The opposite of that bridge to nowhere

An elderly family member recently received a devastating cancer diagnosis.  She gets her care in California from a team of health professionals in a large integrated delivery system.  We’re supposed to be reassured that her care team is working together in seamless accountability–dedicated solely to the best possible outcomes for her, right?  Unfortunately, that’s not entirely the case.  She, of course, has a primary physician and a surgeon.  She had a hospitalist who managed her inpatient post-operative complications.  She has a number of oncologists.   Guess what?  None of these five or six physicians were communicating with each other about her care until family members prompted them to do so.  She didn’t really have much, if any, choice in selecting her specialists.  She had minimal, if any, information about the performance of the various professionals she suddenly needed.

Out of all of the doctors associated with her case, only the hospitalist seemed ready to quarterback her care–but, of course, she lost that doctor after her acute hospitalization ended.  Otherwise, none of her doctors attempted to reconcile her rapidly changing medication list–that is, until family members asked them pointedly about the various medication changes.  The specialist they asked, in fact, was initially completely stumped about her proper medications.  And no one, as far as her family members could tell, bothered to inform her primary physician about her cancer several months into the diagnosis–several weeks after her surgery and a hospitalization that included multiple complications. What’s going on?  Isn’t integrated care supposed to be the new, new thing–the ultimate answer–the way toward accountable, team based, high value care?  What might be missing from this story?   The missing ingredient may have to do with payment.  In a NEJM Online First Perspective article, Building a Bridge from Fragmentation to Accountability–The Prometheus Payment Model, released today, Francois de Brantes, Meredith Rosenthal and I discuss ways episode-based payments, specifically the RWJF-funded PROMETHEUS payment model, might help move American health care from its current fragmentation, poor performance and dysfunction to accountability for high value, coordinated care.  In fact, I might go a few steps further and say that the way we structure payment isn’t just a bridge to accountability–rather the way we pay our health care teams will ultimately make all the difference.    We can all probably agree that fee-for-service payment schemes have largely contributed to the current fragmentation, waste and dysfunction.  That kind of payment rewards more care rather than better outcomes.  It does not provide any incentive for improving care.  Instead, it rewards more tests, more scans, more specialist examinations, more hospitalizations.  It does not marshal the health care team to look for ways to provide the very best coordinated, accountable care for the very best outcome.  Instead, it allows us all to delude ourselves into believing that the latest imaging technique or surgical procedure is better than the tried-and-true–what’s the big deal if our healers make a buck in the process? But what about my relative with the cancer diagnosis?  Because she gets her care with an integrated system, her team is, presumably, all on salary.  They’re not rewarded for providing more care.  Their integrated system receives one payment, by capitation, to provide the care she needs when she needs it.  The notion is that they’ll work together as a responsible team for the patients under their care.  If, however, we put on our cynic glasses–you know the ones that let you follow the incentives, and by that I mean the money–things look somewhat different.  Even in this system, unfortunately, there really is no incentive to provide the highest quality, highest value care.  As my relative’s experience emphasizes, there’s also no incentive for the physicians to work together collaboratively to deliver high value care.  Why?  With capitation we’ve essentially replaced fee-for-service payment in which everyone thinks about their own piece of the pie with a payment scheme in which everyone is “just doing their job” and expecting the system to take care of the rest. That’s why payment models like Prometheus are so intriguing.  As we argue in the NEJM article, these models attempt to foster outcomes-focused collaboration among health professionals.  These models encourage collaboration of professionals working together in accountable teams toward the best outcomes for patients and promote active efforts by those teams to reduce avoidable complications in that care.  With payment approaches like Prometheus it’s all about professionals collaborating to provide high value, team based accountable care while also working relentlessly to reduce the staggering amount of health care waste–one episode at a time.   To me, that sounds like an important bridge to somewhere we all need to be, real soon.

Michael Painter is a senior program officer with the Robert Wood Johnson Foundation. He is a frequent contributor to THCB.

