Bridging Business & Healthcare : Healthcare Management Consultants for Dispute Resolution, Valuation & Clinical Compliance

In a nine page letter last week to CMS, the Mayo Clinic has definitely outlined its position on ACOs. Under the current proposed rules they, like many others, have publicly chosen not to participate. Mayo goes on to say that the proposed regulations are “in conflict” with the way it currently runs it Medicare operations.

Although the Mayo Clinic is only one voice in a growing chorus of dissent, I can’t help but wonder if their voice is louder than the rest. In a public letter to Senators Ted Kennedy and Max Baucus on June 2, 2010, President Obama stated that "we should ask why places like the Mayo Clinic in Minnesota, the Cleveland Clinic in Ohio, and other institutions can offer the highest quality care at costs well below the national norm. We need to learn from their successes and replicate those best practices across our country. That’s how we can achieve reform that preserves and strengthens what’s best about our health care system, while fixing what is broken." With that type of endorsement, it would hold to reason that if Mayo is a model we can all learn from and even strive to replicate, yet they aren’t going to participate in ACOs, would it be logical for anyone to participate?

I know the Mayo model is certainly not the only way to skin the accountable care cat, but they are certainly held in high esteem by most in the medical community and even more so in the political community. Although there are those who believe that one voice alone will not be enough to derail the ACO train, I do believe that Mayo’s position will significantly drive the outcome of the final rule. As a wise friend of mine once said – “Sometimes you have to count the votes, and sometimes you have to weigh the votes.”

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Recently as a colleague of mine and I were debating the latest developments in healthcare reform, he posed a not-so-rhetorical question. “So, when do you think the independent practice of medicine as we know it will cease to be?” Current statistics, if you are believer in statistics, suggest the answer to his question might be “Sooner than you think!” Hospital employment of physicians is up 75% from 2011 to 2012, operating costs in physician practices are up 51% over the last decade, only 25% of practices have successfully implemented a fully functional electronic medical record, all in the face of flat or declining reimbursement. The die does appear to be cast.

However, even in the face of what appear to be overwhelming odds, there still remain a large group of physician practices looking to reinvent themselves in any way needed to assure their continued independence. Although the independent practice as we know it will certainly change, many are unready to write its epitaph quite yet.

So what will it take to remain independent in today’s merger happy, consolidation focused environment? Here are a few thoughts (with many thanks to my colleague Jon-David Deeson for his contributions to the list below):

• Define independence – Practices may not have to be employed/aligned/merged/acquired, but every practice will need to learn to work outside of its own four walls if they are to take advantage of new payment systems, particularly bundled payments. Even the most independent of practices will need to become comfortable sharing data, both clinical and financial, with other groups and health systems.
• Measure and share your value – Living on the reputation of being the best –ologist in town who the CEO comes to see as his/her personal physician is no longer enough.  Those physicians and practices who wish to survive independently must be able to objectively demonstrate their value to patients, physicians, and health systems that they desire to have as partners and customers. Once that value is shown, proactive transparency with the data will be crucial.
• Embrace the new quality - There must be an awareness that the traditional ways we as physicians measure ourselves will not be adequate. Successful groups must not only show that they perform better than national benchmarks, they must also demonstrate that they perform better than others in the same specialty. Relative performance will become more important than absolute performance with regard to almost all measures of quality. In a world of reform, if you are not demonstrating quality outcomes, you may not be able to play at all. Those who wish to thrive must also realize that all quality measures will not objective. Patient satisfaction and communication have always mattered, but now your income will depend on mastering them and proving that you have.
• Change your ways – Although productivity still matters, maximizing your business model around a fee for service, volume focused model will not allow practices to thrive and control their own destinies. Along with the quality focus mentioned above, physicians must learn to not only provide care, but to direct care. Developing and leading a team of providers (physician extenders, care mangers, home health providers, etc..) will differentiate a physician from the rest of the pack. This model is much different than the traditional “the-doctor-will-see-you-now” model of care most physicians grew up practicing, but mastering it will be critical for any practice wishing to succeed.

