How can that be? Isn’t accountable care all about driving physician behavior change? Not really. Instead, accountable care is unlocking the behaviors that physicians have always had, but were constrained to demonstrate. There is a big difference. Behavioral scientists say that changing fundamental human behaviors is extremely difficult and highly unpredictable. Therefore, changing behaviors of a population, let’s say a large population of physicians, quickly and sustainably, is a bridge too far. However, reinforcing and enabling behaviors that likely were present when individuals decided to become physicians is both practical and powerful. Let’s examine physicians practicing primary care.
Last week I introduced you to Dr. Hastings. His infectious enthusiasm and commitment to his patients’ long-term wellbeing made him the perfect example of the first three C’s of Lumeris’ Accountable Primary CareSM Model, called the NineSM C’s, for short. Dr. Hastings demonstrated the power of First Contact (C1), Comprehensive Care (C2), and Continuous, Longitudinal, Person-Focused Care (C3). Today, I want to introduce you to Dr. Tom Doerr, an internist in the St. Louis area to help me illustrate the next three C’s – Coordinated Care (C4), Credible (C5) and Collaborative Learning (C6).
Dr. Doerr aggressively practices Coordinated Care (C4), carefully managing his patients’ transitions through acute and specialty care and minimizing the number of handoffs of care that occur. He cares for his own patients when they are in the hospital, not relying on hospitalists. He is selective about when he uses specialists and which ones. The number of specialist charges for Dr. Doerr and his peers are only 60% of the number seen in a matched fee-for-service control cohort. But when he does use specialists, he relies only on those who are willing to collaborate with him to deliver high quality, yet cost-effective care. In turn, those specialists not only get all of his referrals, but they know that when they see one of his patients, the visit will be highly appropriate for specialty care.
Dr. Doerr also works very hard to be Credible (C5), earning and maintaining his patients’ trust. He utilizes specific behavior and communication skills that engage his patients in their treatment plans. As Dr. Doerr likes to say, “If I am not credible to my patients, I am nothing more than a referral clerk—just filling out referral forms that direct my patients to a specialist for each of their problems.” But because his patients trust him, Dr. Doerr is able to have some of the more difficult conversations physicians have with their patients, such as why the name brand drug they saw on TV might not be any better than the generic alternative, the importance of end-of-life directives, or when the most aggressive treatments available could do more harm than good.
Dr. Doerr instinctively knows that collaboration with others across the continuum of care will benefit his patients. So Collaborative Learning (C6) goes well beyond best practice sharing, although that is part of it. Dr. Doerr is a power user of his EHR, but he wants all the information he can get about his patients. For example, Dr. Doerr has contracted with a payer who is equally committed to collaboration. His collaborative payer provides a Patient Care Profile for each of his patients showing gaps in care, a holistic view of his patients’ drug histories and a clear picture of the cost/benefit of the services utilized to date and invaluable clinical decision support. He works with that payer’s care management team and the physicians in his practice to interpret the information and develop improved workflows. For example, Dr. Doerr says, “I integrate this information into every patient visit because it contains vital insight from across the continuum of care that I can’t get in my EHR.” Dr. Doerr also shares the information with patients and specialists, evaluating the relative cost effectiveness of treatments and procedures. He and his colleagues continuously work with each other and with other participants in the system to improve the practice of medicine and enhance their patients’ experience of care, which is the essence of accountability.
Oh! By the way, Dr. Doerr and his peers consistently deliver better care at less than 70% of the cost of unmanaged fee-for-service Medicare, proving once again there is an inverse correlation between spending more money and getting better results. Imagine that.