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  2. I submitted this post and then headed out on vacation—it’s great to see the passionate and smart discussion. I guess talking about payment causes that.
    There are a couple of points that I should address, though. At RWJF, of course, we’re not about promoting any specific model or solution. I’m sorry if my post conveyed a different impression. Instead, we’re about helping to indentify our nation’s health and health care problems, increasing knowledge about the causes of the problems and promoting the development of potentially viable solutions.
    Our health care problems are vast and impersonal, but they impact real individuals—often in devastating ways. I think we need to keep reminding ourselves of that. My relative’s story is simply one of thousands of similar stories. If we chose to ignore those stories—we’re not doing our jobs.
    The topic of this post was, obviously, the payment piece of the giant health care puzzle. As we’ve described at length in other posts here and widely elsewhere, our nation clearly has an enormous health care quality and value problem. We also have many other related health and health care problems—coverage, health and health care disparities, public health, prevention and so on. Here, though, we’re focusing on health care quality and value. Further, that value problem is hindering our ability to address the coverage problem.
    The ingredients for making some headway on the quality and value problems seem to be: (1) better publicly available information about performance, patient experience and cost, (2) dramatically enhanced engagement of the public—as both patients and consumers, (3) significant resources to help our health professionals improve once they receive signals from measures and demand to improve, and (4) properly aligned incentives to promote and support higher quality, value, collaboration, accountability and relentless reduction of waste.
    In this project, we are trying to highlight that there are perfectly feasible ways to structure payment that help us on that fourth point. Again, payment isn’t the only ingredient—but without payment the other ingredients, even if working together perfectly, will not ultimately deliver sustainable, high value. As several of you noted, incentives aren’t the only thing, obviously. However, we’re fooling ourselves if we don’t think mis-aligned incentives have played an enormous role in creating this mess—and correcting the payment problem is an necessary step on our way out of the mess.
    Some of you commented or asked about Prometheus, itself. There are a variety of additional materials about Prometheus—in the highlighted NEJM article and on the hyperlink embedded in the post. Folks should be aware that all aspects of this payment model—as a condition of RWJF funding—are completely in the public domain. Please feel free to use, study and improve them.

  3. …a la carte reimbursement yields a la carte medical and surgical treatment.
    You say your relative was receiving treatment from a “large integrated delivery system”. How so are they integrated? You described the typical fee for service program (like traditional Medicare).
    Before you go off selling your pet Prometheus model… suggest you define where and how the integration in her current program failed (policy, oversight, EHR breakdown)… you say it was a capitation program and all those specialists were employees. Where was that? Not in CA … maybe UK… but not in CA. Clearly with all the breakdowns … the problem of that ‘system’ was that it wasn’t a system at all … maybe just a figment of your imagination for you to write a proposal to fix.
    Surely someone who has a relative who works for the Robert Wood Foundation ought to be getting better counselling from you as to what should be happening. What were you paying attention to? Writing fiction?

  4. The electronic chart makes it harder to be oblivious of problems and recommendations and interventions which any given provider is not personally providing. You open the chart and you are looking at a list of all the events in the patient’s care, including labs, prescriptions, office visits, referrals for specialty care, correspondence to and from patient, even coverage details.
    Regarding quality of care, the large plans compete for high ratings from independent auditors, primarily NCQA.
    Utilization management is more troubled. In the first place, the traditional criterion of medical necessity can be at odds with prevention and maintenance. (again, the problem can be addressed effectively if auditing agencies require reporting prevention and disease management activity.) In the second place, there is a natural and I think healthy tension between (1)best practice guidelines which are based on what is known to be best for “populations” such as the “average mesothelioma case”, versus (2) provider trying to do what is best for a specific person who may have mesothelioma but also allergies and marital problems, e.g.

  5. As infered in mesothelioma-general.blogspot.com, wether ‘fee’ or ‘pay’, it will work if the appropriate person, in terms of training and disposition, is put on the job.

  6. does a doctor working at mayo receive more respect for his opinion and thus feel less pressure then other doctors? Do patients maybe not trust their Drs explicitly, just when the doctor is doing what they ask?
    the only way to fix this is personal liability, we need to stop making excuses for people passing the responsibility of their care.

  7. Most commenters here forcus on the delivery side of the issue – almost equally important are the consumers that I, as a doctor, still very much prefer to call patients. Their exoectations are important as well.
    From the doctors (or other providers) commenting here, I would love to hear from them if there is one who does not feel, on a quite regular basis, pressured (verbally or implicit) to do something that is not really sensible (e.g. an MRI or other diagnostic test or some kind of treatment). Despite counselling (I am specialist who can afford to spend 45-60 minutes with every new patient, and sufficient time also at follow up), there are numerous patients who just cannot handle the recommendation to watch and wait with a very likely benign problem, or who cannot accept that 1. there are, even nowadays and even at the Mayo Clinic, many cases of diagnostic uncertainty and 2. that they, like so many others, may have nonorganic disease.

  8. When I used to work in a managed care system that paid doctors directly (fairly) and asked them to treat patients appropriately (like they were taught in medical school), we found that most of our management time was spent in coordinating care. From that experience, I concluded that doctors by inclination or lack of training do not make good care coordinators.
    In our sophisticated medical system with a wide range of tests, studies, and specialists care coordination has become a critical issue in both effective patient care and cost of care. Again, the “how” question. How do we bring care coordination to health care reform nationally?

  9. if paying teachers for performance is sych a terrible idea, they teach to the test, etc etc blah blah, why does it work for medical care? Won’t the doctors treat to the test? Won’t that mean anyone that doesn’t present with standard symptons is less likely to get diagnosied since the art of medicine is removed? Or will the bills that implement this new payment method also require all illness and industry behave in a uniform and approved manner?

