We are happy to announce that the authors of Primary Care Breakfast Club published a perspective piece in the New England Journal of Medicine on September 6, 2012. Our piece, titled "The Developing Vision of Primary Care", has received a lot of feedback from all sides. If you are interested in continuing the conversation, feel free to leave a comment.
To read the piece, visit the following link: http://www.nejm.org/doi/full/10.1056/NEJMp1204487
We hope you enjoy and would love to hear your feedback!
Showing posts with label Care Coordination. Show all posts
Showing posts with label Care Coordination. Show all posts
Saturday, October 27, 2012
Tuesday, May 1, 2012
Primary Care Spring
IBM is launching what they are calling the "Primary Care Spring." At the risk of upstaging Occupy Spring they are seeking to revolutionize the way they take care of their employees by widely promulgating the Patient Centered Medical Home (PCMH). They are certainly not the first, but they represent a growing number of large insurers that have jumped on the wagon.
In a YouTube video presentation by Dr. Paul Grundy of IBM that can be found at the above link he describes 3 trends he is seeing:
1. Cost: good comprehensive coordinated patient-centered care saves money
2. Data: we can now help physicians make better clinical decisions because we now have the data needed to do so (how could he give a presentation without mentioning "Watson"?)
3. On-line asynchronous care: medical homes succeed because they allow for on-line and asynchronous care where you don't have to see your doctor to be treated and they don't have to see you to get paid. In this new information age our children will not put up with receiving care any other way.
In short, this is nothing new but it is all coming together across the country. The government, insurers, employers, providers, and patients are all recognizing that accessible, coordinated, patient-centered care really does save money and make people healthier.
You CAN have your cake and eat it too.
-JKR
In a YouTube video presentation by Dr. Paul Grundy of IBM that can be found at the above link he describes 3 trends he is seeing:
1. Cost: good comprehensive coordinated patient-centered care saves money
2. Data: we can now help physicians make better clinical decisions because we now have the data needed to do so (how could he give a presentation without mentioning "Watson"?)
3. On-line asynchronous care: medical homes succeed because they allow for on-line and asynchronous care where you don't have to see your doctor to be treated and they don't have to see you to get paid. In this new information age our children will not put up with receiving care any other way.
In short, this is nothing new but it is all coming together across the country. The government, insurers, employers, providers, and patients are all recognizing that accessible, coordinated, patient-centered care really does save money and make people healthier.
You CAN have your cake and eat it too.
-JKR
Friday, January 20, 2012
Renegotiating Reimbursement: Good Policy or Good PR?
Yesterday Partners Health Care, Massachusetts largest health system, voluntarily disposed of its current contract with Tufts Health Plan and renegotiated a new four year agreement that is expected to lower the health reimbursements they receive by about $105 million dollars over the next four years.
This is significant. In a conversation I had with a Partners executive two months ago he shared that the Partners negotiating team often leaves their contract meetings with groups like Tufts feeling "proud" of the deals they are able to strike with health insurers. My impression was that Partners, with the largest market share of any hospital system in Massachusetts, knows it can throw its weight around and does quite willingly.
Not any more. Partners' decision to rework its contract with Tufts, following a similar renegotiation last year with Blue Cross Blue Shield that is estimated to save $240 million dollars, was likely due to the following.
- Altruism: although not likely the biggest factor, Partners CEO Gary Gotlieb did state that one reason for accepting smaller increases in reimbursements going forward is the growing burden of health care costs on families and businesses.
- Government pressure: the political environment in Massachusetts, and in many areas of the country, is such that all hospitals understand that costs must be cut voluntarily or else the government is likely to do it for them. With Massachusetts congress toying with rate setting as a way to control out of control medical costs, hospitals would rather be a part of a pre-emptive solution.
- ACOs: Partners was recently announced as one of 32 Pioneer ACOs set to begin this year. As part of the agreement, ACOs commit to generating at least 50% of their revenue from business models similar to that of the Pioneer Medicare program. This can only be accomplished through agreements with insurers, employer health plans, and/or Medicaid (called "Participation of Other Payers" in the CMS Pioneer ACO Fact Sheet). As part of Partners' new agreement with Tufts, approximately 70% of the patients in the plan will now be reimbursed via a global payment structure, shifting significant risk to Partners and forcing them to find ways to contain costs for all their patients, not only the Medicare population. This is exactly the goal of the ACO, and to the extent that Partners' participation in the Pioneer program is influencing this new agreement with Tufts, the ACO model is succeeding.
