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One-on-One With Memorial Healthcare CEO Patty Page LaPenn, Part II

December 9, 2009
by root
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In this part of our interview, LaPenn says P4P programs risk rewarding the wrong kind of doctors.

California-based Memorial Healthcare is a four-IPA organization that includes a 35,000-visit-a-year urgent care clinic and a disease management center. The four IPAs represent 220 primary care doctors and 400 specialists – across North Orange County, Anaheim and Long Beach – centered around four hospitals. Primarily handling at-risk contracting with health plans, the IPA has begun working to bring EHRs to its providers. Recently, HCI Editor-in-Chief Anthony Guerra talked with CEO Patty Page LaPenn to learn just want IPAs want, and don’t want, from hospitals.


(Part I)


GUERRA: Whose responsibility is it for patients to get better? If a doctor is misled by a patient about the medications they are taking, so that the physician’s actions result in harm, who is at fault?


LaPENN: First of all, let’s wake up America, we’ve got no PCPs. While everybody is spending all the time focusing on other aspects of healthcare, two to three years from now there’s going to be no doctors to see. I think what they’re thinking is that it should be proportional. So the thing is, if a doctor sees 100 diabetics and everybody has about 7.5 percent who are noncompliant or 30 percent who are noncompliant, whatever it is, you can then find the outliers. So then they say that the doctors who have more noncompliant patients are bad doctors. I think that’s what they’re saying, but correlation does not imply causation. In my own doctor panel that just means the physician is a compassionate doctor. The doctors that have the worst rates in my panel are softies, and the noncompliant patients know other noncompliant patients, and if they find a doctor that’s willing to work with them, that doesn’t berate them or get short with them, then that doctor will build a panel of those noncompliant patients.

First of all, there’s not random assignment of patients to doctors. Doctors attract certain patients. I have doctors who are athletes. If they have a patient that has a single blood glucose of 105, which is way early, they refer them right to our diabetes education program to scare them and get them to the point where they don’t become diabetics. That’s because that particular doctor, as an athlete, is sensitive to getting patients quickly back in line.

When you get into an older population, you can risk adjust, but the biggest danger of judging doctors based on their noncompliant patients is doctors will shun noncompliant patients.


GUERRA: So they’ll arrange their practice to do well in P4P programs by not taking the difficult patients.


LaPENN: Yes. Doctors already have the right to dis-enroll a patient from their practice based on noncompliance. And so, with this scenario, if they’ve got a patient, his A1C is elevated, well, I have to tell you that the wrong kind of doctors are going to have the best scores. The doctors that will do stuff like that for money will have good scores. I have a lot of doctors, they’re family practice doctors, they wouldn’t be in family practice if they were after money, and so the best of them will be penalized and demoralized.

If you randomly assign patients to doctors, then I think this method works, but applying this research-based methodology to the practice of medicine when you don’t have random assignment doesn’t work. I have a public health degree, so I came out of public health research, and it’s obvious to me that people are taking metrics from the business or research world and applying them to the practice of medicine. If you really want to have an impact on patient health, tax them or charge them more for their insurance when they are noncompliant.


GUERRA: If you want to change behavior, hit them in the pocketbook.


LaPENN: Yes. Instead, by hitting the doctor with this, there will be some unintended consequences. We’re working through the PQRI right now on diabetes, and it’s so ridiculous creating all those transactions. They’re taking a very expensive, long way around it if the desire is to improve healthcare.

Let’s talk about predictive modeling. It says when you have a three-day length of stay for a chronic condition, 64 percent of all those people will be dead in a year, or dead in 18 months. So there’s a number of those items like that, and the thing is that if they want all this data because they’re looking for that, then the question is why. How are you going to determine if you’re in the 64 percent or in the 36 percent who’s going to live? The data that they’re asking for on all the quality improvement makes me wonder what they are going to do with it.

They’re going to hold doctors accountable for the outcomes of their patients when the patient has no skin in the game. There’s lots of research that says when you start doing an intervention with a patient, if you ask the question, “How likely are you to change anything you’re doing,” the patients that are not going to change anything they’re doing are going to tell you they’re not going to change anything they’re doing, and the fact is they’re not going to change what they’re doing.


GUERRA: {laughing} So they’re not even going to lie to you.


LaPENN: No, and it’s people who make their living sitting in cubicles on computers, who probably belong to a gym already, they’re the people who show up most frequently when we do an open call for cholesterol and heart disease screening and all that stuff, we don’t get the sick people. We get the worried and well.


GUERRA: You mentioned the PQRI program. Would you say the administrative burdens of that program are too large and the financial incentive too small?