Stanley Feld M.D.,FACP,MACE
The following is a special message to members of the Dallas County Medical Society (DCMS) from Dr. Cindy Sherry. Dr. Sherry is a very smart woman and an excellent physician.
She is also extremely tactful. If you read between the lines of her message, you will sense the difficulty and mistrust physicians have for hospital systems. You will also understand the government’s lack of interest in physician innovation.
If physicians threaten hospital system’s vested interest even if it is to improve patient care in a community the hospital system is against it.
There is no need to ask why physicians should mistrust the promises of hospital systems. Hospital systems must prove their sincerity to the physicians in the community and not the other way around.
Dr. Sherry describes the way Centers for Medicare and Medicaid Services (CMS) received the Dallas County Medical Society (DCMS) representatives. The DCMS has a plan that can help the indigent patients in our community.
I think the plan will work.
The message I got from Dr. Sherry’s special message is CMS is too busy to listen to physicians.
They simply do not have the time or the bench strength to work on something that might capture the imagination of medical communities in other cities and other states. The physicians’ ideas might lead to additional innovative ideas that could markedly decrease the cost of delivering medical care in America.
However, the government has its mind made up and is not interested.
“DCMS News: Special Message from the Dallas County Medical Society President
Dear Fellow Members of DCMS:
As your president, I would like to tell you about your DCMS executive committee’s May visit to the national headquarters of CMS (Centers for Medicare and Medicaid Services) in Baltimore. Joining me were Immediate Past President Rick Snyder III, MD; President-elect Jeff Janis, MD; Secretary-treasurer Jim Walton, DO, and CEO Michael Darrouzet.
To begin with, getting into CMS was more complicated than getting through security at DFW airport. At the gate, our car was thoroughly checked, including under the hood, in the trunk and inside all suitcases, and all passenger IDs were examined. IDs were rechecked at the building entrance, plus we and all our belongings passed through metal detectors, overseen by armed guards and guard dogs.
In preparation for the trip, we acknowledged that the Medicaid 1115 Waiver opportunity had passed to transition Project Access Dallas to a physician-led ACO (accountable care organization) called My Medical Home. Therefore, the intent of our meeting with CMS was not to create a last-minute effort to revive the program, but rather to keep our concerns about the Waiver alive, and to express these concerns to the people in charge. We wanted to inform the CMS policymakers about how their plans and goals for the underserved population of our region are being interpreted and implemented in the offices of physicians and in the halls of hospitals. Furthermore, although we remain sorely disappointed in our Big 5 Dallas-area hospital systems for their role in thwarting the transition of Project Access Dallas to My Medical Home, we did not make this trip to air dirty laundry or to ask CMS to intervene in a hospital-physician dispute.
Our concerns are centered on the reality that health care is in transformation across this country, including Dallas. Now is the time for DCMS physicians to assert our leadership and to work to ensure that the transformation occurs according to guiding principles — principles that will lead to programs that provide quality care to all of our citizens; principles that will ensure that resources are deployed across the healthcare continuum, not only for hospitalizations and ER visits. We had embraced the principles and goals espoused in the Waiver, including collaboration, accountability, transparency, and a focus on access, wellness and quality.
While in Baltimore, we spent about 90 minutes voicing our concerns with CMS representatives, including Steven Cha, MD, chief medical officer; Rob Nelb, Texas 1115 Waiver project officer; Therese DeCaro, senior adviser to Cindy Mann, deputy administrator, responsible for development and implementation of national policies governing Medicaid; and Julia Hinckley, acting deputy director of the Children and Adults Health Program Group. We realized that they are office-based, policy personnel who have no interaction with patients or physicians that would enable them to fully grasp how their plans play out across communities. We also recognized that a resolution to our immediate problem would not be forthcoming, so we remained focused on constructively sharing concerns that have the potential to impact future programs and decisions.
We emphasized our belief that a truly transformative plan would create a new financing and delivery model that would include outpatient clinics, specialty and primary care physicians, community care transitions, community health and pharmacy navigation and transportation, referral management and case management, and preventive and wellness services.
We further stressed the need for more balance in the use of funds. With current funding focused on hospitals, how could one realistically expect the transition to more affordable and more coordinated outpatient care? The current focus on hospital funding disregards the recent results of the needs assessment completed as part of the Waiver process, which largely is outpatient-focused. This funding imbalance omits ambulatory care clinics, care coordinators and physician compensation from the equation.
How did the CMS staffers respond to us? They pointed out the depth of the problem they face — each state is submitting numerous proposals, adding up to innumerable programs from across the country. They simply don’t have the bench strength or depth to adequately oversee the programs in the detail we described. They used glorified terms of transformation such as “collaboration,” “innovation” and “transparency” in the Waiver, but also acknowledged that these are long-term goals, and that they do not expect their immediate fulfillment. They have no plan or capability to police the programs, instead relying on state and local administrators. They acknowledged that the letter from county medical societies represented a desirable component of a region’s proposal, but the medical society did not possess veto power, and that the letter would be considered as one piece of information among many in the proposals. In point of fact, the medical society letter was a requirement added at the state level; it did not originate at the federal level.
CMS officials also acknowledged that the dispersal of funds should be more balanced. However, they said there is no mechanism or pathway for the funds to flow differently, and integration of outpatient care truly is a big challenge.
To the CMS officials, our visit was a reality check for them to hone in on questions such as, “How is the process working? Can it be improved?” Our visit served as the launching pad for them to begin a conversation for future policies. Based on our initial conversation, they have bolstered some of their regulations for interim follow-up reports and they have incorporated requirements for learning collaboration plans. These midcourse corrections now allow for future 2-year funding windows rather than 5-year approvals.
Probably their best take-home message for us was that we (physicians, in general, and DCMS, specifically) need to strengthen our voice and increase our clout through our political connections, and that we should have been able to recruit political allies locally and statewide to help us be more effective and support our position.
In conclusion, the visit with CMS strengthened the DCMS executive committee’s resolve that the Blue Ribbon Task Force for the Underserved is heading in the right direction. We remain committed to moving forward and creating an innovative plan through activating leaders — including physicians, hospitals, outpatient facilities and services, midlevel providers, and business leaders— from all corners of the community to work together to blaze a trail for a more cohesive plan to provide health care for the underserved citizens of Dallas. It was an honor to represent the 6,500 members of DCMS in Baltimore.
Cynthia Sherry, MD
President, Dallas County Medical Society”
Many physicians throughout the country have said, “Why bother?” The answer is because you cannot give up. Some how Americans will wake up.
Our government is by the people for the people. We are the people.
Not government bureaucrats!
There you have it. Leonard Cohen is right. “The Dice are Loaded.”
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone
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