  10. how does any such system account for non complaint patients? Are doctors going to be willing to take a 30% hit becuase a patient refuses to follow instructions? Are these patients then going to be black balled by providers? Why would anyone treat poor or minority patients who are less likely to and less able to follow through on treatment plans?
    I would love to see how all this measuring of complaiance and peroformance actually works real time. If we can’t trust doctors not to abuse fee for service who are you going to trust to grade patients honestly?
    Noticed the trade names are already copyrighted, looks more like someone trying to find a payday then actually improve care.

  11. Are my doctors the only ones left who actually communicate with each other? Notes are shared following visits with specialists (ie. my neurologist and rheumatologist) and PCP. The three keep each other in the loop and I’ve even arrived at a visit with one and had her recap my previous visit with another. Even down to the detail of one having given me samples of a particular drug.
    Do these doctors work together? Not in near proximity nor within an umbrella organization. The only thing which they have in common is that they each participate within my health insurance coverage (PPO).
    Who of these doctors and a nurse practitioner earn the highest payment from my insurance company? The nurse practitioner when we get into a more lengthy discussion which often turns to current research, opinions on various treatment methods (which I do not use), and the fact that the drug rep who says Nuvigil would be much easier to get approved through insurance for use in MS is full-of-it since the NP hasn’t successfully gotten a single patient’s insurance company to cover it.
    Maybe I’m just fortunate enough to be living in a different dimension when it comes to the delivery of my health care. However, I still don’t have insurance coverage of prescriptions which keeps me bordering on poverty.

  12. Health care deform is not ever going to be for the benefit of the patient. It is all about benefit for the government.
    Tonight the chief medical correspondant for CNN was sound-byted to say that Medicare wil not go away assuring seniors their care was safe. If it was not going away, then just put everyone on it.
    But you can’t pay for it, can you Mr. President. You can never pay for it. You can’t pay for it now and you sure can’t pay for it when everyone is on it, or something like it.
    Only with the dollars in the patient’s hands alone will there ever be sensible healthcare spending.

  13. I agree with you, Deron. The old rules that used to make people toe the line no longer operate – sense of duty, shame, guilt, loss of reputation or image in the community. It’s because our communities themselves have disappeared. I don’t know if we will get that back; something else will have to rise in its place.

  14. This isn’t healthcare problem, it’s a societal problem. We want more, faster, and bigger.
    It is no coicidence that we have problems in both the financial and healthcare sectors. Other sectors will surely follow. We are devoid of depth in society. We are becoming increasingly superficial in our thought. Quality has taken a back seat to quantity and deliberation has taken a back seat to speed. The fact that Twitter even exists should be a red flag.
    I don’t mean to be an alarmist, but we need to wake up. I have as much knowledge of the healthcare system as the next guy and I can tell you that this isn’t just a healthcare problem. Docs, patients, insurance reps, pharma reps; I work with them each and every day. Everyone is out for themselves.
    Unless someone figures out how to inject social responsibility into the veins of the population, we will face these problems, sector by sector.

  15. If time for coordination during a busy clinic day is not budgeted, it becomes something to “squeeze in” to a schedule where there is no room to squeeze anything in. Seeing patients pays the bills, spending time on the phone discussing patients doesn’t.
    Capitated vs. fee for service vs. straight salary doesn’t change anything unless doctors return to reasonable patient panels and reasonable clinic schedules. As long as they are on the hamster wheel they won’t have time or the inclination to properly coordinate. They’ll continue to be too busy.

  16. Interesting but ultimately unsatisfactory. A national health care reform plan which purports to change physician behavior through payment schemes requires just that – a national system. Currently private insurers and Medicare make a mish-mash of integrated care.
    So ask yourself the “how” question. How do we bring all care providers into a fully coordinated system that assures appropriate care for all patients? Most doctors who paid attention in medical school know what appropriate care is. They just don’t provide it for a variety of reasons, sometimes due to poorly coordinated care.
    If we do manage to create a system to fully coordinate care and assure appropriate care, who will control it? The insurers? The government? The medical community?
    My vote is for the medical community. Unfortunately, this professional community seems so beaten down by the insurers and Medicare that they look more like the Iraqi army in the midst of “shock and awe”. Doctors I know tell their kids not to go into medicine. That is pathetic.
    I have little hope for health care reform unless the medical community stands up and retakes control of medical care.

