One Small Step

Posted on April 25, 2011 by Mark Browne

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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A new "ist"?

Posted on April 11, 2011 by Mark Browne

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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