At least 60 doctors are registered to prescribe drugs from pain clinics in Palm Beach County, FL—a group that includes criminals and physicians fined by regulators for sloppiness or negligence, according to a Palm Beach Post review of county, state, and federal records. Authorities say unscrupulous pain management centers are attracting crime and fueling a spike in drug overdose deaths. In response, Florida leaders are calling for laws that would bar felons from running pain clinics. But some legislators, regulators, and observers argue rogue physicians are just as serious an issue, the Post reports.
In this article published by the New York Times, Anne Marie Valinoti, MD, discusses etiquette surrounding what patients call their doctors, and vice versa. Valinoti stresses the importance of patient-physician communication and says "let's face it: all communication starts with what we call one another."
There is much to debate in drafting healthcare reform legislation: who to cover, how to cover them, how to pay for it, and who will pay. But one thing seems clear: The current provider payment model that is based on a fee-for-service chassis is going to have to change. The inherent incentive to do more than may be necessary coupled with inadequate accountability for the quality of care or health outcomes are two major reasons for rethinking the nation's dependence on the fee-for-service model.
Accountable Care Organizations ("ACOs") are being proposed as part of Medicare payment reform and are also being considered by some commercial carriers as a mechanism to shift responsibility to networks of hospitals and physicians for "bending the cost curve" and improving quality. Is your organization (either hospital or physician group) ready for a world of ACOs? Regardless of the organizational model selected, here are the top ten questions to discuss among senior leadership to identify action items to prepare for the "new world."
1. Do you have the ability to aggregate clinical and financial data from community physicians as well as hospital(s), pharmacies, and independent diagnostic centers? Clinical integration, including a robust data warehouse, will be an absolute necessity if you expect to be an ACO..Real-time reporting with alerts and reminders based on evidence-based guidelines and benchmarks—at the point of care—will be critical. Longitudinal analysis of costs and outcomes across episodes of care as well as across populations of patients goes well beyond the capabilities of most hospital or medical group decision-support functions today.
2. Do you have the culture and discipline necessary to measure and enforce clinical and service standards? This isn't just a "brush-up" on traditional medical staff peer review. This means creating a discipline that is less forgiving about inconsistent application of established standards and protocols. It requires timely information (e.g., "report cards") as well as timely feedback loops and education. It also requires enforcement of sanctions if expected behaviors/outcomes are not being met. This will apply to physicians, clinical staff, and administrative leadership.
3. Do you have a culture that embraces and encourages a relentless pursuit of improved quality and efficiency in care delivery? Achieving the types of cost savings likely to be demanded will require rethinking traditional ways of delivering patient care. This starts at the physician office and includes every component of care along the continuum. It truly begins in the patient's home, where efforts to engage patients in taking responsibility for their health and self-care will be ever-more important. The way that most patients interact with our healthcare system hasn't fundamentally changed in 50 years, despite advances in technology and changing demographics. While there are some models that may hold promise (e.g. medical home, wireless technology), the successful ACO will continually promote innovation in search of "a better way" to delivery clinical care.
4. What is the depth of physician leadership to assist in driving this change? Clinical integration, care delivery redesign, development of clinical guidelines, and reporting—all necessary components—require a deep bench of clinical leaders. Today there is too often a dependence on a few physicians who are continually relied upon to drive change. Developing emerging leaders through education and empowerment will be critical steps to be accomplished sooner rather than later. This includes physician leaders as well as other members of the clinical team such as nursing, pharmacists, social workers, and educators—and yes, even administrators.
5. How do you currently interact with your community? As providers, generally we prepare ourselves for the times when patients come to us for care or advice. But in an ACO world, we will need to think more about the general population in our community—how do we reach out to them even if they do not need medical care right now? What opportunities for electronic communication, home monitoring, or other forms of interaction have we implemented? How robust is our patient web portal? Do we really live our mission statement (which in many cases is to "improve the health of the communities we serve")?
6. How honest are you in assessing what you really do well (and not so well)? In today's world, the incentive is to provide as broad an array of services and capabilities as possible in an effort to capture as much volume (and revenue) as possible. But in an ACO world, it is likely that you will want to take a much more objective view of what kinds of services you should be offering versus those that you should contract with others in the community to provide—who can deliver better outcomes more efficiently. This is the time to truly evaluate, for example, whether you should be providing open heart surgery or whether another community provider is really more capable of delivering the outcomes and efficiencies required in a global payment environment.
7. How close are you to having a "care management" culture to address the continuum of care? Do your case managers work closely with hospitalists and other physicians in assuring that the most efficient care is delivered both in and outside the hospital (e.g., follow-up appointments, alerts for repeat admissions, etc.)? Do your primary care physicians have mechanisms to identify problem signs in patients with chronic disease (e.g., ED activity, specialty referrals required, etc.)? Case management, where the focus is on managing patients who present with complex problems, needs to evolve to care management, where potential problems are identified before they result in expensive care. Ultimately, this will require the capability to do predictive modeling to identify both individual patient risks as well as more general trends that impact health status of a population.