Whatever the reasons, I applaud any move by hospital systems to voluntarily forego future payment. Additionally, I applaud any move toward global payments and the taking on of risk by hospital and physician groups. However, scale must always be kept in perspective. While $105 million dollars is no small amount, with an annual budget of over $8 billion dollars and capital expenses totaling $3.2 billion dollars over 5 years, it doesn't seem like so much. Additionally, there has been little talk of where the $105 million dollars in "cuts" to Partners bottom line will come from. The hope is that money will be saved through care coordination and a focus on the high utilizers or perhaps a reduction in capital investments year over year. I imagine that if savings do not materialize, however, chronically underfunded mental health and substance abuse programs will instead be on the chopping block, and this would be an unwelcome result.
Despite my significant skepticism of the hospital market environment in Massachusetts and at the risk of being duped by what may turn out to be simply a PR move, I am encouraged that, whether it be altruism, the political environment, government policies, the market at work, or some combination of these, the system appears to be working. At least for today.
Tuesday, November 22, 2011
An Evening with Dr. Blumenthal
I just got home from a fascinating 3 hour talk with Dr. David Blumenthal. You can read more about him here, but he is basically one of the leaders in the quality field of health care and recently spent 2 years working in the Obama administration as the head of Health Information Technology (HIT). He came to speak to our US health policy class at the Harvard Kennedy School of Government and a smaller group of us had dinner with him afterwards. I wanted to share a couple things he spoke about that I found compelling.
Cost
Dr. Blumenthal answered one question about cost containment, which has been a hot topic in the national debate of late and something I've been reading quite a lot about. His answer was not novel nor complicated but brought my attention back to the reality of our health care system. 5% of the patients account for 50% of the costs. Atul Gawande wrote about this in his The Hotspotters article in January and countless others have shed light on this as well. Blumenthal's answer was simple: "Go where the money is." He spoke about better coordinating care, keeping these patients with multiple chronic diseases out of the ER and hospital, and actively pursuing them to better manage their care. Call them at home everyday, visit them in person, lay out their 15 or 20 medications for them, and fill in every gap where their care is dropped.
My reflection is this: If we are serious about reducing health care costs, and there is no doubt that we now are, we must work tirelessly to first find these patients in our health care system, even if they are not our own. We must proactively engage them in the medical system so that we are not caught reactively responding in extremely inefficient ways. We must think system-wide about the ways in which we currently fail to fill the gaps and bring all of the sometimes dozen providers for these patients into the discussion. And we must find innovative ways to engage the patients and their communities to embrace healthier attitudes and behaviors the are community driven.
Health Information Technology
We couldn't spend three hours with Dr. Blumenthal without talking about health IT, something he spent the last two years of his life on in Washington. Here are some of his reflections:
-Health IT is rapidly expanding across the country and has doubled in the last 2 years
-Competition and decentralization of HIT is good because it is driving innovation in the field. There are now over 1300 different private companies providing HIT and the innovation they are creating will have enormous positive impacts decades into the future. Quelling that force now in favor of a more unified system is the wrong thing to do.
-That being said, cross-talk is an important part of the future of our electronic medical records (EMR). Patients need to be able to take their records with them when changing locations and health systems. The government has put in place standards that are being adopted by the private HIT enterprise. Providers will also have to achieve some standard of meaningful use in the coming years to earn the substantial savings available through the stimulus bill that passed in early 2009. It is up to providers to put pressure on the health IT companies they work with to comply with these standards
-Privacy isn't nearly as big an issue as people say it is. Technology has been developed. Barriers to the sharing of information is primarily systems and politically generated.
-He doesn't have much sympathy for small practice physicians who are complaining about the cost of switching to EMR. The previously mentioned stimulus bill has provisions that will more than pay for their implementation, provisions that amount to $100 of tax revenue per American citizen to make this happen. He says this indicates that the public prioritizes it and it is high time providers do too.
-He is very optimistic that HIT will continue to grow, and it is necessary, but not sufficient, to attending to many of the problems in our health care system.
Quality
Dr. Blumenthal is a national leader in the quality movement in health care. He spoke at length about this during our structured lecture with him. Quality essentially was put on the map in the late 1990's after the Institute of Medicine's report in 1999 called "To Err is Human." This was followed in 2001 by another report from the IOM that Blumenthal described as a seminal document called "Crossing the Quality Chasm." Prior to these reports, quality was not on the policy map as much of an issue.
Quality is something that I admit I don't think about much. I tend to be of the mindset that our health care system is pretty darn good, but I often compare it to other places I've been in the world that have far worse health systems but also shoddy electricity. This fails to ask the important question, "How can we do better?" If I truly reflect on my medical training, I'm appalled at much of what goes on in the hospital and even in the outpatient setting. Care is so fragmented that providers are often very under-informed about the stage of care delivery a given patient is in or a recent change in treatment plan proposed by a different physician or service. The bottom line is that lots of bad things happen all the time with even more near-misses to make even the most inexperienced clinician worried.
