Sunday, July 19, 2009

How much we could change

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.


76 Degrees in San Diego said...

Your commitment to, and provision of, graduate and undergraduate medical education (and improvement) could be a valuable component in your relationships with accountable healthcare entities.

Anonymous said...

I have said before, any cooperation between hospitals and physicians will be a "shotgun marriage." This may be less (or more?) true of academic centers than community hospitals, where independence is fiercely guarded by the docs. The proper incentives are the name of the game - a concept which has so far completely escaped our government....perhaps the recent drop in Obama's approval rating will generate some leadership.


Julie Rosen said...

Global payments not only represent the promise of higher quality care, but a better patient experience as well. Studies have shown that during care transitions, patients’ wishes, values and preferences often get lost in the shuffle. If you improve caregiver communication between care settings, hopefully that important information will be passed along as well.

Julie Rosen

Gene Lindsey, M.D., President & CEO, Atrius Health said...

Thanks to Paul for acknowledging that Atrius Health is trying to improve health care in the Commonwealth. I want to raise the audacious possibility that what could be learned in the interaction between organizations like BIDMC and Atrius Health could contribute significantly to the national effort to achieve universal coverage.

In addition to establishing a strong relationship among the patient, primary physician and the hospital, it is also key that the relationship between physicians and the hospital be more than a “vendor relationship” where price is the driving force. Groups of primary physicians and multi-specialty group practices like Atrius Health must coordinate efforts with hospital partners in the spirit of the “triple aim” to improve the health of the population, enhance patient experience, and control the per capita cost of care.

Much of the inefficiency in the current system occurs at the handoff of care from the ambulatory environment to the hospital and back. There are great opportunities for new efficiencies in service delivered in and out of the hospital if we can cooperate better between office-based physicians and the hospital. Hospital and ambulatory care must be conceptualized in a new unified fashion if we want to make it easier for the patients that we share to be healthy.

An unfortunate consequences of the last few years has been that competition created by fee for service payment and the relative underpayment of primary care has fostered an environment where hospitals and ambulatory systems now must both compete and cooperate with one another. There used to be a fairly clear delineation between the hospital and the physician’s office. That is no longer the case. As more care moves from the hospital to the ambulatory space, and as both hospitals and physician groups look to ancillary testing and to delivering in-patient procedures in the ambulatory environment, there is the growing possibility of redundant assets and of generating cost that could be saved in a highly integrated ambulatory/hospital partnership.

Competition usually improves the environment for the consumer by lowering cost or increasing quality. In this case, however, incentives are not well linked to performance in healthcare so this type of competition can have the paradoxical possibility of adding costs as physician groups and hospitals try to compete for procedures that can be done in the ambulatory space.

Atrius Health envisions working with community hospitals and academic medical centers to define the optimal partnership model between ambulatory and hospital based practice. To achieve the quality that is patient centered, safe, timely, efficient, effective and equitable, Atrius Health is committed to redefining the critical partnership between hospitals and the ambulatory practice. This is perhaps the most important work to be done to achieve the economic promises of global payment in the context of quality.

The breakthrough savings and efficiencies of global payment depend on creating Accountable Care Organizations that can optimize the partnerships between organizations like Atrius Health and the Beth Israel Deaconess Medical Center where the basis of the relationship is the shared value of true quality. Organizations like Atrius Health have the infrastructure and geographical spread to coordinate optimal relationships with hospitals across a large geography. We need a financial model of shared risk that will support these optimal relationships.

The challenge lies in the ability to keep the needs of the public central to the process. The resources needed are currently available and allocated. Cooperation and innovation in the relationships between institutions like Atrius Health and BIDMC could rescue wasted resources and reallocate them to reduce the per capita cost of care. What we need is for organizations to come together with a vision of the benefit that can accrue to all of us if there is a willingness and commitment to look for new ways to replace competition with cooperation.

Disability Insurance for Physicians said...

I completely agree with the idea of a, "true partnership" as you put it. The more interaction between patients and doctors the better. If there is a way to get all of these entities on the same page health care would run a lot smoother.

Anonymous said...

Since I don't live in Massachusetts, can someone explain their concept of 'global payment'? I always envisioned global payment as a bundled payment to both doctors and the hospital (or outpatient facility, whatever) for an episode of patient care. The op-ed says Atrius Health has "years of experience with global payments." Does this mean one payment to Atrius health which is then divided among all the various primary care/specialists? If so, exactly how is that divison made?


Anonymous said...

Not for an episode of care, for the entire year's worth of care. Yes, this gets divided between Atrius and tertiary hospitals and others who might be involved in the care. They would have to explain how it gets decided who gets what portion.

Anonymous said...

Sorry to belabor the point, but I thought from the op-ed that Mass is just now considering instituting the global payment you describe. So then how could Atrius have years of experience with such payments? That's why I asked about the definition. Thanks.


Anonymous said...

Atrius, a derivative of the original Harvard Community Health Plan, always favored capitated contracts and has had them to a greater or lesser extent over the last several decades. Some other groups, too, have preferred to work under that system. But the preponderance of contracts in the state currently are based on fee-for-service.

The recent payment reform commission recommendations are encouraging a wholesale shift in the state from FFS to capitation, making the latter the dominant, if not the only model.

Anonymous said...

I get it now, thanks. Interesting that they "favor" capitation, when others scream about it. Obviously they've found a way to make it work.
I suspect the efficiencies of such a large group practice are a large part of it.
Since Mass seems further down the road that the feds seem to want to tread, I am hopeful they can make their new ideas work.
ps somewhat off-topic, see the article in the Health section of the Washington Post today entitled "Hospitals tally their avoidable mistakes", concerning mandatory reporting. The quality movement is progressing, by inches....


Anonymous said...

Not only favor it but strongly favor it. In the early days, they had to fight with insurance company marketing and sales people to let them offer managed care! For Dean Robert Ebert at Harvard Medical School, who founded HCHP, fee-for-service medicine was incompatible with medical ethics.

nas said...

Hmm intresting post, im really clued up on healthcare overbroad (from uk) but imo the nhs is the best system possible for healthcare.