rates of preventable hospital admissions. How can that be, when larger groups can more easily facilitate communication and referrals?

Fleming: I practiced in a small multidisciplinary group, and we had a pretty good track record of chronic disease management and keeping patients out of the hospital. We had a large panel of elderly patients, many of them in long-term care facilities. As part of that practice, we had nurse practitioners and we worked very closely with home care services. We collaborated with hospice groups. We had an excellent working relationship with our emergency care department and with urgent care groups within the community. So in many ways, our group — and many of the small groups that are out there — do function as a team. What we’re talking about are patient-centered neighborhoods, where we have not just primary care, but we have subspecialty care that is networked into the care of the patients. Communication occurs across the system, across practices and between specialty teams.

MC: What is the role of the health plan in facilitating this?

Fleming: The most constructive thing is for health plans to promote the team-care process and to provide appropriate incentives that can be attained through reasonable efforts by the health care team. Teams can be rewarded not just through reimbursement, but through other support that can be provided by health care plans, such as medication reconciliation and good Web sites for patient educational materials. Health plans are very important stakeholders in the welfare of patients. They are going to have to function as a partner to the clinical care team and to the patient — be part of that triad.

MC: I am sure health plans would agree. Many of the clinical executives at health plans have been working toward that since the earliest HMOs.

Fleming: We’ve come a long way in recent years. High-functioning care teams that are successful recognize that payers are part of the process and part of the team. If that partnership is done well, we are going to be able to achieve the goals that we are setting out to achieve.

MC: Health plans have traditionally used utilization review and precertification to rein in waste, which is usually estimated at 30 percent. Physicians push back on those quite a bit. Is that attitude going to change, or are we going to be looking at other ways of reducing inappropriate utilization?

Fleming: It is going to have to be a multipronged approach. For a while, we are going to have to do some level of precertification, especially for the high-end interventions that tend to be overutilized. Precertification is becoming more fluid because payers and health systems share the information that’s needed more effectively. But we still need an option for a physician to be able to call a physician at the health plan and talk things over. On the other end, we need to continue to educate physicians and other members of the health care team about how to use clinical evidence more effectively. Part of this will happen by default through the reimbursement and meaningful use processes that are being required. We also need to have a more team-centric, multidisciplinary educational process where, as part of the curriculum, we look at our interventions through a high-value lens, looking at outcomes as well as cost-effectiveness.

MC: Patients have had to take on higher copayments and co-insurance. Is the ‘skin-in-the-game’ argument legitimate?

Fleming: Patients need to be accountable, but as we get to huge deductibles and huge copayments, that really discourages patients from seeking health care. The Affordable Care Act is trying to level the playing field, especially in preventive care where there are zero upfront costs for the patient for certain kinds of services. In the long run, that will bring down costs and improve quality of life and hopefully prevent undue hospitalizations. We need to find that balance.

MC: What have you experienced in practice?

Fleming: Cost has become an unintended side effect of much of our treatment. When I talk to my patients about doing an MRI or seeing a surgeon, I say, ‘I don’t want to create a financial burden for you.’ We need to inculcate our discussions with cost and value with our patients and with each other as we move forward in this amalgamation of change that we are dealing with right now.

We have to be as facile about the financial issues related to health care as we are about the science of medicine and about the clinical outcomes and the quality of care that we provide.

MC: Physicians haven’t traditionally talked with their patients about the cost of health care.

Fleming: We are getting more comfortable with it, but in years past, we tended to avoid it. We’ve been afraid of it because the patient may get upset that it is going to cost so much, and they may choose not to do what we think is in their best interest. We also don’t always have the information that they need. Patients often ask us, What is this going to cost me? And most of us don’t know the answer to that. Even if we had the price list from our hospital, we don’t know what the final bill is going to be. We can have a financial person talk to them and try to make some predictions, but invariably we are wrong in what we tell them. That is changing, and it has to continue to change. We have to be as facile about the financial issues related to health care as we are about the science of medicine and about the clinical outcomes and the quality of care that we provide.

MC: What can health plans and CMS do to help?

Fleming: I don’t know everything that is covered by a particular plan, and I rarely have a handle on a formulary that is approved by the plan, because I know that changes all of the time. The patient should carry their medical record and their insurance information with them, but in easy-to-understand language so that we can converse effectively about it.

MC: I should think that would be an extension of the electronic health record.

