Bridging the Great Divide Between Healthcare and Business: Part 1

It’s no secret there’s a wide chasm between healthcare and business, and even more so, between clinical medicine and healthcare administration. You’ve likely heard cautionary tales of providers who “went to the dark side” and chose administrative positions over clinical medicine, and there’s certainly no love lost between the two.

We have clinical providers of systems who want to give good patient care, and we have system administrators tasked with developing self-sustaining business that offers a quality product (i.e. healthcare) that consumers want and need.

East is East and West is West, and never the twain shall meet.

Much could be said about the origin of the divide, but essentially it boils down to the false economy developed by fee-for-service and third party payers with deep pockets. This system created extreme wealth but didn’t function like a real-world business. And the lack of normal economic boundaries caused costs to spill over into our population with devastating effects.

The goal here is not to focus on how bad off we are, but to shed some light on how we ended up here and what can be done to bridge the divide and move together toward the Triple Aim. In the following posts of this series, we’ll take a look at what’s needed from providers and administrators to begin the bridge-building process.

Where we are now

Before the ACA, business and the government (as well as the uninsured, in some cases) absorbed the majority of the high costs of healthcare. Now much of the financial dysfunction has shifted to healthcare consumers, making our general population acutely aware of the problem.

This article and other similar stories about life after the ACA further reinforce the gravity of the situation. The issue isn’t just a matter of who pays for healthcare; the problem is that healthcare is simply too expensive for everyone involved in the equation.

Cost creates a huge barrier for healthcare consumers to accessible, quality care, even if they have insurance under the ACA. The ACA made insurance affordable for some, but many still can’t afford healthcare in its current state due to high copays and deductibles.

A brief history lesson

It’s fair to say the dysfunctional relationship between healthcare administrators and providers is a disaster that has been decades in the making. Every system across the U.S. is struggling, but no one really wants to deal with the root of the problem.

Up through the 1980s, virtually no practice was owned by a hospital system. It was so easy to make a living as a doctor in those days that medical schools offered little, if any, business training for practitioners.

When HMOs came on the scene in the early 1990s, private practices became far less viable. Physicians began selling their private practices to hospital systems and became employees of those systems.

The problem is that because doctors weren’t well versed in business, they brought poor habits (and a reluctance to change them) into the more controlled environment of hospital systems. As a result, we started seeing the ramifications of the myths they (and by extension, patients) had come to accept about the care delivery process:

7 Care Delivery Myths

  1. If a provider produces quality clinical care, his or her business is guaranteed to survive.

  2. The patient’s expectations should control the visit in order for the provider to meet the patient’s needs.

  3. Quality care demands a lot of time.

  4. A good provider shouldn’t pay attention to time.

  5. If it’s not expensive, it’s probably not quality care.

  6. Socializing with patients is just as important as clinical effort.

  7. If a provider is unable to see a patient, another provider (who doesn’t know the patient) can deliver the same quality of care.

This kind of mentality isolated business and clinical care and put them at odds with each other. It justified providers’ rejection of business norms—like efficiency, competition, and innovation—because they believed this kind of care was what a good provider should provide. But in reality, it came at a tremendous cost to their patients and posed significant problems for administrators.

There’s no such thing as a free lunch

In part to curb this kind of thinking, HMOs and Medicare began trying to establish some kind of connection between the level of clinical care and the cost of care for that level. This was the environment in which the “blank check” payment structure was created. Patients could go to as many providers as many times as they wanted and get any test they wanted—and a third party payer would cover everything. But because of the blank check, the healthcare industry never had much motivation to limit care in order to produce health or fix the lack of normal business parameters.

Fee-for-service and third party payers helped us survive the environment of the chasm for a while. But these factors, along with the continuing poor business practices of many providers, created an economic catastrophe for government, businesses and healthcare consumers. It’s also what ultimately led to our large uninsured and underinsured population.

Bridge construction ahead

There’s more discussion to come on this topic. We’ll look at other aspects of the issue—and practical steps to move us toward resolution—in following posts in the coming weeks.

The important point to realize is that we have to acknowledge the divide between administrators and providers. The problem is evident; now we have to fix it in order to achieve sustainable business and accessible, quality care.

To bridge the gap, we have to protect what’s critical for good clinical care while also protecting what’s critical for business to thrive. And both sides must be involved to bring about a truly successful solution that will bridge their two worlds.

Check out the second post in this series for a look at how providers can help bridge the gap by recognizing the poor business practices we often bring into the exam room.

Can ACOs Make Money?