It is certainly getting tougher by the day to practice medicine independently, but for those that are willing to innovate and embrace change rather than pining for the “good old days” of medicine, there may yet be hope.

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In its June 1 letter to CMS, the American Hospital Association outlined a litany of concerns and issues with the ACO proposed rule as it is currently written.  One of the key concerns brought out by  AHA was the large number of quality metrics to be tracked by participating organizations, currently set at 65 different measures.  Their proposal goes on to suggest that CMS consider a “concise set of measures” be included in the startup phases of ACOs to encourage greater participation and a greater likelihood of success in improving those metrics.  The AHA did not, however, define what it thought those metrics should be that would adequately define high quality care delivery.

Although there are certainly many quality metrics out there currently defined by CMS and others, most would agree that they have failed to capture the measurement of the delivery of truly high quality care. With that in mind, I am going to attempt, at least in part, to fill in the blank left by AHA.  Here are my thoughts on what might constitute a few new core measures for quality.

1. Physician and nurse communication as a “trigger metric”.  Even in the most sophisticated healthcare systems, thorough communication to the patient so about their care is not always the focus for all caregivers.  No communication – no quality reward. 
2.  Percent of participating physicians using clinical decision support tools – A version of this metric currently exists in the proposed rule, but is limited only to primary care.  With the rapidly growing complexity of care, not using decision support tools as they become available will become akin to not using antibiotics to treat infections. We must learn to work in new and innovative ways, using all the tools we have available, if we truly wish to improve care and lower costs. 
3. Time to implementation of evidence based care – The medical field continues to be content with slowly adopting therapies and interventions that are known to work and save lives. As an example, the use  of care guidelines around the insertion and care of central lines has been definitively shown to save lives, yet adoption across the country is not yet universal. Adoption of this type of guideline should be expected within one year of release of data deemed as “clinically significant” by a panel led by physician experts in clinical quality.

This list may not be complete and may not represent exactly the type of quality metric that CMS or AHA has in mind.  However, if we as a healthcare system, cannot successfully address some of these tough issues at the very core of care delivery, we have little hope of reaching our defined goals of truly providing the highest quality of care that we know can be delivered.

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Yesterday was no different than many other days in my life as a consultant.  Two clients, three cities, and finally arriving late evening at the hotel. It had been a long day of travel and I was looking forward to getting into my room and off of my feet. As I got onto the elevator, for some reason, the inspection certificate caught my eye and I felt compelled to read it. Capacity 1750 lbs. No more than 5 passengers. Inspection good through January 2012. And then I saw it – Certified by the State Administrator for Elevators and Amusement Rides. Elevators AND Amusement Rides?  Did I miss the “You must be THIS tall to ride this ride” sign? Visions of “approved” rusty carnival rides whirling in the air made me very glad to step out of the elevator and onto something a bit more structurally sound.

This week a new study from Mayo Clinic was released, outlining the volume of colonoscopies a physician must perform to demonstrate expertise as rated by an objective test of endoscopic skill. The study showed that the number of procedures needed to show competence in colonoscopy was nearly double the 140 procedures currently recommended. It also raised questions regarding many procedures and the training required to attain true expertise in performing them.

As we continue to plunge into a world of healthcare accountability based on value and not solely on volume, I have to ask the question: are setting the quality bar high enough? It is a difficult discussion for many practices and health systems to have, but the question of clinical competence must be expanded beyond performance that is simply ”greater than the state or national average.” Have we given our nurses and clinical staff the appropriate training to truly excel in caring for our patients? Are we holding all physicians to the same high standards for every procedure, in every setting?  Have we allocated our financial resources to truly focus on the highest clinical outcomes attainable, not just performing better than our nearest competitor? 

