Ideal Medical Practices

So you want to be an ACO. Choose a winning strategy that does well by doing good.

Accountable Care Organizations are all the rage in the health policy world.  They're going to reorganize the delivery of health care in a way that improves clinical outcomes and reduces the cost of health care.  ACOs will receive bundled payment for 'episodes of care' and if they do a good job will benefit from the savings.

In theory this is a terrific idea and it may in fact turn out well.  We'll have to be on the lookout for interpretation of ACO that might lead some organizations to dump complicated patients (they'll hurt the bottom line), or to limit care in a way that erodes the clinical outcomes & experience of care (think back to the experience of some under the old 'gatekeeper' approaches that gave managed care a bad name).

What predicts a winner in the ACO world?

• The ACOs that win will be those that figure out how to keep their whole vertical organization whole while investing in interventions that significantly reduce preventable emergency room use and hospitalization
• They'll need to know where to focus interventions, so will need very good data and analytic capabilities
• The ACO winners will reach for an increasing share of the primary care market or will have to mothball hospital bed while dialing back on the capacity of their procedure shops
• The winners will invest their primary care network with the tools and resources necessary to deliver effective primary care (and will need a means to disseminate new techniques and strategies)
• • Primary care that has excellent delivery of:
  • • Access
    • Continuity/relationship/communication
    • Comprehensive services (delivering more of the care in & through primary care)
    • Care coordination (the primary care team is the source of coordination through the entire ACO)

When primary care is delivered well, populations served achieve the goals that will be set for ACOs by the payers: improved clinical outcomes, improved experience of care, reduce the total cost of health care delivery.  When primary care is delivered well, the cost improvements come as a benefit of good outcomes and not as a trade-off from onerous restrictions and expensive & wasteful 'prior authorization' interventions.

This does not have to be done through a big and expensive bureaucracy in the ACO - the primary care work force knows what it should be doing.  The PCPs may need some help understanding how to move from groups of co-workers to high functioning teams, they definitely need some help getting off the hamster wheel so that they can focus on their patient needs and less on the administrative nonsense, they need measurement approaches that identify actionable and accountable behavior of the primary care practice so that they can make appropriate course correction.

There are terrific models of teaching primary care networks how to work in this brave new world, the impediment is not the willingness to engage in this new work, it is in the compensation policies that reward volume with only lip service paid to quality, it is in payment policies that reward volume instead of care, it is in cost containment strategies that push oceans of paperwork and 'check-the-box' silliness onto underfunded primary care practices.

Real success in the ACO world requires an honest review of current policies and aggressive shift of those policies to support care delivery that achieves the outcomes.  The ACO world is predicated on a dramatic shift in payment policy. 

The choice is now up to the delivery system: do you want to be a winner?

Dr. Berwick, in his own words, to his own daughter

The ACP Advocate Blog by Bob Doherty: Dr. Berwick, in his own words, to his own daughter

A visionary in health care describing the choice new physicians can make to give compassion and healing their due place in our profession.

Follow the link, read the commencement address.

Leaving The Organization But Not The Practice Of Medicine - Better Health

August 11th, 2010 by DrAlanDappen in Better Health Network, Health Policy, Opinion, Primary Care Wednesdays, True Stories

via getbetterhealth.com

A terrific piece by Dr. Alan Dappen drawing the parallel between the change in the way he works and Ann Rice's decision to exit the organized church but continue her faith.

How long will it take for the simplicity, elegance, and savings of this approach to become apparent to businesses that purchase health care?

Even when matching like patients, the outcomes of this kind of practice are far better than typical practices that are forced to work on the hamster wheel.

In the front lines of the billing wars: throwing good money after bad arming up for the battles

I received an unsolicited email today announcing a course I can take and/or send my office coders too. Yeah, that's right, we have to hire 'office coders.' They're specialists in this war who know how to probe the enemy's weaknesses to see if there's a way to win payment for services rendered.

The whole war is stupid, adding immensely to the cost of health care - using up dollars that could be either spent on delivering better care, making care accessible to more people who are currently without, or could go to make premiums less expensive. 