You can probably make money, but first you have to make change

If improved coordination and value-based reimbursement are going to be among the pillars of healthcare reform, then Accountable Care Organizations will be one of the most reliable means of getting there. Once we arrive we’re going to find a landscape filled with cost and quality benchmarks, closely measured accountability, risk stratification, population health management, re-aligned incentives and alternative compensation models.

In the midst of these challenges and new approaches the one question all of us are asking is, “Can ACOs make money?”  The simple answer seems to be … “It depends.”

What we’ve learned from studying stepping stone initiatives like the CMS Pioneer Program and the Medicare Shared Savings Program, as well as other ACO and bundled payment models is that some uncertainty still remains regarding the economics. More financial data will be forthcoming and it will undoubtedly bring more definitive results, but given the upfront investments needed in technology, staffing and other infrastructure, initial success isn’t a slam dunk, even for ACO participants who have had some previous experience with capitation.

Although success may not be guaranteed it is taking place in a growing number of instances and a look at the first generation of ACOs offers a good idea of what needs to be in place. These factors include a particularly strong focus on HIT capabilities, the ability to keep outmigration from the organization to a minimum and a clear picture of expenditures.  What may not be communicated in an evaluation of current ACOs, however, is the softer criterion of personal transformation.

On the most basic level, moving toward an ACO model of care delivery and reimbursement involves change, and as human beings in general and healthcare people in particular, change doesn’t always come easy. That’s why along with our questions related to the economic viability of ACOs we should be asking ourselves if we’re ready to transform clinical and administrative behaviors on the scale needed to make value-based medicine effective.

At the very least, that kind of transformation will involve changes in workflow and staffing, a different approach to – and different criteria for – decision making, a significant increase in reporting requirements and a shift to managing care along the total health continuum.  In addition, it will involve at least some movement away from traditional practice methods and a concentrated emphasis on patient-centered care including tactical features like more open access scheduling, more online tools for patients and extended hours.

At best, the transformation that necessary to make ACOs pay off will, ultimately, center on what I have always believed to be the most important single feature of primary care medicine: the relationship and associated interaction between patients and physicians. The personal motivation and the clinical imperative for care providers to understand more about the environment and overall context in which their patient lives, works and recreates – and the corresponding trust on the part of the patient to share this information – is essential for effective treatment, especially when it comes to managing chronic disease.  Similarly, that same relationship is critical for preventive care information to be valued by the patient and family, whether it’s conveyed directly by the physician or through another team member.

It’s very likely that the conversation around ACOs will remain centered on analytics, economics and the ability to embrace financial risk.  As your organization confronts those issues, just don’t lose sight of the fact that it’s equally important to embrace the kind of cultural changes that will strengthen the patient-physician bond and improve our ability to implement true patient-centered care. Because no matter where you end up in the area of accountability, that’s where you begin.

Is Care Coordination the Future of Primary Care Medicine?

It may be, but the road leading there has some challenges

As the team-based care model and its focus on care coordination expand throughout the world of primary care, so do the “coordinator” analogies. For example if you like sports, you might view the primary care physician as the quarterback of the team or the coxswain of the racing boat. If your interests run to music the PCP is the conductor of the orchestra. For cinema buffs, he or she is the director of the film.

To extend the analogy, it’s clear these particular coordinators would have a problem if, respectively, the offensive tackle decided not to block, the sweep refused to row, the first violin didn’t want to tune up and the star wouldn’t memorize her lines. You get the idea. Team-based coordinated care only works if everyone involved is open to being coordinated. When it comes to primary care medicine, the coordinated team includes the patient who, if we’re doing it right, is at the center of the whole process. And that’s exactly where we’re starting to see a growing concern.

As individuals and families covered through employee health plans or other forms of public or private insurance are becoming exposed to higher out-of-pocket costs for their health care, we can expect a corresponding increase in non-compliance based on financial pressures. It’s a simple equation. Less comprehensive plans and the higher co-payments and deductibles that go with them mean more and more people will make the decision to forego needed therapies, medications and procedures because they don’t think they can afford their share of the cost.

Given this scenario, what role can physicians play to improve treatment plan adherence in the face of healthcare sticker shock? To start with, we’re not financial advisors so a direct assault on the underlying economic concerns is not going to be part of our repertoire. What can be highly effective, however, is a more open approach to talking about costs before going forward with potentially expensive diagnostic procedures or ordering medications in those instances where it may not be affordable in either the short or long term.

In an excellent article on this subject in the New England Journal of Medicine the authors contend that having this kind of discussion is as important as sharing information on the potential side effects of treatment – with the belief that the anxiety created by financial concerns is a type of negative side effect in its own right. The article goes on to suggest a number of important reasons why a greater degree of transparency and open communication in the exam room has important benefits to patient outcomes, to the patient-physician relationship and to the healthcare system as a whole.