As the concept of measuring value and holding each other accountable for outcomes evolves, we must be cautious not to measure only what we currently can track and assume that it is good enough. We must continue to push to measure that which truly demonstrates a standard of excellence, not just a standard of competence, even if that means that some physicians or health systems won’t be able to provide that service until they can demonstrate a higher level of care. It may be difficult, but until we in healthcare hold ourselves to these new, higher standards, we will never know if we are getting elevator or amusement ride quality.

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Ask anyone who was alive in the 60’s to list the greatest accomplishments of our country and they will most certainly include the successful flight of Apollo 11 and the first moon landing.  The US spent nearly $25 billion dollars to get Neil Armstrong and company to the moon and back, but what did we really see when we got there?  Buzz Aldrin captured it best when he looked at Neil Armstrong and said: “OK. About ready to go down and get some Moon rock?” $25 billion dollars and over 200,000 miles to get there and we get…moon rock.

In 2008, the US government spent nearly $400 billion dollars on Medicare with another $200 million on Medicaid, and the numbers continue to grow every year. We now find ourselves facing the challenge of nearly 500 pages of new rules governing how this money will be spent and facing a long and arduous journey to find new models of care delivery to somehow make this all work in a new and different way. If and when we finally reach the promised land of Accountable Care Organizations, what will we find when we finally arrive?

The creation of new models of care delivery may be the greatest challenge healthcare has faced in decades, but where we actually end up may not be the most important part of the journey.  Even though our Apollo astronauts came back with a bucket of rocks, the trip to get there had great value in and of itself.  Without it we may never have had dialysis machines, CT scanners, contemporary physical therapy machines, cook/chill equipment, Mylar, athletic shoes, or even cordless power tools. 

What new innovations will come from our journey to a new world of healthcare? A patient portal app that is standard on all smartphones?  New medication delivery systems that eliminate the need for IV lines entirely? True real-time quality measures and interventions? - (Mr. Browne,  this is your patient care coordinator. I see through your iPhone app that your BP has been above baseline for 5 days. Have you been taking your medications?) And many, many others….

The destination of the new care model as it has been currently defined may end up being no more exciting or memorable than a big pile of moon rock, but the innovations we create along the way may just make it worth the trip.

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Since the term hospitalist was coined in 1996, this new specialty has grown faster than any other in the history of medicine.  Continued financial pressures on primary care, combined with increased restrictions on resident work hours and the desire of physicians for a more manageable lifestyle, created a perfect environment for the rapid growth of this field.  The success of this model has spawned the creation of similar models in obstetrics (the laborist) and, most recently, surgery (the surgicalist).  As I read through and began to digest the proposed rule for implementation of ACOs over the last week, I began to wonder if we were once again creating the perfect environment for the creation of a brand new kind of specialist….

The proposed rule has more than 50 pages dedicated to defining specific quality measures, how they will be used, and how physicians will be rewarded (or punished) based on their performance. There are 65 metrics currently outlined, the majority of which are to be measured in the outpatient, primary care setting.  Metrics include seven measures on patient satisfaction in the primary care setting, rates of 30-day post discharge visits, surveys for patients on how well they understand their care plans, “ambulatory sensitive conditions” (diabetes, CHF, dehydration, pneumonia, and others) measured both on how well you manage them as well as your ability to keep patients with these diagnoses out of the hospital – and the list goes on.  The rule goes on to outline that you must report on and perform well on each and every one of these metrics if you wish to participate in any available shared savings. The potential financial rewards for many organizations are great as are the adverse risks of underperforming. 

Primary care has been thrust into the center of medicine once again (can anybody say capitation?), but this time it appears that at least some of this model may actually stick.  Although putting the primary physician in the proverbial driver’s seat will have advantages for managing care and outcomes, there is only so much a physician can do in a day.  How will primary care physicians find the time to continue to do what they have always done – diagnose, treat, and care for their patients?  Ladies and gentlemen, I give you, The Preventionist.

