by Vince Kuraitis JD, MBA and Jaan Sidorov MD, MHSA, FACP
Gazing at the horizon, we foresee the potential for a tectonic realignment among physicians, hospitals and payers. Here’s a quick visual representation:
This essay is the first of a seven part series. In this first post we will capsulize our vision of this potential 100 Year Shift, answer initial FAQs, and lay out the structure for the rest of the series.
The Lynchpin — Changing Economic Incentives
In the past, physicians and hospitals have benefited from mutually supportive economic interests.
My guess is you’ve probably never asked yourself this question. A quick preview:
- Technical barriers aren’t the limiting factors to Facebook becoming a care coordination platform.
- Facebook’s company DNA won’t play well in health care.
- Could Facebook become the care coordination platform of the future? If not Facebook, then what?
1) Technical barriers aren’t the limiting factors to Facebook as a care coordination platform.
Can you imagine Facebook as a care coordination platform? I don’t think it’s much of a stretch. Facebook already has 650 million people on its network with a myriad of tools that allow for one-to-one or group interactions.
What would it take to make Facebook a viable care coordination platform?
- More servers to handle the volume — not a problem
- Specialized applications suited for health care conditions — not a problem
- Privacy settings that made people comfortable — more on this later
- A mechanism to identify and connect the members of YOUR care team — really tough, BUT this is NOT a technological problem, but a health system one
Suppose you are a 55–year-old woman who is a brittle diabetic. Your care team might include a family physician, an endocrinologist, a registered dietitian, a diabetic nurse, a ophthalmologist, a podiatrist, a psychologist, and others. Ideally you’d have one care plan that coordinates the care among members of the team, including you.
What’s the reality of today’s health care non-system?
- There is no formal designation of “your team.”
- There is no mechanism to designate one “plan” that coordinates the plays among your team members.
- It’s possible that multiple quarterbacks are calling the plays for your care.
- It’s possible that members of your team have no knowledge THAT you are being treated by others and HOW you are being treated by others.
Care coordination today is in the stone ages — there is no system for care coordination.
Supplying a modern Facebook-type technology platform doesn’t change this. The major limiting factors in Facebook’s becoming a care coordination platform aren’t technological.
Let’s look a bit deeper.
Let me try to get you in the right frame of mind to read one of the most remarkable white papers in a long time: Better to BEST: Value Driving Elements of the Patient Centered Medical Home and Accountable Care Organizations — released yesterday by the Commonwealth Fund, Dartmouth Institute, and PCPCC.
Having been a debater in high school and then trained as a lawyer, my default mode of thinking is to be critical:
“Hey, Vince, how ya doin’? Great day isn’t it?”
“Well, …err…maybe, maybe not…actually, here’s 14 reasons why not.”
My wife and friends kindly tell me that this personal quality can be insufferable, and if you’ve ever met a lawyer you know what I’m talking about. My internal defense mechanism against my inner-critical brain is simply to turn it off — just go along for the ride and live in the moment.
To the extent that you can connect with what I’m saying, I suggest that before reading this report that you turn off the critical part of your brain.
If you’re a regular reader, chances are you’ve read individual white papers on these topics:
PCMH — the Patient Centered Medical Home
Access to care for the un and underinsured
HIT — health information technology and the HITECH Act
Payment reform, especially as it’s been discussed around ACOs (accountable care organizations).
“Better to Best” transcends all these topics — it weaves them together, displays the interrelationships, and describes specific components of what a truly integrated health system could look like.
Is economic credentialing — the use of economic factors such as loyalty and utilization rates in the physician credentialing process — a potential tool for primary care physicians to lead ACOs? and reestablish the vitality of primary care in American health care?
Keith Wright and Gregory Drutchas’ incisive article Economic Credentialing: A Prescription To Secure Shared Savings Under Accountable Care provides useful history and context about economic credentialing:
For many years, the use of economic factors by hospitals in making medical staff credentialing decisions has been the subject of much discussion and debate among physicians, groups such as the American Medical Association (AMA), healthcare providers, payors, and attorneys….the implementation of healthcare reform is likely to bring the debate over economic credentialing to the forefront once again.
While economic credentialing has been talked about a lot, it’s rarely been used.
The controversy over economic credentialing arises again with ACO’s…and this time the answer might be different — and opportunistic for primary care.
Economic Credentialing from the Hospital POV— The Big Red Button
From my personal experiences, the threat of a hospital imposing any type of economic credentialing on their medical staff has been a big red button issue — akin to a hospital declaring war on some physicians, with the risk of alienating nearly all physicians.