Care coordination is an essential element in the Patient-Centered Medical Home. Likewise, it’s a critical part of the way ACOs are going to work and the foundation of our ability to provide the right care at the right time in the right place.  But without the buy-in, literally and figuratively, of the patient and often the family, without the compliance of the person who’s at the center of all the coordination resources and efforts, the full promise of care coordination won’t be realized.

Talking directly about the cost of care isn’t something we train for and is generally not the easiest kind of conversation to have with patients. Beyond the possibility that they might range from mildly awkward to downright difficult, however, these discussions are becoming part of the way we should orient our view of the whole patient. And if we believe care coordination is the future of primary care medicine, or at the very least, a big part of it, conversations related to potential out-of-pocket costs are something we need to have. There’s that much at stake.

Dr. Peter Anderson Speaks: FPM Article Reports Long-term Benefits of the Family Team Care Model

Dr. Kevin Hopkins of the Cleveland Clinic describes the revolutionary results he achieved by following our clinical model…

“I realized that I was going to need some help if I wanted to practice medicine for the next 30 years….I was inspired by… Dr. Peter Anderson, who had implemented a new type of practice in Newport News, Virginia, and achieved dramatic improvements in key metrics….This high-efficiency alternative to the traditional medical practice model is designed to reduce patient waiting times and increase quality of care, accessibility, and the satisfaction of physicians, clinical employees, and patients….I quickly became convinced that this was how primary care, and primary care physicians, could survive.

The article goes on to quantify the impressive improvements in operating profit and patient access he attained.

I am so gratified to see Kevin’s success.  To his great credit, he was self-aware enough to recognize his need for help and strong enough to follow through on the needed changes.

What Does the Doctor-Patient Relationship in Your System Look Like

Are you building an environment that supports the doctor-patient relationship, improves the exam room experience and increases patient satisfaction?

Despite a growing interest in some of the “soft” skills related to medicine and the enduring hope that reform will provide a more fertile ground for change, healthcare has generally transitioned away from the time when physicians developed strong interpersonal bonds with patients. You can blame time restraints, the depersonalization potential of the EMR and the way doctors are paid. But whatever the cause, the fact remains that the doctor-patient relationship has suffered.

Unless your organization is moving toward concierge or direct care, making the most of an abbreviated time period in the exam room is going to be part of your future. One way to get there is to improve the physician’s role in the interaction by focusing on his or her bedside manner. While there are differences of opinion on the degree to which certain people skills can be taught and learned, the range of tutorials, classes and training sessions related to this non-clinical but highly important area of medicine would seem to suggest that nurture has an equally strong footing with nature.

But some limitations remain difficult to overcome. Every physician has a different personality. Some are more communicative than others. Some are better listeners. Some are simply more empathic. So if you’re looking for total consistency in physician behavior within your organization, there’s a good chance you’re going to be disappointed. On the other hand, you can help level the playing field through a common approach in the exam room that can increase the opportunity for a successful encounter. And a lot more.

It starts with moving from the traditional medical practice model to team-based care. This more collaborative approach has been shown to increase practice productivity and overall efficiencies, improve access and increase gross patient revenues in the practices that implement it. At the same time it enables physicians and patients to maximize the time they spend together.

By delegating those responsibilities that don’t require direct physician involvement – data collection, documentation, certain aspects of education, reinforcement of the treatment plan and most follow-up information – to trained and empowered clinical assistants, the doctor is freed up to do what he or she is singularly qualified to do.  At the same time, when the various elements that make up the exam room encounter are shared, the doctor is able to direct her or his full attention to the patient.

This focus means more actual time spent with the patient as well as a perception of more “quality time” based on the removal of distractions. It also means you’re able to rely on objective measures like templates and protocols, staffing strategies and a commitment to a team care model rather than the subjective, and not always consistent, nature of individual personalities.

The result is a range of benefits that cover everything from economic stability to professional satisfaction while, ultimately, strengthening the doctor-patient bond, one of the more elusive but important determinants of quality outcomes.

How Redesigning the Exam Room can Change Healthcare

How Redesigning the Exam Room can Change Healthcare

What does the space shuttle Challenger explosion, Anatares rocket explosion and exam rooms have in common?  One thing is for certain; the two explosions embedded a cautionary tale of defective O-rings deep into our national psyche. Overlooking a very small component within the total system could result in catastrophic failure.

As someone prone to look for metaphors in just about anything, I wondered if there was some type of O-ring equivalence in the world of medicine. Granted, the exam room may exceed the O-ring to the solid rocket booster ratio terms of actual proportion, but it’s still a very small part of a $2.9 trillion health care system – and one, I think, that offers a perspective on why that system isn’t working well and how it can be improved without waiting for government action.

