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

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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As a healthcare consultant, I live in a world of TLAs – three letter acronyms. Accountable Care Organizations are ACOs, and are kind of like PHOs (Physician Hospital Organizations), which sort of remind us of clinically integrated IPAs (Independent Practice Associations). Once we have made that shift from actual words to brief alphabetical snippets, the meaning of the original words seems to get confused or even lost entirely. This may be the case with one of our latest acronyms – PCMH.

Many would say that PCMH stands for Primary Care Medical Home but recently I have seen the definition shift. PCMH now can also mean the Patient Centered Medical Home – which, when you look at most published definitions, still looks more physician centered than patient centered. Much of our society is already light years ahead of medicine when it comes to being consumer centric. As I considered this, I wondered what a truly Patient Centered Medical Home might look like. Not one that just talks about the patient, but one that is all about the patient.  

Whose network is it anyway? Primary care medical homes are all about coordination of care by a single physician, one who can make sure all of my medical needs are met with high quality and efficiency. In a Patient Centered Medical Home, the physician is part of the patient’s network, not the other way around. Why would I want only one doctor to care for all of my needs? If I have diabetes, CHF and osteoporosis, I want to choose the best endocrinologist, dietician, cardiologist, rheumatologist, nurse practitioner, and maybe even an acupuncturist if I happen to believe it might help my pain. In a patient centered model, the physician is no longer the coordinator of care; the patient has assumed the majority of that role.

Care when I want it– In a primary care medical home, access is important. Things like weekend hours, evening hours, and even telemedicine are key components. In a patient centered medical home, the physician’s schedule is not the issue at all; the patient’s schedule is the key. Access to care would simply be on demand, 24/7. Sound extreme? Think ATMs and TiVo. When is the last time you heard a 25-year-old ask when the bank was open or when a TV show was on?

No secrets - Physician led medical homes focus on transparency. Sharing information with patients and patient education is an important element of their success. However, in the world of instant access to information, including medical information, a patient centered model would move fromtransparency about information to listening to information that I, as the patient, bring regarding me and my care. Current models of care are still designed for the medical information and treatment plans to flow from the physician to the patient, not the other way around. Patients may not have the level of education that we as physicians have, but they do have access to the same information and, at times, new and different information, that we may not always consider. The information playing field may never be leveled, but in the new healthcare world it is certainly tilting more toward the patient than ever before.

Making sure we understand the meaning of the new care models we are developing is critically important as reform marches on. Words are important, and how we interpret them is even more so. MD – Medical Doctor – still has great meaning, and I believe it always will in any new care model. But to many people, MD is also beginning to mean Modern Doctor - and that definition is still in the works. 

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My last several posts have been, shall we say, a bit on the frustrated side, so I’ve decided today to change my approach and embrace my inner optimist. Rather than lament the challenges surrounding us as we all swim our way through the muck and mire of healthcare reform, I have resolved to focus on the positive and share some of the new care models that are being tried by some very innovative folks. To be sure, these ideas are not what has been in the mainstream press and not one of them has the momentum of ACO’s, but I believe there are some real pearls in each of them. This list is not complete by any stretch and I would love to hear about others that I might have missed.

• The Prometheus Payment system – The theory of getting a group of physicians together to decide what it costs to care for a particular disease, paying them upfront, and then holding them accountable for the care is a very interesting physician-led twist on the ACO. Several large health systems are trialing this system as we speak. It has significant backing through the Robert Wood Johnson Foundation.
• FaircareMD – By striving for transparency in pricing, this model targets those with large out-of-pocket expenses and lets patients choose their doctors based on price. Wouldn’t this get interesting if it also included good solid quality measures and let patients choose on value? Maybe we could call it ValueCareMD….?
• Practice Fusion – Practice Fusion provides a completely functional EMR free of charge (yes, that’s right – free). The EMR is web-based and ad-supported with non-intrusive ads throughout the product, shifting the cost away from the provider to the vendors.
• Care Practice – By providing 24/7 urgent care and house call service this group has embraced the concept of “radical access” leading to “the practice of least resistance.”
• Qliance and One Medical Group – These models are bringing concierge care to the masses. For a fee similar to your monthly gym membership, you can get a greater level of service and attention than your traditional primary care practice as well as online records access and same day appointments. This may appeal to those with a high deductible HSA plan and who are becoming more and more cost conscious.
• Hello Health – By putting patients in charge of their own healthcare through creative use of the Internet and social media, this model is truly on the leading edge of the healthcare curve, and it may be just what the doctor ordered for the new iPad generation.
• ZocDoc – Think OpenTable.com but for medical appointments. The website says it all: Find a doctor. Choose a time. See a doctor. You are in control.

