First Draft Scenarios

First Draft Scenarios

The following 8 scenarios were created during the March 24-25, 2005 Physician Accountability for Physician Competence Summit in Fort Worth, Texas.

The scenarios contained here are not intended for wide distribution, nor to be seen as final in any way. They were created as part of a process which will lead to more refined and polished scenarios available for distribution. If you have any questions about these or the final set of scenarios please contact Carol Clothier at the Federation of State Medical Boards at 817-868-4000.

These 8 scenarios are entitled:

1. FAA
2. Consumer Driven-Care
3. Niagara Falls
4. Xanadu
5. 1776 Freedom
6. Golden Noose
7. Alliance
8. Physicians as Tools

Team 1 FAA

It's now about 2005. We have Dr. Frances who has two patients named Herb and Mabel. It is a world in which the baby boomers are coming of age. There is a static supply of physicians. There is stress on the system. The expectations of patients are very high.

Herb and Mabel are quite a bit overweight. Dr. Frances meets them in the office. She does a quick history and finds that along with some other telltale symptoms, their blood pressure a little high. As the years go by, she suggests options they could choose so that the potential catastrophic diseases might be averted.

As we move into 2010, Dr. Frances reads that the government has mandated electronic records and wonders how to integrate that into her practice. She wonders how she's going to manage the care of patients. She sees that this practice is supporting the need to shift towards health prevention.

Dr. Frances sees that if she were to think more about disease prevention and that if at least 2000 other physicians were to think this same way, this would save the system a lot of money down the road by 2015.

At the same time she reads about this EMR and notices that there is a blueprint put into place by the government for sharing information with 3rd party payors.

By the time we get to 2015, Dr. Frances, being proactive, has already purchased an EMR which helps her facilitate disease management by having automatic flags come up so she can do cookbook medicine. She never misses a test she should be ordering. She has the ability to get remote diagnostic testing from other physicians. She can also treat people while they're at home. For some, the patient-doctor relationship becomes much better and for others, it just becomes more routine. There are some diagnostic tests that can be done at home.

While all of this is happening, the government is moving forward with the blueprint for systems of patient data and how it will be connected. They negotiate with provider communities around their issues. There are trade-offs. If the providers comply, the government will make changes to the system to reduce inefficiencies. (We wonder how we're going to pay for all of this.)

As we move into 2020, 80% of the providers are using electronic medical records and the cost of that is borne by the provider community. There is connectivity between those communities. The federal government will be the entity who takes on the responsibility to take on patient satisfaction. They will look for feedback and ways for improvement. There will be a partnership. The government is interested in the system of healthcare and cost containment. The states are focused on the providers themselves. There is some question whether patients and providers' expectations will change. We wonder if cookbook medicine will affect their satisfaction.

There is some consideration of taxing the system in order to pay for this. And that's about it for our story.

Team 2 Consumer-Driven Care

It's 2020 and we have a headline: "Deep Satisfaction with U.S. Healthcare". People are suddenly satisfied with their healthcare, their providers, autonomy, and ability to choose. The physicians are very happy people.They now do what they went to school for. The employers have productive on-the-job employees. The government's role is reduced to light monitoring.

To understand where this process began, we see how costs were out of control. We chose a typical American process which is to have a crisis. We also used Kotter's methodology of getting to urgency. It doesn't matter who is sharing the burden of the costs. It's all too much for everybody. No one felt like they had any options.

We developed a political campaign strategy. The purchasers, patients, physicians, unions, advocacy groups, lawyers. We developed a group called SCHIP. We brought together groups such as regulatory boards, spokesgroups, US Congress, and CMS to work this out.

The control of money is going to the people. The consumers will be in charge. They will use their own money. There may be a voucher system. We did agree that there will have to be coverage for catastrophic care. Everything has to be transparent and IT has to be embedded in this process.

Physicians must use good IT as well. It must enhance the relationship between the physicians and the patients. We built a culture of continual improvement. We decided to do some experimental models. We can also identify groups around the country that are implementing this into the delivery practices.

