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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Guest

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Mike Painter
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Mike Painter

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… Read more »

DKBerry
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DKBerry

…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… Read more »

jackbrahms
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jackbrahms

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… Read more »

Fredrich
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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.

Nate
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Nate

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.

rbar
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rbar

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… Read more »

Popster
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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… Read more »

Nate
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Nate

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?

Nate
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Nate

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… Read more »

Lisa Emrich
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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… Read more »

MD as HELL
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MD as HELL

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… Read more »

bev M.D.
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bev M.D.

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.

Deron S.
Guest

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… Read more »

pcb
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pcb

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.