Last week I was honored to attend a discussion at the White House convened by Health and Human Services Secretary Kathleen Sebelius. It was one of those rare “clear my schedule immediately” invitations; I thank my patients and family for allowing me to take this last minute trip.
Physician leaders from around the country were invited to the White House for a dialogue with lead government health officials (specifically administrators from the Center for Medicare and Medicaid Innovation) over the challenges and opportunities health care providers face in the race to meet deadlines set by the Affordable Care Act (ACA). What followed was a fascinating, solutions-oriented discussion about how government can support and incentivize the provision of health care that both patients need and doctors strive to provide. As expected, common points of discussion were challenges to building a Patient Centered Medical Home (PCMH), achieving electronic medical (EMR) record meaningful use, and developing Accountable Care Organizations (ACO).
Now before you stop reading, give me a chance to make this migraine-inducing jargon make sense. Your experience with the health care system may change in the near future.
Let’s say your mother has a common collection of health problems. She has high cholesterol, diabetes, nagging low back pain, and has been depressed after a hip replacement surgery earlier this year. She takes medications of all shapes sizes, each with its own peculiar dosing schedule that is near impossible to keep straight. It seems she is constantly going to doctor visits of various kinds. She knows she needs to eat better but after each modest dietary adjustment she repeatedly settles back into her unhealthy diet. She (and you) feel discouraged. Contrary to your expectations, your mother’s clinic is making things worse. Her doctor, though well-meaning, does not have all of the records from past specialist visits. Most of the fifteen minutes at the clinic visit is spent figuring out if all the medications are being taken correctly, completing medication refills, and skimming lab results. Her doctor makes a passing statement about eating healthy with a knowing smile. Finally, the clinic visit sprint is over leaving both patient and doctor breathless. Your mother never got a chance to ask her specific questions, let alone connect with her doctor in a meaningful way. Both patient and the doctor are unsatisfied with the visit. Perhaps worst of all, your mother’s health is no better as a result. Sadly, this story currently reflects the reality in doctor’s offices across the country.
Cue in health reform. Included in the ACA and related regulations are incentivized models to address many the challenges illustrated in the story above. The Patient Centered Medical Home (PCMH) offers a model for providing comprehensive, continuous, high quality care. This is how it could look for your mother. Your mother can easily make an appointment with her own doctor as soon as she needs a visit. At the visit her doctor steps into the room already up to speed on your mother’s problems because she has had ready access to past visits and specialty records through a recently installed electronic medical record system (see below). After the doctor visit, a pharmacist swoops in to help organize and schedule medications. Then a dietitian gives her practical, incremental diet change ideas that will be reviewed at future visits. A care manager stops by to pull everything together, reminds your mother about upcoming specialty visits, and schedules a home visit to see how your mother is keeping up with her care plan. From home, your mother can take ownership of her own health by accessing her lab results through an online patient portal. Finally, mom will be asked to regularly evaluate her doctor and clinic so their performance is responsive to your mother’s needs.
An advanced electronic health record (EHR) is vital to the ideal care you mother deserves. A set of standards called “meaningful use” was fashioned to ensure that these systems are designed for high quality patient care. Not only does an EHR designed for meaningful use keep medical files organized, it allows for sharing of records with other professionals, and creates mechanisms to follow health trends in a individual or panel of patients. My own clinic in Oakland is currently going through these growing pains.
While your mother’s care is improving, you may not even notice that her clinic is seeking to be a part of an Accountable Care Organization (ACO). ACOs connect primary care doctors with specialists and hospitals in a model that incentivizes good health outcomes or results. Currently, much of the health care system is set up so that providers get paid more for doing more—like more visits or more tests. Intentional or not, if someone get paid based on the number of times they do something, the financial incentive is to do more, even beyond what is necessary. Ideally, any service provider, including doctors, should get paid for achieving good results rather than feeling the financial pressure to do more. ACOs allow providers together to decide the care and outcome standards that will be tied to income. These goals are intended to improve the quality of care while decreasing cost by avoiding unnecessary tests and procedures.
I think it can be summed up in this way, these changes strive to ensure “the right care, for the right person, at the right time.” Ironically, if we do this well, the total cost of health care should decrease.
So how is it going?
My first reaction would be to not-so-artfully dodge that question with an honest “it’s complicated”. The White House meeting involved a discussion about pilots of various models across the country (some with outstanding results). The government is hurriedly and rigorously trying to figure out what does and does not work so it can swiftly scale up proven models. The administrators we met with were eager to solicit ideas from providers and patients on the ground. Some challenges doctors highlighted included: how to tie in specialists into the medical home and ACO; the lack of reforms in child health; and how to incentivize good stewardship of health care dollars for higher quality care. I was pleased to witness genuine engagement from high-level government officials at this meeting. It gave me hope that through all this chaos, we will achieve a health care system that will be a big step up from where are now. All in all, good things are happening.