Provider Accountability Meets Patient Choice

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?

ACOs and Population Health - It's the Denominator, Stupid !

ACOs or Accountable Care Organizations were created by the health reform legislation proposed by President Obama and passed by the legislature one year ago. They are the Nation's new hope in reorganizing the financing (and, it is hoped, the delivery) of health care to support improved outcomes. Patients are not required to belong to an ACO and the ACO does not restrict the patient's access to any caregiver they choose. The ACO is, however, incentivized financially to help the patient organize their health care to achieve a better outcome and thus, save the health care system money. The money saved, in one model being proposed, is then shared between the payer (the insurance company or government in the majority of cases) and the provider (the ACO).

Now that the Medicare regulations have been proposed (by CMS on 3-31-11) it is clear that the attribution method used to assign patients to an ACO does nothing to encourage a health care provider to reach out to their community to engage new patients. To be in a particular ACO, the patient has to get the plurality of their care with a provider in that ACO. To be paid a premium for that patient's care, the provider must focus on optimizing the care of that patient - definitely a good thing to do.

But if I want to improve the outcomes for people with diabetes in the community, I have to outreach to the community, focusing not just on the patients who are already getting a plurality of care from me, their doctor, but rather on the at-risk patients, patients lost to follow-up, and patients who have scattered and disorganized care - using emergency rooms as their family doctor. Only by reaching those patients who are not regularly in the care of a given provider can we achieve better outcomes at a community level.

The problem is not unique to ACOs. All quality improvement programs, rewards for doctors to improve the care of their patients and all quality recognition programs for providers focus on improving the care of patients we already see. This is surely important as doctors everywhere give suboptimal care - usually missing needed preventive health care interventions and focusing on acute care needs. But to improve population health we must reach out to those who do not have a regular source of primary health care.

To accomplish this we need to change the entire process of quality reporting and add some community based outcome measures into the expanding list of measures that are used to evaluate the work of physicians. As we move our patients into ACOs, we must be sure to simultaneously increase our focus outside of our practices and make sure that we engage people not currently in organized primary care systems.

As we develop quality reports we should run them all in two ways. First, we should run them to assess the quality of care we are giving to the patients who have committed their care to us - those who, for example, have been to see us at least twice in the past year. Second, we should run our quality reports using, as a denominator, any patient who has ever been into our health center with the condition being evaluated. This will measure how well we do with patient engagement, how well we are doing with outreach to those lost to follow-up and will encourage patients who have dropped out of care, to re-engage. Even if we do not have the resources to do frank community outreach, efforts to reach this group of patients will help to address those who are not in care and will help build our patient base as well. ACOs need to develop a mechanism to support this type of work in our practices, lest they just become another reward for caring for those who are already committed to a source of care.