The Preventionist will focus solely on the optimization of care as defined by CMS, BCBS, and any other outside entity or payer.  They will only see patients with conditions defined as focus areas for cost and quality, nothing more.  Diagnostics or other conditions? Leave that up to your family physician.  Acute illness?  We have a nurse practitioner that will see you now.  Without this focus on the ever-rising bar we are being measured against, how will any organization be able to truly succeed? This may be taking this looming model of primary care to an extreme, but ask any internist who has practiced more than 10 years if they ever thought, when they first began, they wouldn’t be caring for their own patients in the hospital?

The new rules are upon us and I do believe they were well intentioned and designed (at least in theory) to lead to better care for patients and populations at a lower cost by charging primary care, once again, to steer the ship.  However, in our haste to create a model to save money and to care for the most challenging patients, I fear we may be creating just what we are trying to avoid – misaligned incentives and a model of care that is even more fragmented than the one we have today.
 

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As I was getting my daily fix of ESPN this morning, something a bit different than the routine scores and highlights came across my TV. Two very talented men, both potentially bound for NFL stardom, were showcasing their talents for scouts, coaches, recruiters, and reporters – a panel of judges if you will. Although these players have certainly proved their talents in the past, these workouts will likely determine which player an NFL team will choose to build their future around. These workouts are vigorous, competitive, and very, very public. As draft day approaches, there is a running tally of whose stock is up and whose is down. Which player is at the top of Mel Kiper’s big board? Who will be drafted in the top ten? Will they succeed or be a bust?

As I listened to the reporter break down every step of Cam Newton’s latest pro day, I wondered what it might be like if physicians were put through this type of workout and evaluation before we were “chosen to play on a team?” If professional entertainers are subject to this type of scrutiny, shouldn’t we expect at least that from those of us sworn to care for the sick and “do no harm?”

I thought about the standard recruiting process for most physicians. A check of our background and training. A reference check from those with whom we have worked. An interview or two and a nice dinner. All of this is usually followed by an offer and a contract. Not exactly the NFL combine when it comes to assessment of quality.

The world of quality in healthcare is at a pivotal point in its history. Tracking of quality data and performance is certainly central to any health reform effort, but when it comes to individual physician performance, we admittedly have a long way to go. The arguments over which data are good enough and whether or not it “applies to me” continue to be the core of many discussions in many physician lounges and hospital board rooms. We may not ever get to the level of intensity seen on NFL draft day, but if we truly hope to deliver the highest level of quality for our patients, we must be more open to increasingly higher levels of scrutiny and evaluation of our performance.

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As a consultant, I spend a lot of time on airplanes and subsequently get to meet a new “person in the next seat” almost every week. Once the small talk is over, the conversation is nearly the same every time. “Oh, you work in healthcare! What do you think about all of this reform stuff anyway? Is there an answer?” I’m always very cautious how I frame my answer. As those of us who work in this world know, there is not AN answer so I am very careful not to endorse one model or the other, keeping the conversation turned toward the general nature of reform and the complexities it entails. 

Well today I am breaking my own rule. I want to talk about a model that just might work. I’m not sure if my inspiration was generated by the storms this weekend, making me feel a bit like the good Dr. Frankenstein, but I began to consider what a new model of care might look like if we took the best parts of some good models and built an entirely new “beast.” My thoughts are not entirely complete and your feedback is welcomed, but here goes….

The model is based on the following premises:

• Some of the best and brightest physicians have become frustrated with the complexities of billing, the noise of paperwork, and the inability to care for an unmanageable number of patients to make ends meet. As these complexities worsen, more and more physicians will either leave practice, seek out a partner (read “hospital”) to accept the growing economic risk, or move to a model of “cash for care”.
• A small number of the sickest patients consume a large share of available medical resources. In many of the new models proposed, safeguards are built in so that physicians don’t select these patients out of the care model as the risk for caring for them poses too great of a financial penalty.
• Carrots work better than sticks.