Even though CMS has created a Center for Innovation, true innovation is much more likely to occur on the fringes in models like the ones mentioned above. I, for one, will be watching these new and exciting innovations closely as they continue to evolve. PPACA is certainly not the only game in town and others are providing us with lots of great ideas and information along the way. Maybe the healthcare reform glass is half full after all.

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Over the last several days I have been pouring myself into the latest information from CMS on what lies ahead in the world of quality – that being the proposed rule on Value Based Purchasing as published in the Federal Register. As with most things that the government produces, I prefer to read the original text, not only the summaries, as many of the finer details tend to get overlooked.

As I dug into the first page, I was actually a bit encouraged. We all know that quality will be included in whatever form of reimbursement is on the horizon and CMS’s approach sounded reasonable. 

Scoring methodologies should be reliable, as straightforward as possible, and stable over time and enable consumers, providers and payers to make meaningful distinctions among provider performance.

Makes sense to me. Then I read on….

After a 7 page description on why the metrics chosen were the most appropriate metrics, CMS goes on to dedicate a full 20 pages of the 39 page rule to describing the proposed scoring system, including a discussion of the use of "cube versus linear models" of the exchange function to determine ultimate distribution of payments among hospitals. It reminded me a bit of my vector physics classes from undergrad, but a little less understandable.

As those of you who know who know me well, I am in full support of integrating the measurement of quality into any reimbursement model. However, by trying to so fully objectify this measurement, it appears as if CMS has created (or at least proposed) a system that is begging to be gamed by those that participate in it. How long will it take for vendors to begin promoting “key indicators” that, if focused on and improved, will lead to greater reimbursement? And even if these “key indicators” are met, will we really see any appreciable improvement in quality of care? By focusing on payment reform first and care delivery reform second, we are once again creating another model of measurement rather than a model of improvement.

I don’t have all the answers, but I do believe as do many of my colleagues, that for any new delivery system to succeed, there will need to be a greater degree of collaboration between physicians and hospitals. If a measurement system of this complexity is ultimately implemented, it may very well lead us to the law of unintended consequences. By focusing on the details of the payment system and not the improvement of the delivery system, we make it more difficult, if not impossible, to achieve the integration, alignment, and redesign necessary to build the new delivery system that we can all agree is sorely needed.

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This may be a surprise to some of you, but I do not look good in a mu’u mu’u. For those of you who may not know, a mu’u mu’u is a very comfortable, very loose fitting Hawaiian dress that just sort of hangs off the shoulders of the wearer. It is designed to fit almost anyone and to be worn for any situation. And although it may fit over my frame, I certainly do not look good in one.

As I read and follow what’s happening in the healthcare landscape, it seems to me that many people are searching for the mu’u mu’u model for healthcare. What can we design that fits (most) everyone in every situation? And by doing so we have lost sight of the fact that there are very likely multiple solutions to this very complex problem.

Last week Atul Gawande wrote an excellent article in The New Yorker entitled “The Hot Spotters” that asked the question Can we lower healthcare costs by giving the neediest patients better care? His arguments were both persuasive and thought provoking. I do believe, this model may indeed work for certain patient populations – the sickest among us, but will almost certainly not work for the remainder of us. Models such as Qliance in Seattle or Hello Health in New York City provide new and innovative ways of seeing patients and will be great for some, but will not work as well for the patients Dr. Gawande describes.

Much of the discussion and debate on Capitol Hill and around the country is focused on which model will improve quality the most and save the most cost. This equation too frequently circles back around to a model which is driven by the most efficient payer structure or by what will fit into the already existing mammoth infrastructure that exists in healthcare today. As long as we continue to ask the question of which model is best, I fear we will continue to get the same answers. The question we should be asking is how can we best care for very different patients with very different healthcare needs. Before we all get herded blindly into the ACO corral, let’s be certain we are focusing on caring for the needs of patients, not just the need to have a solution.

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