Fleming: Wouldn’t it be great if everyone had access with one click to the same medical record and the patient’s insurance information? That would be huge.

MC: One of the things that has come along in the last few years and will cost money is the wellness movement. How do you and the ACP feel about the value of these programs?

Fleming: They are profoundly important. We have not globally promoted true wellness programs in the care of our patients. We talk about lifestyle changes, we talk about losing weight, but there’s a lot about wellness that we are not talking to our patients about. Insurance plans are just starting to promote these things, such as effective guidelines for alcohol consumption, the use of tanning beds, and how to keep kids from starting to smoke. Again, this needs to become part of our training. That’s where much of the health care cost is ultimately going to be controlled. Every time we keep that 13-year-old from picking up that first cigarette, every time we encourage a 16-year-old to put a helmet on when riding a motorcycle, we’re a step ahead in terms of prevention. Those who are paying for health care and those who are providing the health care and those who are seeking health care need to be in lockstep in that effort.

MC: Some physician offices are in chaos with all of the demands from insurance companies and the government. It seems to be a major burden. What is your sense of how internists feel about that, and do you see light at the end of the tunnel?

Fleming: There is universal discontent as to the administrative burden that physicians are feeling right now, even in high-functioning clinics. There are pods of excellence out there, where they have effectively been able to control the administrative process by which patients are cared for. Some have found the use of scribes to be helpful and they engage a team of people to care for patients. These pods are also geographically unified so they can communicate more effectively, and they have easy access to electronic medical records for decision support and information regarding the patient. So I think there is light at the end of the tunnel — but it’s a really long tunnel.

MC: What are the main concerns?

Fleming: Many physicians in practice feel quite overburdened by a lot of the regulatory processes, by the fact that formularies tend to change, by not knowing whether they are part of the narrow networks that are getting created. Physicians are very frustrated by the electronic medical record, documentation requirements, and meaningful use — all of which were put in place for the right reasons. We are just not quite there yet in terms of making all of these requirements user friendly so that we can have a seamless, effective process in the clinical setting. Much of the dysfunction relates to the EMR and not being able to communicate effectively because the systems are different. But there are many changes that are taking place in practice right now. Physicians are afraid. The maintenance of certification process has been hugely burdensome, especially to internists. They have to jump through many hoops in order to stay certified so that they can stay licensed so that they can stay on the provider lists of their health plans and continue to practice in their health systems. And they have no control over it.

MC: You mentioned that some practices are making it work.

Fleming: We can fix all of this. We’re a generation away from having young physicians who are facile with electronic medical records, plus the technology is going to continue to improve. And there are practices that have been able to make their systems more functional. One of the problems is that we’re creating greater expectations, and those expectations ultimately fall on those of us who write the orders. It’s a catch-22. We want to have the authority to order tests, to provide treatment, and to make meaningful changes in patients’ lives. But we have to do it within health care systems that are becoming increasingly complex. Many of us feel that we’re losing control — that we’re no longer calling the shots. That’s the majority of physicians now, not the minority.

MC: Will the greater reliance on evidence-based care return some of that feeling of control?

Fleming: If physicians who are coming into practice realize what the expectations are and understand that they are going to have to practice evidence-based medicine, and they are trained in that way, the worm is slowly going to turn. We’re going to adapt. We’re all smart people. It helps when we feel we are part of the process of change and we have some say in how those changes are occurring. Part of what the ACP is trying to do is be the voice of internists so that we can make positive change and see value in that change. Right now, so many of us think of these new regulations as make-work, and we don’t fully understand why it has to be so complex.

MC: Are CMS and health plans not coming to the table with their proposals and their ideas to try to work them out with physicians and hospitals?

Fleming: It’s such a big table. CMS and health care plans are doing what they feel is reasonable and right. What they are concerned about is making sure that Medicare and Medicaid are sustainable, and they are trying to control costs effectively in ways that they feel are best for society. The hard part is making sure that we are speaking the same language. There are advisory mechanisms for CMS, and we have physicians involved in that as does the American Medical Association and probably every medical professional group out there. But it is so complicated and the stakes are so high that, oftentimes, changes are made in spite of advice to the contrary from professional groups that say something is going to be detrimental. We need to be very careful that change is effective and appropriate and that we understand the impact on patients and on health care teams. Here’s the idealist in me: If we really trust that everyone is trying to do the right thing and they are trying to serve the needs of patients, we’ll get there.

MC: Thank you.