I have used the last two blog posts to introduce the Accountable Primary CareSM Model*, or the NineSM C’s* for short. To illustrate the power of the model, I used examples of some incredibly passionate and committed primary care physicians to demonstrate the first six C’s. I am going to do the same for the remaining three C’s: (C7) Cost-effectiveness, (C8) Capacity Expansion, and (C9) Career Satisfaction. The transparent bias this discussion implies around the importance of more effective primary care is intentional. Please note this bias is not intended at the expense of specialists or hospitalists, for that matter. In the earlier article with Dr. Hastings, his unique and tightly coordinated network of relationships with specialists who share his commitment to better, more cost-effective outcomes, is both comforting to his patients and produces amazing results.
Making health care more cost-effective has always stirred emotions, harking back to the early days of managed care — mental images of men in blue suits with MBAs rather than MD degrees huddled in sleek office buildings, conspiring to deprive patients of necessary health care services using sophisticated utilization management algorithms without regard to quality outcomes in the name of saving money. To the extent this imagery was accurate it existed because only half of the data needed to effectively manage care — financial data for reimbursement — was available. Clinical data necessary to measure clinical quality was elusive; trapped in paper files or archaic systems that defied access. When you only have financial data, you make financial decisions.
Today, we are accumulating a treasure trove of digitized clinical data, when combined with financial data, gives a holistic view of what is going on with a patient and the population they are part of. Getting this powerful, new information in the hands of primary care physicians committed to the first C — First Contact (C1) is a game-changer for our health care system and is a key determinant whether Cost-Effective Care (C7) is achievable. Cost-effectiveness occurs when the right care is delivered at the right time at the right place. The appropriate practice of cost-effective care proves what we have all suspected: There is an inverse correlation between spending more money on health care and getting better results.
Dr. Chuck Willey is an internist in his 29th year of practice at Innovare Health Advocates. Dr. Willey made a longstanding commitment to be a truly accountable care physician. He says, “Part of my duty is to help my patients afford the care I recommend.” He finds ways to reduce cost for his patients, his practice and the payer, by aggressively focusing on prevention and taking full advantage of clinical and financial data. It helps him determine who needs care, when they need it, and to make better decisions when he is delivering care. He implores his patients, “Don’t shop for health care without your personal consultant — me!” The $750 billion of wasteful, inefficient and unnecessary services the Institute of Medicine estimated will not be resolved with more regulation or a new committee (IOM, 2010). It just might get fixed by giving Dr. Willey the information he needs to make better decisions in consultation with his patients and incentivizing him to use it.
Dr. Willey and other accountable physicians understand that in order to provide high-quality, cost-effective care, physicians have to be paid differently. That includes rewards for achieving quality outcomes, but also incentives to Expand their Capacity (C8) through the use of technology and physician-extenders, including nurse practitioners, care managers, social workers, and other professionals practicing at the top of their training. Dr. Willey represents one of the largest single investments made by our health care system. The time and resources required to educate and train Dr. Willey makes it self-limiting as to the ability of our country to produce more Dr. Willey’s. Leveraging Dr. Willey with talented people who can manage many of the duties previously performed by Dr. Willey through a re-designed care delivery model, powered by heretofore unavailable information, relieves stress on everyone, including the health care system. Dr. Willey says, “The performance of my experienced nurse practitioners compares very favorably to ‘outpatient only’ PCP’s.” Leading the care team, rather than being the care team, has enabled many physicians, like Dr. Willey, to step off the hamster wheel and provide better, more patient-centric care to much larger patient panels.
The final C, Career Satisfaction (C9) is one that we, at Lumeris, have championed from the inception of our company a decade ago. We feel so strongly about it, when we embraced Don Berwick’s Triple Aim, we added a fourth aim — Physician Satisfaction. Given the fact that physician satisfaction surveys around the country are registering record lows for this measure that is a pretty high bar for measuring success. My conversations with physicians suggest they decided to embark on the arduous journey of becoming a licensed physician primarily for three very straightforward reasons:
- Strong desire to help people
- Attain financial security for their families
- Exercise some control over their lives and daily tasks
Most agree they have achieved few, if any, of these goals. This is particularly true of primary care physicians, who for decades have felt the brunt of the treadmill of volume-based health care. Things are changing now.
By restructuring the care delivery model, empowering physicians with more information, and realigning their incentives around value-based delivery of care, we are changing the culture of care with more meaning and significance. Dr. Willey has done this by structuring his work environment to simplify procedures and workflows, preserve control, and emphasize autonomy and order in his practice. Dr. Willey notes, “I enjoy my life’s work. I make tangible differences in many patients’ lives and they hug me for it. I have increased the value of my contribution, creating value for the patient and payer, and get commensurate and respectful pay as a result.” Career Satisfaction (C9) may turn out to be the most valuable C for optimizing the performance of our health care system, unlocking the critical component missing in earlier attempts — the creativity, passion and know-how of the country’s best primary care physicians.