My colleague Gene Lindsey, CEO of Atrius Health, appeared twice in the Boston Globe in the past few days, once as the author of an op-ed, and once as the subject of an interview in the business section. As always, Gene offers thoughtful observations on current matters, and he comes to these issues with a wealth of personal and institutional experience.
I'd like to focus on a few of his points and explore the implications for an academic medical center like BIDMC. With regard to the movement towards capitated (er, now, "global") payment schemes, Gene perceptively notes that:
There needs to be a way to connect patients to primary-care physicians so that payment is made to the organization providing the care. Optimal Accountable Care Organizations will need to have a scale large enough to accept the risk of providing care on a fixed budget and the expertise and infrastructure to manage risk.
This is consistent with the message I sent to our staff a few weeks ago, where I noted:
We need to enhance and expand our clinical relationships with community hospitals and multi-specialty groups to provide a specific focus on quality and safety, to ensure that patients get the right type of care in the right place, but also to provide a dramatic improvement in the communication about patients' needs and the status of their care.
If Gene is right about primary care doctors having an ever-increasing role in managing the continuum of care in the future, the structure of the institutional relationship between primary care organizations like those in Atrius Health and the tertiary care organizations exemplified by BIDMC matters a lot. One model, which could be functional but not very interesting, is that the tertiary center would serve as a vendor to the primary care practice. In essence, this is mainly a commercial role, with a focus on the rates charged by the hospital for the services it "sells" to the PCPs.
A more vital role, though, is a true partnership, in which the medical and administrative staff in both organizations constantly seek ways to improve the patient experience. While there will always be the business aspect of who gets what percentage of the global payment, the real time and effort would be spent on improving communication of patients' clinical information, on enhancing modes of treatment based on the latest evidence, on taking steps to reduce the possibility of harm to patients at all stages of their treatment, and on helping staff in both settings redesign their day-to-day work to make it more rewarding and efficient .
In Gene's words, the latter approach reflects a commitment not to focus on "how little we need to change [but] rather [on] how much we could change." That sounds just right, but it is fair to ask tertiary hospitals how good they are at change and how well they have endorsed change in the past. Our place has learned a lot about change during the past few years -- first out of necessity when we had the near-death experience of the post-merger debacle -- later out of choice when we established audacious goals for patient quality and safety and satisfaction, when we committed ourselves to unprecedented levels of transparency of clinical outcomes to hold ourselves accountable, and when we adopted a staff-driven approach to process improvement.
The main thing we have learned about change is to be modest about what you know and what you don't know. We look forward to the opportunity to learn from Gene's group and others in the state as we pursue the creation of accountable care organizations that are truly accountable, truly care, and truly are organized.