So here is the plan. Why not pay the best and brightest physicians to care for the sickest patients as simply and effectively as humanly possible? Let’s take the best parts of a concierge model of care, throw in a bit of primary care medical home and a touch of Dr. Gawande’s hotspotting model and see what we get.

The model would work like this. Take a population of no more than 300-400 patients with at least one chronic disease as their primary diagnosis and assign them to one physician. This physician would be responsible for the care of those patients and those patients only. But rather than pay the physician through any type of complex, CPT driven payment mechanism, pay them cash. No billing, no coding, simply cash up front. Sound too much like capitation? Here would be the key difference. In a capitated model, it is assumed that too much care is given and the payments are designed to reflect the risk of managing care down to a certain level of payment and reimbursement. Physicians are motivated by avoidance of an undesired negative financial outcome. In this model, the assumption up front would be one of excellent care. Remember, only those physicians who have demonstrated that they are already the best of the best in caring for complex patients would be invited. Physicians would receive payments based on their continued provision of the highest quality care to patients - not just to avoid negative outcomes, but assure positive ones. Payments would be based on the assumption that at least one hospital admission for at least half of the patients would be avoided on an annual basis. Although current payment structures for hospital care are based primarily on the volume of admissions, this model will set the stage for a value based model of reimbursement that is likely represents the next iteration of hospital payments. If you assume that a hospital admission for a chronically ill patient can quickly add up to $10,000 or more, you would very easily have enough cash flow to run a practice.   In order to assure that excellent care was given, outcome based quality and cost metrics would be measured on all patients. There would be no “quality bonuses”. Quality care is assumed and paid for on the front end. As long as the highest quality is continually demonstrated, physicians would be allowed to continue practicing in this model.

So in the end here is what we get:

• Patients who need the most care get focused attention from the best physicians leading to better outcomes of care than they can achieve in our current fragmented system.
• Unnecessary care, in particular expensive hospital based care, is reduced, thus decreasing total costs to the system.
• Physicians are rewarded (instead of penalized) for caring for complex patients with financial recognition, and by minimizing the administrative burdens inherent in practices currently.

As always, the devil on any idea like this is in the details, but if we are to come up with meaningful solutions we may need to develop a tolerance for living out here closer to the edge of creativity, avoiding the gravitational pull of current thought and the status quo.

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“Primum non nocere” – First, do no harm. This is one of the first things we are taught as physicians going through training. If Hippocrates were alive today, I think he would make it even simpler – “Do the right thing. Every time.” It seems simple. It seems so straight forward. But as we all learn, practicing medicine is neither of those things. To many physicians, medicine seems to have become a maze of complex clinical algorithms laced with a myriad of regulatory and legal hurdles and barriers to overcome. And at the center of it all is the dirty little issue no one seems to want to discuss – defensive medicine and tort reform.

On Jan 25^th, to very little fanfare, the HEALTH act was reintroduced into the House and passed by the Judiciary Committee several days later. The bill has been introduced to congress annually for the last 6 years with little or no traction at all. The bill, which focuses on medical malpractice reform, is a mere 28 pages in length - 1900 pages less than PPACA. The bill’s basic tenets are pretty straight forward: cap punitive damages; replace joint and several liability (in other words, not every physician can be held liable for the actions of other physicians); set statute of limitations on filing claims; and limit the amount attorneys can make on malpractice claims. 

The arguments on both sides of tort reform are certainly passionate, both for and against, but one thing is certain – sweeping the discussion under the proverbial rug and doing nothing (again) is no longer an option. Whether defensive medicine costs $7 billion, as the CBO claims, or $70 billion, as the AMA claims, it is a very real practice leading to the waste of very real dollars. 

We are all trying to make progress on changing the healthcare system to one that is focused on decreasing costs, improving outcomes, and holding one another accountable. If we do not address this barrier to providing high quality, appropriate clinical care, our ability to focus on the real issues will continue to be clouded and our chances of developing a truly improved care delivery system are greatly diminished.

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