8. Does your approach to capital decision-making include consideration for the potential of the project or equipment to improve efficiency or enhance quality—or both? Traditional ROI models that assume a consistent revenue stream based on today's payment structure could lead to decisions that may be appropriate in the short-term, but fateful for the long-term. Assumptions should weigh the risks of a rapid change in payment structures. And leadership must weigh the pros and cons of investing in the future (i.e., IT and care management infrastructure) versus investing in the present (e.g., more imaging equipment).
9. What incentives are built into your compensation structures? Productivity models (e.g. wRVUs for physicians) work well in a fee-for-service environment, but if payment requires efficiency and quality outcomes, is your incentive structure going to facilitate achievement of the desired behavior and results? Also, a review of incentives for administrative leadership may be warranted—do the incentives reward "silo" performance at the expense of system-wide performance?
10. How informed is your board, medical staff, and middle management? Moving toward systems of accountable care requires all oars moving in the same direction, at the same time, and with a consistent effort. That won't happen unless everyone knows that the rules are changing. The change in mindset and definitions of success will not happen overnight, and in fact will likely take years. Assuring that all participants have a view into the future will facilitate effective change.
The concept of ACOs requires an organizational culture of mutual accountability based on individual responsibility—with a focus on optimizing the health (not just the medical care) of all patients. Are you ready?
Laura Jacobs is a senior vice president with The Camden Group, a hospital and medical group consulting firm in El Segundo, CA. For more information on preparing your organization for ACOs, call 310/320-3990 or e-mail ljacobs@thecamdengroup.com.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
The current relationship between hospitals and physicians has been built around rewarding for volume of services and not quality. That model is breaking down as reformers in Washington have hospital and physician inefficiency in their sights, with Medicare pushing toward value-based purchasing and experimenting with a payment system that rewards a system of coordinated care. In this HealthLeaders Media Breakthroughs report that you can download for free, four leading hospital systems—Gundersen Lutheran Health System, Sanford Health-MeritCare, SSM Health Care, and Virginia Mason Medical Center—share the lessons they have learned about adding quality to healthcare.
That's an increase of about 4 million people from previous estimates released in August 2007.
Additionally, 45.4 million people of all ages, or 15.1% of the population, were uninsured at the time of an interview, which covered a period between January and June of this year. And 31.9 million, or nearly one in 11 people, had been uninsured for more than a year.
Other highlights of the report, collected from the National Health Interview Survey, revealed that during the first six months of 2009, 8.2% of children under 18 were uninsured. During the same period, 60.6% of unemployed adults between the ages of 18 and 64 had been uninsured for at least a portion of the last year.
"During the first six months of 2009, 22.7% of persons under age 65 years with private health insurance were enrolled in a high-deductible health plan (HDHP), including 6.4% who were enrolled in a consumer-directed health plan. Almost 50% of persons with a private plan obtained by means other than through an employer were in a HDHP."
The number of people under age 65 with private health insurance who were enrolled in a HDHP also increased between 2007 and 2009, regardless of whether the enrollee was covered by his or her employer or purchased coverage directly. For example, for those purchasing health coverage directly, the numbers of people with a HDHP went from 39.2% in 2007 to 48.7% for 2009, as measured in the first six months.
The survey was based on interviews with 32,694 people.
The CDC released the report as elected officials debate various ways to enable more people to have health insurance coverage.
The report disclosed additional findings:
From January to June 2009, 12.3% of poor children and 11.6% of near poor children, defined as living in families earning below the federal poverty threshold, did not have health coverage at the time of the interview. But the percentage of near poor children who lacked coverage at the time of the interview decreased from 15.6% in 2008 to 11.6% in the first six months of 2009.
The percentage of near poor adults aged 18-64 years of age who lacked coverage at the time of the interview increased from 37.7% in 2008 to 43.2% in the first six months of 2009.
Lack of health insurance coverage was greatest in the southern and western regions of the U.S.
Hispanic persons were considerably more likely than non-Hispanic white persons, non-Hispanic black persons, and non-Hispanic Asian persons to be uninsured at the time of the interview, to have been uninsured for at least part of the past 12 months, and to have been uninsured for more than a year.
Cheryl Clark is a senior editor and California correspondent for HealthLeaders Media Online. She can be reached atcclark@healthleadersmedia.com.
Senate Republicans have vowed to use every available tactic to delay voting on the healthcare bill as Majority Leader Harry M. Reid (D-NV) continues efforts to unify Democrats in support of the legislation, the Washington Post reports. Republicans showed they were prepared to extend the healthcare debate as long as possible, with Sen. Tom Coburn (OK) demanding that a Senate clerk read aloud a 767-page Democratic amendment. Three hours later, the amendment to create a Canadian-style single-payer system was withdrawn. But Republicans are expected to make a similar move when Reid introduces the revised Senate bill, which is likely to top 2,000 pages and which cannot be similarly withdrawn, the Post reports.