Monday, October 26, 2015

Collaborating for better care

On March 23, 2010 President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act and otherwise referred to as Obamacare. PPACA was designed to be the financial, technological, and clinical transformation of hospitals and primary physician practices. The goal of PPACA was that healthcare would be more affordable and accessible for all people as well as it would decrease the financial impact of healthcare on the government. Theoretically it sounded good, however there is a major glitch in the system which has prevented it from attaining an important component of the overall goal, a decreased emergency room (ER) visits.  According to a May, 2015 USA Today article, three quarters of ER physicians report surge in ER visits since PPACA became effective.
You may be asking yourself, if more people have medical coverage under PPACA, why ER visits would be on the rise. The answer, projected to be a problem before PPACCA’s implementation, is the insufficient number of primary care physicians to keep pace with the number of the newly insured. More and more, physicians are opting out of primary care due to the level of reimbursement which does not correlate fairly to the multi-services needed to provide optimal care. The lack of a balanced patient/physician ratio means longer wait times for appointments driving those in need of care, not necessarily emergency care, to the ER. The other side of the story according to The American College of Emergency Medicine press release is that 97% ER physician report treating Medicaid patients daily who were unable to find a doctor willing to accept their insurance. Medicare is not immune to this either as increasingly physicians are not accepting patients with Medicare either. Even more frightening is a growing trend where physicians are moving towards a direct pay/concierge practice (contract for service) where the third party payer (insurances) are eliminated. My concern is are we beyond the point of repair and if not what can be done to possibly correct it?
Admittedly, countless attempts have been made by health care leaders and policy makers to address eliminating fraud, checking errors, compelling following guidelines, educating healthcare consumers, etc. with none having the desired impact.  My concern is are we beyond the point of repair and if not what can be done to possibly correct it?
Michael E. Porter, a professor at Harvard Business School and Thomas H. Lee, MD, chief medical officer at Press Ganey Associates in their article The Strategy That Will Fix Healthcare have outlined a strategy which I believe is worth considering.  They emphasize to create a successful strategy one must have concise goals. The main goal for both healthcare providers and stakeholders should be improving value for patients. Value should be defined by the outcomes that matter to healthcare consumers in relation to the cost to achieve them. Raising value requires improving the outcomes without increase in cost or lowering cost without compromising the outcome. The strategy is a six step process:
·         Step 1. Organize into Integrated Practice Units (IPUs)

The manner in which we deliver care needs to be transformed. Care should be organize around the healthcare consumer’s needs and medical condition/s. IPUs treat not only the condition but also all related conditions and complications associated with it. An example would be the treatment of diabetes. Diabetics also can have directly related eye and kidney problems. In addition to clinical care there is also the need for educational and counseling services. This helps to encourage patient engagement in their care as well as support to make lifestyle changes. IPUs help eliminate fragmented care because services are provided at one location and are coordinated by a team.

·         Step 2. The Cost and Outcomes for Each Patient Is Measured
The outcomes and cost by condition is rarely tracked by providers or insurers. This gives insight as to why reforms have failed to change the progression of usefulness of the healthcare system. In those instances where measures are done, the focus has mainly been in the area of mortality and safety. Using diabetes again, providers gauge such things as lab values (A1C or LDL cholesterol) as outcome markers. Yet for the diabetic what matters is maintaining vision, avoiding dialysis, reducing their risk of a heart attack, stroke or the need for amputations. These are the true markers to measure cost and outcome for diabetes.

·         3. Bundled Payments for Care Cycles

The two current payment systems, dominant payment or fee-for-service address, fail to reward for improvement in the value of care. With the global payment system (single payments for patient’s care) providers are rewarded for spending less. Fee-for-service rewards providers for volume generated (how many of services they provide) without consideration of value. Bundled approach reimbursement is made to cover the full care cycle for a chronic condition over a specific period of time (usually a year) or primary and preventive care for a defined population (healthy children, adults or seniors as an example). Bundled payments encourage both a team approach and high valued care. 

·         4.  Integration of Delivery of Care System

In 2011, 69% of healthcare organizations were multi-site. Multi-site healthcare organizations are generally stand-alone units that provide duplicated services. By integrating systems there is a higher possibility of eliminating fragmented and duplicated care, while optimizing the care delivered at the site. To achieve such a system there are four things to consider – scope of services, concentration of volume in fewer locations, matching the right service for location, and integrating patient care across all locations.

·         5.  Expand Geographic Reach

The delivery of care is generally localized to geographic areas. To provide superior and specialized care to more individuals requires strategic expansion of IPUs. Full service hospitals/practices focus on volume and not necessarily improving value. One model for expansion is the creation of a hub-and-spoke model. Main facilities (the center of the hub) handle more complex cases with the satellite facilities (the spokes) handling the less complicated care.  The other option is the clinical affiliation model. The IPU partner with community providers or other local organization and use their facilities. An example is the approach taken by MD Anderson. They lease outpatient facilities on community hospital campuses utilizing the hospital’s operating room and other inpatient and ancillary services as needed. This is a win/win situation. The local affiliates benefit from the expertise of the parent IPU and the IPU broadens their market share, regional reach and referrals of complex cases. 

·         6.  Build an Enabling Information Technology Platform

This is perhaps the meat of the strategy…the ability to develop an interactive supporting information system. History has seen failure in this area due to complicated rather than integrated multidisciplinary care. The right IT-system can help IPUs work together and tie all the parts of a well-structured delivery systems together.
This strategy is being implemented increasingly throughout the United States. Just recently a local facility in my area became the “gold star” of cardiac care with the joint alliance between MedStar Heart Institute and the Cleveland Clinic Heart and Vascular Institute. According to Dr. Stuart F. Seides, the Heart & Vascular Institutes Physicians Executive Director, “our whole is now greater than the sum of our parts…with this alliance, the future of heart care in this region is transformed”.
I envision the coming in of an era where this is done for not just heart disease but for all aspects of care.

Please give me some feedback on this one…until next time…NAMASTE.

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