Sunday, October 25, 2015
There is no question that there is an enormous push now for what is being called Value Based Purchasing of health care services. In a sentence, payers would like to pay providers for achieving certain outcomes related to reducing the overall cost of care, while keeping people healthy by improving their care. It is a worthy goal.
As primary care physicians have struggled to move in this direction they have encountered two major obstacles. The first is that many patients with the poorest health and the highest health care costs have behavioral health and/or substance abuse problems. The second is that social factors, long considered out of the purview of medical or mental health care, have emerged as major risk factors for ill health and extraordinarily high health care costs.
So to prepare for the future, where payment will be based on cost and quality (together referred to as “value”), health systems must figure out a way to integrate care for behavioral health, social and substance use issues into their delivery models – either through providing those services on site, or through referral arrangements.
Many people now talk about integrating care and there are many organizations and providers trying to achieve this. We often see this as the introduction of psychiatrists or other behavioral health providers into a primary care practice or the development of a referral relationship with good reporting back and forth between primary care and mental health.
I have wondered what truly integrated care would look like. You know, the kind where each specialist focuses on their own area of expertise but every person seeing the patient in the office is responsible for every aspect of their care and well being. I believe an essential tool here is a fully integrated electronic health record – one which organizes progress notes chronologically irrespective of who the provider of care is that wrote the note or whether they are a primary care provider, behavioral health provider or a social worker trying to get housing for the patient. Just as importantly however, is the requirement that every person touching the patient is working to help the whole patient and shares a common interest in all parts of the patient’s well being.
Let me cite an example of how I will know when we have achieved this level of integration.
A 53-year-old patient with hypertension, diabetes and depression is seen bimonthly by her primary care physician and is being seen in every month by the Institute’s psychiatrist. The psychiatrist reads his own prior note to recall the patient’s last visit to him and then proceeds to read the most recent primary care note as well. He notes that the patient was started on a new hypertensive medication on the last visit. He asks “I see Dr. Jones started you on a new medication for your blood pressure last visit. How is it going? Any problems with it?”
The patient answers, “As a matter of fact, I had to stop it after a few days because of a rash. I guess I was allergic to it.”
“If you don’t mind, I’d like to check your blood pressure while you are here since it was a bit high on the last visit to Dr. Jones,” says the psychiatrist.
“Sure. That would be great.”
As it turns out, the patient’s blood pressure is very high.
The psychiatrist then asks when the next appointment is scheduled with Dr. Jones.
“Not for another 6 weeks,” the patient replies.
“After our counseling session, I’d like you to see someone for your blood pressure before you leave. Would that be OK?”
“I’d greatly appreciate that.”
At the end of her visit with Dr. Jones, he calls the nurse on the primary care team, explains the situation and the patient is put in with a physician on the team to adjust her medications.
It’s not about people with different interests in the patient each sticking to their own domain. It is about each member of the patient’s care system being concerned about the whole patient. That’s the Holy Grail. Now we just need to figure out how to get there.
Saturday, September 26, 2015
The health care system overall - and community health centers and family practices are no exception – have been constructed on a very paternalistic model. We pretend we know what is best for our patients and make a system of comprehensive care that requires continuity, appointments to be kept, and patients to obey our orders for preventive care. And we are increasing being evaluated and paid on our ability get our patients to comply with all of the preventive and chronic care imperatives that are determined to be today's best practices.
While we are evolving this system, patients are choosing to go to other models of care for urgent issues, camp physicals, immunizations, as well as for simple problems. They seek problem focused, convenient, rapid throughput visits without being engaged in discussions driven by our advice about other issues and our response to EHR-driven reminders.
We have to pay attention to what is happening now that new immediate care options are available more and more to our patients and we have to figure out where our comprehensive care model fits in. I don’t have the answer to this yet but we have been talking about it a lot in our management team meetings.
Imagine that your life is in disorder and its three days before school starts, you forgot to get your child’s immunization updated and need a school physical form filled out. Our health centers see this as a disruption in our appointment system and have difficulty accommodating this type of visit in an efficient manner.
Our patients, however, can now go to any of a dozen local sources of immediate care and get this done. I think we need to be able to figure out a way to keep our patients with us, while still allowing them to have a short visit if they need it, to accommodate their last-minute issues (haven’t we all had them at one time or another?) and still maintain them in our practice. If we stick with our old model of requiring people to get care the way we think it should be done and remain oblivious to their chosen care model and the proliferation of places where they can get it respected, then we are truly in trouble.
The real issue now is that accountability for quality will still lie with their primary care provider team, yet our patients will have more and more choices for more convenient care in between their main chronic illness visits. How we will adjust our practices to deal with that?