This is what Dr. Blumenthal has been trying to remedy. So while I often push quality issues to the back of my mind, they are an area we can drastically improve on. We will save money if we keep people's blood pressures and hemoglobin a1c's under better control and don't order unnecessary costly imaging studies. We will save lives if we prevent infections in the hospital by washing our hands. And we will make much better clinical decisions if we have electronic records that remind us when we are doing something outside best practices. I think we can do a lot better to improve quality and I am excited that through better care coordination and the smart use of HIT we can work to accomplish so much more than simply containing costs. After all, our primary goal is helping patients get and stay healthy.
JK-R
Cost
Dr. Blumenthal answered one question about cost containment, which has been a hot topic in the national debate of late and something I've been reading quite a lot about. His answer was not novel nor complicated but brought my attention back to the reality of our health care system. 5% of the patients account for 50% of the costs. Atul Gawande wrote about this in his The Hotspotters article in January and countless others have shed light on this as well. Blumenthal's answer was simple: "Go where the money is." He spoke about better coordinating care, keeping these patients with multiple chronic diseases out of the ER and hospital, and actively pursuing them to better manage their care. Call them at home everyday, visit them in person, lay out their 15 or 20 medications for them, and fill in every gap where their care is dropped.
My reflection is this: If we are serious about reducing health care costs, and there is no doubt that we now are, we must work tirelessly to first find these patients in our health care system, even if they are not our own. We must proactively engage them in the medical system so that we are not caught reactively responding in extremely inefficient ways. We must think system-wide about the ways in which we currently fail to fill the gaps and bring all of the sometimes dozen providers for these patients into the discussion. And we must find innovative ways to engage the patients and their communities to embrace healthier attitudes and behaviors the are community driven.
Health Information Technology
We couldn't spend three hours with Dr. Blumenthal without talking about health IT, something he spent the last two years of his life on in Washington. Here are some of his reflections:
-Health IT is rapidly expanding across the country and has doubled in the last 2 years
-Competition and decentralization of HIT is good because it is driving innovation in the field. There are now over 1300 different private companies providing HIT and the innovation they are creating will have enormous positive impacts decades into the future. Quelling that force now in favor of a more unified system is the wrong thing to do.
-That being said, cross-talk is an important part of the future of our electronic medical records (EMR). Patients need to be able to take their records with them when changing locations and health systems. The government has put in place standards that are being adopted by the private HIT enterprise. Providers will also have to achieve some standard of meaningful use in the coming years to earn the substantial savings available through the stimulus bill that passed in early 2009. It is up to providers to put pressure on the health IT companies they work with to comply with these standards
-Privacy isn't nearly as big an issue as people say it is. Technology has been developed. Barriers to the sharing of information is primarily systems and politically generated.
-He doesn't have much sympathy for small practice physicians who are complaining about the cost of switching to EMR. The previously mentioned stimulus bill has provisions that will more than pay for their implementation, provisions that amount to $100 of tax revenue per American citizen to make this happen. He says this indicates that the public prioritizes it and it is high time providers do too.
-He is very optimistic that HIT will continue to grow, and it is necessary, but not sufficient, to attending to many of the problems in our health care system.
Quality
Dr. Blumenthal is a national leader in the quality movement in health care. He spoke at length about this during our structured lecture with him. Quality essentially was put on the map in the late 1990's after the Institute of Medicine's report in 1999 called "To Err is Human." This was followed in 2001 by another report from the IOM that Blumenthal described as a seminal document called "Crossing the Quality Chasm." Prior to these reports, quality was not on the policy map as much of an issue.
Quality is something that I admit I don't think about much. I tend to be of the mindset that our health care system is pretty darn good, but I often compare it to other places I've been in the world that have far worse health systems but also shoddy electricity. This fails to ask the important question, "How can we do better?" If I truly reflect on my medical training, I'm appalled at much of what goes on in the hospital and even in the outpatient setting. Care is so fragmented that providers are often very under-informed about the stage of care delivery a given patient is in or a recent change in treatment plan proposed by a different physician or service. The bottom line is that lots of bad things happen all the time with even more near-misses to make even the most inexperienced clinician worried.
This is what Dr. Blumenthal has been trying to remedy. So while I often push quality issues to the back of my mind, they are an area we can drastically improve on. We will save money if we keep people's blood pressures and hemoglobin a1c's under better control and don't order unnecessary costly imaging studies. We will save lives if we prevent infections in the hospital by washing our hands. And we will make much better clinical decisions if we have electronic records that remind us when we are doing something outside best practices. I think we can do a lot better to improve quality and I am excited that through better care coordination and the smart use of HIT we can work to accomplish so much more than simply containing costs. After all, our primary goal is helping patients get and stay healthy.
JK-R
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