Management guru Peter Drucker wrote that the two most difficult organizations to “manage” were hospitals and the military. Most hospitals work hard to integrate physicians in decision making and they share a great deal of information about clinical and business issues.
By Rich Elmore and Arien Malec. Rich Elmore is the Direct Project Communication Workgroup leader and Vice President, Strategic Initiatives at Allscripts. Arien Malec is ONC’s Coordinator, Direct Project and Coordinator, S&I Framework.
A patient’s health records are no longer confined to a doctor’s office, shelved inside a dusty file cabinet. With the advent of the Nationwide Health Information Network, a framework of standards, services and policies that allow health practitioners to securely exchange health data, medical records digitized to be easily shared between doctor’s offices, hospitals, benefit providers, government agencies and other health organizations, all across America.
This health information exchange is dramatically enhanced by the Direct Project. Launched in March 2010, the Direct Project was created to enable a simple, direct, secure and scalable way for participants to send authenticated, encrypted health information to known, trusted recipients over the Internet in support of Stage 1 Meaningful Use requirements. The Direct Project has more than 200 participants from over 60 different organizations. These participants include EHR and PHR vendors, medical organizations, systems integrators, integrated delivery networks, federal organizations, state and regional health information organizations, organizations that provide health information exchange capabilities, and health information technology vendors.
The Health IT Policy Committee has published proposed Stage 2 and 3 Meaningful Use Recommendations and they’re open for public comment until February 25.
I’ll share a couple of particularly useful and well written analyses and commentaries by colleagues.
Health IT guru and thought leader Dr. John Halamka writes about The Proposed Stage 2 and 3 Meaningful Use Recommendations in his blog.
This is a great article to get a thumbnail overview of all the proposed recommendations. John lists 38 criteria and provides a quick commentary on how challenging he sees each of them. (Keep in mind that he’s CIO at one of the most HIT-advanced health systems in the country — your definition of “easy” and his might not be alike.)
Will ACO (accountable care organization) IT models be walled gardens or open platforms? i.e., will ACO IT platforms focus on exchanging information within the provider network of the ACO, or will they also be able to exchange information with providers outside the ACO network? (If the question still isn’t clear, click here for a further explanation.).
At the December 13 meeting of the HITPC (Health IT Policy Committee), the MU (Meaningful Use) Workgroup proposed a first draft of HITECH Stage 2 and 3 objectives.
A full list of objectives for Stages 1, 2 & 3 is available in the PowerPoint presented to HITPC.
The proposed objectives contain a mix of items that are:
- Unchanged from Stage 1
- Similar MU criteria with higher implementation goals, e.g.,
- Stage 1: CPOE for Rx orders 30%
- Stage 2: CPOE for 60% of Rx, lab and radiology orders entered by licensed professionals
- Clarifications or more detailed specifications
- Discretionary objectives moved to core set
- New items
Here’s a list of proposed new objectives for Stage 2 MU:
Medicare has (finally) recently released a report showing home run results for a disease/care management demonstration project!
Evaluation of Medicare Care Management for High Cost Beneficiaries (CMHCB) Demonstration: Massachusetts General Hospital and Massachusetts General Physicians Organization (MGH)
Remind Me Again About the CMHCB Medicare Demo…
The CMHCB started in 2005. My recollection is that the demo requirements were extremely similar to the Medicare Health Support (MHS) project, with a few exceptions: 1) Applicants had to include direct care providers (delivery systems, physicians) in their program design, 2) patient populations were significantly smaller than MHS. Please comment on anything I’m missing.
I’ve included an addendum at the bottom providing more info about this little known and not widely discussed Medicare demo.
…and what was the MGH CMP project for the CMHCB?
The American College of Physicians (ACP) just released a well-reasoned and thorough position paper, The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices.
As I’ve written before, the Big Idea behind ACOs (Accountable Care Organizations) is the notion of accountability, not the specifics of organizational structure.
The purpose of the ACP position paper is to address the gaps that exist in care coordination when a physician refers a patient to a specialist. The obvious and logical answer proposed is to develop “Care Coordination Agreements” between primary care physicians and referring specialists, and the position paper takes 35 pages to explain why and how.
A simplified way of thinking about Care Coordination Agreements is that they recognize that coordination of care is a team sport, that specialists are part of the team, and that this paper proposes rules of the game about how primary care physicians and specialists should play together on behalf of their common patients.
However, there’s a great big CAVEAT buried in the position paper. I don’t doubt the earnestness of the authors, but I do take this caveat as a Freudian slip recognition that not all specialists will be eager to play on the team and to play by the rules: