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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