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

2,080. 40 times per week. That’s the number of wrong site surgeries still happening annually in hospitals and clinics across the US, according to a recently released study from The Joint Commission. I read the article with great interest yesterday morning as I was making my way through several airports traveling to a client site. As I walked through an airport I stopped to watch several news stations, expecting to see some outrage at such statistics. Maybe even a catchy new headline – “The War on Error”.  I watched them all - CNN, Fox News, the political gamut – and saw…nothing. Not one story. Not even a passing interest. 

Have medical errors become so much a part of the fabric of our healthcare system that this type of news doesn’t even merit a mention? Has getting the wrong care become not only accepted, but expected?

As healthcare reform continues to press forward, we continue to design fixes that will allow us to slowly evolve into a new delivery system, all while not changing our current system too much or too quickly. We seem to have agreed somewhere along the way that some frequency of errors is acceptable, and that we need to work on this slowly, lest we break the system we have worked so hard to create.

This study proves what we already know – our healthcare system is still broken. How long will we as a nation continue to tolerate slow and steady fixes to the system, and at what cost? 

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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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