John emailed to say how happy he was for one of his patients with diabetes.
“He rarely ever follows up with me and rarely ever gets his blood work done (I always have to beg his wife to get him in), and his last 4 HGBA1Cs were 14.9, 12.7, 10.6, and 12.0 (in Dec 2011). Yesterday, his HGBA1C was 7.5! He is walking 30 minutes a day and is writing down everything he eats. He is down 8 pounds from the beginning of the year and feels great.” - John
John has a solo independent family medicine practice and uses an electronic health record. John’s intervention was to hire a part-time nurse wellness coordinator and house her in his office. This RN enjoys the interaction with patients and the ability to use a greater range of nursing skills and training than is typical in most practices. The intervention starts with four one-hour long sessions, either one-on-one or with family, and then graduates to follow up phone calls.
John’s revenue comes exclusively from insurance payments (no membership or extra fees charged to his patients). He pays the RN for 16 hours per week of work, yet his practice receives no extra payments, bonus, or incentive dollars for the wellness coordination work or the improved outcomes. John worries that charging patients for this additional support will discourage participation by those who most need the help, so he is reluctant to charge a fee for these services.
The evidence base for the intervention:
- Changing health behavior has the greatest potential…for reducing morbidity and mortality and for improving quality of life across diverse populations…50% of mortality is from 10 leading causes of death linked to lifestyle changes such as tobacco use, poor diet, inactivity, alcohol and drug use, and sexual behavior[i]
- Randomized trials of simple coaching demonstrate lasting impact on patient outcomes.[ii]
- This coaching can be replicated and used by primary care practices to help patients improve outcomes.[iii]
This collaborative physician/nurse coaching model is likely to help other patients in the practice. Efforts like this tend to improve overall clinical outcomes, the experience of care, and the total cost of care.
High performing health systems are founded on good primary care. Good primary care leads to better outcomes and lower total costs of care. Good primary care includes much work that is not part of the current funding stream. This lack of adequate primary care funding hamstrings effective primary care and is one of the root causes of the cost/quality we face today.
One solution may be the aggregation of small practices into larger health systems. This solution is receiving almost all the attention of those interested in improving health care, but some evidence points out that this aggregation adds to the overall costs of health care without necessarily improving outcomes.[iv]
Would it not be interesting to support networks of primary care practices like John’s to:
- Reduce the threshold of adoption of techniques that improve outcomes
- Achieve economies of scale in population health management across solo and small practices
- Provide a sufficient attributed patient population for accurate tracking of outcomes (real outcomes like hospitalization rates, ER visit rates, not a bevvy of bioclinical intermediate measures that often have little to do with what really matters[v])
Health plans should by all rights be very interested in this approach but seem to spend all their time negotiating with hospital-centric ACO types that must by their nature struggle with goring their cash cow to achieve “shared savings.” A primary care virtual ACO has no such conflict of interest.
I’m not suggesting anyone drop the hospital-centric ACO work, but where is the action on the primary care virtual network model?
[i] Evelyn P Whitlock et al., “Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-based Approach,” American Journal of Preventive Medicine 22, no. 4 (May 2002): 267–284.
[ii] Tim A Ahles et al., “A Controlled Trial of Methods for Managing Pain in Primary Care Patients with or Without Co-occurring Psychosocial Problems,” Annals of Family Medicine 4, no. 4 (August 2006): 341–350.
[iii] John H Wasson et al., “Clinical Microsystems, Part 2. Learning from Micro Practices About Providing Patients the Care They Want and Need,” Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources 34, no. 8 (August 2008): 445–452.
[iv] Gardiner Harris, “More Doctors Taking Salaried Jobs - NYTimes.com”, n.d., http://www.nytimes.com/2010/03/26/health/policy/26docs.html?pagewanted=all.
[v] David B. Reuben and Mary E. Tinetti, “Goal-Oriented Patient Care — An Alternative Health Outcomes Paradigm,” New England Journal of Medicine 366, no. 9 (March 2012): 777–779.