What's really depressing is that policy makers want to add to the complexity by welding additional code sets to this beast as the measurement system for 'quality.'  There is a better way.  There exist simple measurement sets that don't come as huge unfunded work loads to already stressed primary care offices.  Policy makers should broaden their horizons beyond the usual beltway suspects and at least pilot some of the approaches that have lead practices to  improved population health outcomes and experience of care without pouring millions into third party measurement and consultancy empires.

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Providing great primary care reduces preventable ER visits & hospitalizations

If you look under the covers of the Group Health Cooperative 'medical home' initiative at its Factoria clinic you will find an environment that gets a lot closer to supporting great primary care:

• Panel size reduction from 2400 to 1800
• Exempt physicians from the toxic productivity pay incentives
• Add capacity to the primary care team
• Give them a little bit of coaching on 'how' and give them time to step back and look at what they're doing so they can do it better
• Group Health does not own hospitals so doesn't have to worry about that cash cow hemorrhaging over the positive effects of good primary care (fewer people landing in the ER or hospital)

It is important to keep pointing out that the probable root cause of the improvement at the practice level has to do with moving closer to an environment that supported good access, relationship, comprehensive care and care coordination.  These attributes define primary care.

Group Health has had electronic records for a long time.  They have been working the Chronic Care Model for a long time.  These elements were in place before the Factoria medical home experiment so it may be safe to assume that these elements had little if anything to do with the before/after changes.

The likely source of the improvements in the Factoria example are similar to what we saw in the Ideal Medical Practices project: solo and small practices decompress their practices so that they can provide their patients better access, relationship, comprehensive care and care coordination.  Patients in the Ideal Medical Practices project practices had results very similar to those in the Group Health project: superior experience of care, better clinical process and outcome measures, and were less likely to end up in the emergency room or hospital.

Great primary care = better access, relationship, comprehensive care and care coordination.  Great primary care translates to the outcomes we want and need: improved experience of care, better clinical process and outcome measures, and reduced ER and hospital use.

We can deliver great primary care when create a supportive environment for great primary care:

• A panel size that does not exceed the capacity of the practice
• Payment policies that support the outcomes and not the billing wars
• Measurement that focuses on the right elements and doesn't get lost in peripheral detail

We can get the results we want for American health care -  better population health outcomes, better experience of care, lower costs - when we have the guts to take on the sacred cows.  Group Health is doing it.  Ideal Medical Practices are doing it.  More employers are leaving the broken system and purchasing or starting their own primary care systems, more and more physicians are leaving insurance rules behind so that they can get back to real patient care.

The status quo system is broken.  All we need for real change is the will to take it on.

Building the foundation for great primary care is not rocket science

Primary care is the foundation of high performing health systems, and when more people have better access to good primary care, those people are more likely to achieve good health outcomes, less likely to end up in the hospital or emergency room, and health care costs are lower.  So it seems that policy makers are keen on the idea of supporting primary care.  Yay.

Good primary care has four cardinal features:  good access to care, a relationship over time, comprehensive services, and care coordination.  This makes primary care different from the rest of health care.  Doing a good job on these cardinal features results in the good outcomes listed above.  Doing poorly on these translates to worse outcomes and increased costs.

So how can we get some more of that good old primary care?

The solution is pretty simple.  If you ask Rob Reid MD who with colleagues published the paper on the Group Health Cooperative PCMH work @ their Factoria practice, you'll find out that some simple interventions lead to profound results:

• Reduce the panel size and stop fee-for-service productivity incentives to help the practice unit get off the hamster wheel
• Add some incremental staff to support the extra work of care coordination, outreach to patients, etc
• Provide a small amount of training on process improvement
• Let the professionalism of the staff drive the work

This work can be replicated in practices large and small across the U.S.  All it takes is a little bit of breathing room.  Group Health has breathing room because it has its own insurance product and can call its own shots.  GH is not beholden to hospitals looking to keep beds & emergency rooms filled.  Finally, they chose to support excellence in primary care.  The early results in publication look good.  I expect continued and improved excellence and outcomes.

The part I like best about the GH Factoria experiment is the degree to which they replicate the work of the Ideal Medical Practices project in which volunteer practices got off the hamster wheel by reducing their own overhead and panel size.  From a huge integrated system to solo independent practices.  There's a lesson here.