Team3 Niagara Falls

In 2005 the medical delivery system was on the cusp of a daring advance which was expected to provide significant improvement in the quality of the delivery of healthcare to the American public. Information technology and an electronic health records at the point of care in every hospital and office was touted as the promised salvation to the quality woes in the healthcare system. However, organized medicine, licensing boards, specialty boards, federal and state governments, and the payer community could not agree on either the basic ground rules or data sets to get the process started. Physicians were fighting the battle of decreasing revenues aggravated by Congressional failure to solve the SGR problems. Neither the private insurers nor the federal or state governments followed through on previous promises to help fund physician investment in the EHR. This set up misaligned incentives for MD investment. Due to this, the increase in physicians with EHR stalled well short of predictions.

This system limped along for several years during which time more and more patients and organizations came to possess more and more data. With no agreed upon national, state or specialty standards, what was viewed as valid data depended on the perspective of who used the data. Attempts to make aggregate data confidential failed because of the legal profession’s demand that any aggregated data be fully discoverable for the purpose of litigation. In several areas of the nation, instances of false manipulation of data to increase market share began to surface. In many of these instances, this manipulation of data actually was responsible for worsening rather than improving criteria.

This toxic state of data collection left a serious trust vacuum between patients and the entire healthcare community over the quality of American healthcare. By 2020, multiple data sets, many conflicting, were required at each patient encounter. Numerous entities to include CMS, specialty boards, state licensing boards, and payers had so many different standards that there was no way to validate even the basic definition of quality of care or physician competency.
Team 4 Xanadu

This is the flip side of what you just heard. We're fragmented and we hope to get to a common output. Several summits occurred and we were wise enough to bring all the constituencies to the table. We questioned how we can get the government involved.

We recognized a new candidate to the oval office. She has a daughter who moves to Virginia. The daughter wondered, "How am i going to get the information to find out the right doctor?" She called her mom with this question. This woke up the candidate to realize that she had a new platform from which to make her pitch.

"I want to run on a healthcare reform platform. We need to look at data together. I am moved by this idea that medicine and the surround community needs to be brought together and not be fractious."

We had a candidate we could work with. She wins the election. The summit reconvenes. There was an agreement that there would be a common definition of competence. As it moves forward, the docs in the group push back and wonder what's in it for them.

A bargain was struck. If we improve quality, we will look at issues that reduce cost in the system and do tort reform. There was an agreement on measurement, licensure and linking licensure and board certification.

The docs are in. Our candidate runs again and wins again! Here comes another summit.

Now there is agreement that the data that has been accumulated must be validated and made available. She will fund this will federal dollars. She will put together a single website, so that whether you're a payor, patient, or healthcare organization you can find out about any practitioner in the system. If you're participating in the system, there is no where to go outside the system to get more data

The 2016 election comes up and gets the go ahead to run for a 3rd term and she wins. The headlines are replete with the announcement of this unified healthcare system. Her granddaughter calls, history repeats itself, and she asks for help finding the right doctor. She tells her granddaughter about the website and all is well.

Team 5 1776 Freedom

We got to this by the pressure on the system. There were financial incentives for 3rd party payors. There were also market incentives for making these changes.

Suzie Q. trains medical students in the use of technology. This is part of a geographical alliance where there is a capacity for self-insuring.

Our first patient is a woman who is an obese smoker. She comes into the lobby using a thumbpad which brings up her files and her records. She is assessed initially by a para-professional who has credentials certified by a state board.

This woman is handled in the disease management protocol based on the best evidence of the profession at the time. Appropriate outcomes and care are available to the practitioner for treatment of the patient. This also shows the appropriate prescriptions as well as any drug interactions and physical findings.

In the process, the patient goes for follow-up. She has a safety check done and all of her questions answered. The system indicates that she can go to acupuncture to help smoking cessation. By monitoring her indices, her entire health is in better hands.

The information throughout is gathered into the computer and is available for peer review. There is a system of looking for variants in outcomes. There is a measurement for assessment of all the professionals in the system.

Any questions and follow up can be sent through the internet or by phone. The performance data is provided online. Similar data is also available through 3rd party systems that have a pay for performance.

Part of this alliance allows for technology to be used for professionals who are not in group. These can be leased. The alliance requires individuals to participate in board certification.

Team 6 Golden Noose

Here we are in 2005 with various pressures for increased government roles. The stage was set by several factors such as terrorism threats, decrease in employer's coverage, naive belief that money would be saved and that health IT is a boost to the economy.

Also by 2006, there is a scandal with the ACQN. It turns out the data gathering is suspect. The entire board resigns in disgrace from a major conflict of interest. The trust of the public continues to spiral down.