  17. Your relative’s experience exactly reflects my mother’s recent hospitalization – the family member becomes the default coordinator. Fortunately for my mother I am an M.D. but what happens to the poor families to whom this “system” (joke) is a mystery?
    Doc99 is correct: it used to be that the patient’s doctor personally called in all consultants and they personally called him/her back with their diagnosis and recommendations. This era is long gone – now an order is written in the chart for the nurses (or clerk) to call Dr. X for a consult. Dr. X. is left entirely on his own to find out about the patient and what the pertinent question is. No wonder he compounds the insult by not calling the primary back. This used to be just considered “good medicine” – not something one had to incent. Many docs have just drowned under the chaos of the current “system” and given up good medicine.
    FYI, another explanation of the Prometheus system by the same authors, along with other pertinent information about health care reform, can be found at the New England Journal of Medicine’s special website on health care reform:
    http://healthcarereform.nejm.org

  18. Mr. Ballard,
    The doctor-patient exchange was valuable to both physician and patient, she said, adding “There can be no health care reform without medical education reform.”
    I agree with this quote entirely. When we have employeees of pharmaceutical firms teaching our medical students and funding our programs, and less emphasis on patient care, microbiology, nutrition (unfortunately, also industry-sponsored), we can’t begin to talk about insurance reform.
    Working in healthcare for decades, I witnessed countless situations similar to that patient’s. How sad.
    My own doctor made house calls. He used common sense before prescriptions. He retired at age 75 last month. His kind are few and far between.

  19. The “integrated delivery system” in the example sounds more like an “aggregated delivery system”, which is really no system at all. Putting them all under one roof doesn’t constitute an integrated system, regardless of how you pay them. Commonality of purpose, clinical philosophy, and financial bottom line are key ingredients of true systems like Mayo and Permanente.

  20. In fee-for-service, there is an incentive to do more, and no incentive to coordinate. In capitation, there is an incentive to do the least, and no incentive to coordinate. In pay-for-performance, there is an incentive to do the right amount of care and coordinate IF THE PROVIDER IS AT THE ORGANIZATIONAL LEVEL WHERE THE PERFORMANCE IS BOTH MEASURED AND PAID, and even then only if the providers actually believe in the measurement.
    Those are big if’s.
    Incentives always work. If they aren’t working, they aren’t in place, no matter what is written on a piece of paper.

  21. What a mess. As I read I recalled a panel discussion on C-SPAN yesterday moderated by a woman from Health Affairs Magazine. I don’t recall the people but one panelist related a story of a cancer patient whose options had run out, but her oncologist still offered some kind of radiation implant in her brain. The woman telling the story, a physician herself and friend of the patient, called the oncologist and asked, “Do you think this will do any good?”
    After a pause he replied, “No, not really. I think nothing will work now.”
    When asked why he made the recommendation, he said “I didn’t want her to think I was abandoning her.”
    The inquiring friend asked him if he might be able to do a house call and explain it to the patient in person. She said for the first time in his career he made a house call and he was in his fifties.
    The doctor-patient exchange was valuable to both physician and patient, she said, adding “There can be no health care reform without medical education reform.”
    It was an unusually poignant moment for a panel discussion. I think this story puzzles together with yours in some way.

  22. Michael,
    Thank you for making a case for phasing down the current fee-for-service reimbursement model. I totally agree with you that it drives up utilization of health care services, encourages waste and does not guarantee value for money compared to other developed nations. Unfortunately, healthcare reform is now health insurance reform, with little emphasis on care delivery costs and outcomes.
    At the same time, pay-for-performance models have their limitations too. There is an article,
    http://www.oberlin.edu/economic/Papers/HealthConf/PayPerf_Golden.pdf
    that focuses on those. Eventually, I would expect a mix of pay-for-performance, capitation and fee-for-service compensation, whichever appropriate.

  23. Very careful about the heart attack studies in findrxonline indicate that we must be careful and avoid any situation that we regret later, remember that those increases in weight and which have much dependence on cigarette and alcohol are the most vulnerable to a sudden heart attack care.

  24. Nice post. Perfectly illustrates how organizational integration does not necessarily lead to integration of clinical care.
    However, I’m not sure a new payment system is the answer. It’s more of a human system issue…the organization needs managers whose responsibility is integrating the care actually received by patients (i.e., creating teams and making them function well). For a capitated delivery system, the proper financial incentives are already in place. The problem is not incentives; it’s that humans–and especially organizations–don’t respond to incentives in a rational manner most of the time. Behavioral economics and organizational psychology are the fields that will help draw the best lessons from this example.

  25. First, it would be nice if you would describe how Prometheus works and how it actually incents. I realize by not doing so you create an incentive for me to read your articles, but frankly I think it diminishes your otherwise interesting post.
    Second, the don’t think any incentive system makes management or quality control oversight unnecessary. An accountable organization still has to be held to account. It would be nice if everything just happened automatically, but I don’t think that’s likely.
    Patients and their families will still have to be willing to hold their doctors to account. And at least there is a somewhat organized structure to call on. Does the hospital do any quality control to make sure it’s teams are working as teams? Did you or your relatives raise this issue with management?
    I am guessing that the best integrated organize care systems have good management as well as a structure that makes success more possible.

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