There is a turn back to the government as a safety. Hillary Clinton takes advantage of this. Government mandates that everyone reports everything. By 2010 we have reported tremendous amounts of physicians' data and there is a push to develop practice guidelines nationally. What the federal government is interested in is different from what the private organizations are interested.

There is a physicians database created and the result of this is that by 2012 we've discovered that some states have done a bad job of policing poor performing physicians. Now that we see that some states have really bad physicians, the government gets even more involved and makes sure they cannot practice through such means of medicare refusal.

By 2012, this does measurably improve physicians quality, but it doesn't come without a few costs. By 2015, many of the organizations for data quality management are derived from Medicare and other healthcare organizations and the data from MacroHard was found to be invalid. Many of the gains were real, but now the public trust has diminished with this system.

By 2016 the republicans have taken over the office again. Our offices are computerized. It's much easier to identify the worst physicians. There is generally better data out there but the doctors are still dissatisfied because of the burdens of data reporting requirements. The federal government has taken over the responsibility for reporting data but the patients and physicians are both dissatisfied with this arrangements.

By 2020, Jenna Bush turn 36 and the republicans can stay safely in office.

Team 7 Alliance

As a result of certain drivers, there was a major catastrophe in healthcare and all of a sudden many disciplines went into a crisis. All of a sudden people realized that we spent 16% of our GNP on what? Healthcare?

People were worrying about their particular issues but no one had an eye on the entire system. In order to change the system, putting caps and limits on or bandages were not enough. We needed to build programs where that dealt with systems.

There had to be a willingness on the part of the profession to fund healthcare education throughout its entire continuum. There had to be a recognition of workforce needs. All of these drivers required a summit meetings in which the government and the profession would collaborate to develop standards of care to assure the public that physician competence would be maintained throughout the lifetime of the physician.

We needed a unified voice of medicine and then healthcare. Each element has to have its own unified voice. There must be a mechanism for data management, tort reform, and others issues.

The partners in this collaboration had to trust each other. The product that comes out of this was to develop a universally agreed upon by all stake holders for standards of competent clinical care. This had to be approved by all appropriate agencies.

The mechanisms would also include a system of improvement over time. We would have a new medical organization which would speak for all medicine. This would require the alphabet soup of all medical organizations. We chose to develop a Secretary of Health and only Health. We also felt it was critical to have a public voice within this discussion. The eventual hope would be data management and synthesis would drive quality through measurement. It would include remediation for those who fell below a certain standard.

For the real kicker, this would be paid for by the profits of gas and oil.

Team 8 Physicians as Tools

It's 2005 and Harry who has been an employee of GM since 1974 and his wife Louise is also employed there because they couldn't afford healthcare on just Harry's salary. GM is only one of the employers who have abandoned healthcare for their employees.

Harry and Louise have joined an organization which is a derivative of AARP which admits anyone over the age of 25. They have petitioned the government to be cognizant of the quality and availability of healthcare. There is a recognition now that physicians and providers cannot deal with chronic disease. This consortium of citizens realize that the system is ultimately responsible for the quality of care. The new generation of physicians is eager to be employed and join the organization, enjoy their kids, take vacations, and only work 40 hours a week as opposed to being on their own and having no life.

This has set in motion a political maelstrom. Hilary has been elected in 2008 and the setting is there for having a comprehensive look at healthcare. CMS has collected an enormous amount of data so they can look at the quality of care in a novel fashion. They don't look just at the individual provider but also look at systems.

Congress gives CMS the authority to establish a Medicare for all. Congress realized they couldn't control the whole thing, so they established a Federal Reserve of Health. Jim Thompson was appointed as Director of the Federal Health Reserve. It was considered that his name should be changed to Lifespan. (laughter)

By 2020, there are a minimum of 150, and maybe as many as 1000, integrated delivery systems responsible for monitoring the competency and providing standards by which physicians are being evaluated. These systems employee virtually all physicians, held together by information systems.

Americans require the necessity to spend their money how they like, so there is also a system for people who want to choose to purchase insurance on the open market. Everybody is happy. The quality is no longer at the same quality as it was 2005 because there isn't the budget that we had then.

Physician Accountability for Physician Competence Summit • March 24-25, 2005 • Page 1