On its most essential level, the exam room is where the patient-physician bond is forged, a relationship that can never be overemphasized as to the improved quality it imparts to individual and population health. When it’s at its best, the exam room includes more than one person to assure that the physician can remain focused on the patient, not on the EMR. It also offers an indication to the patient that he or she has access to a clinical team to enhance care coordination.

Sequentially, the well running, team care exam room represents a critical component in the Patient Centered Medical Home, which supports a more effective delivery model for primary care medicine, which in turn, forms the foundation of healthcare reform itself. And on the more personal level, the exam room is where we are most likely to gain our greatest sense of satisfaction in practicing medicine, along with the financial remuneration that makes it all possible.

I’m not exactly sure of how directly the O-ring and the exam room correspond in terms of failure potential, but I do know that in many practices some re-design is in order. Most of those practices will need some onsite support to reach the optimal level of efficiency. But however you choose to improve your exam room process, it’s time to start.

You may not feel like you’re changing the U.S. healthcare system right away, but there’s a very good chance that you will change the way you practice medicine while you gain more enjoyment in the process.

What does your exam room need most?

Chances are an Improvement Will Work as Well as a Re-invention

If you’ve followed previous blogs it won’t come as a surprise that I put a lot of emphasis on the exam room not only as a key element in an individual practice, but also as a critical step in strengthening primary care medicine itself. As the path to healthcare reform becomes increasingly difficult to clearly follow, it’s a safe bet that I’ll focus on the exam room even more as one of the aspects of the medical world over which we can actually exert control.

Of course, whenever we make changes in any part of the way we have practiced in the past there’s always going to be someone who tells us, “Don’t re-invent the wheel.” If you’ve been given that familiar advice lately, roll this over in your mind:

The research and engineering team that helped develop steel belted radial tires certainly didn’t re-invent the wheel. They didn’t even re-invent the tires that go on the wheel. But they certainly improved them. In the process countless lives were saved over the years from blowout-related accidents. And a lot of people never had to endure the stress of getting a flat tire on a dark and lonely highway.

There’s a pretty direct analogy with the exam room. What we’ve been doing has kept things moving along, but “road conditions” are getting more difficult. This is due to the increase in individuals with health insurance, the expanding population of older adults with multiple health issues and the increased demands of documentation. Let’s face it, the EMR has not been the panacea we hoped for with regard to improving either patient care or workplace conditions. All of these factors have melded into an increasingly difficult scenario.

There’s also that inconvenient shortage of PCPs that we read so much about. It probably stems from a combination of burnout and earlier than expected retirement as well as a growing lack of enthusiasm for Primary Care, a field that’s high on work load and comparatively shorter on reimbursement.

That’s why I keep talking about the exam room and the benefits of a coordinated team approach to care based on deep protocols, a physician willing to make changes and a well-trained and empowered staff that serves as a data gathering and information resource. A staff specifically trained to function inside the exam room to let you focus on patients, not computers. It’s not only a place to start, it’s a place where we can truly make a difference in a relatively short amount of time – especially when compared to the wholesale reconstruction of a broken healthcare system.

Clinicians tend to be intelligent and highly capable people. Most of us, however, are not inventors. But we can all be improvers. The good news is that you can be a highly successful physician on both a professional and personal level without re-inventing the wheel … as long as you keep making it better.

Overcoming Ongoing EMR Challenges

Overcoming Ongoing EMR Challenges

The AAFP Seeks Needed Improvement Through Legislative Action

As a practicing Family Medicine physician I was an early adopter of the electronic medical record (EMR) so I have long and personal experience with its advantages and disadvantages. Now, while working with practices across the country to help them transition to an effective Team Care model, I am also keenly aware of the compatibility and integration problems brought about by the plethora of different vendors and systems.

I know I share this EMR frustration with most primary care doctors, so it was particularly gratifying to see the efforts that the American Academy of Family Physicians (AAFP) is now directing toward solving some of the major challenges. The EMR is the sharpest two-edged sword in health care. In the midst of an aging population with multiple chronic diseases, the EMR is a critical tool in keeping vast amounts of data organized and available for competent care. Yet not using this tool appropriately has dramatically weakened the entire industry.

Over the years, the AAFP has actively sought lawmaker assistance to help heal various aspects of our healthcare system. The current resolution presented by the AAFP board calls for members to encourage federal policymakers and CMS to create “significant and compelling incentives and disincentives for all electronic health record vendors to enhance their current EHRs in specific ways, including:

  • Enabling interoperability

  • Adopting a standard format for patient health information

  • Creating a user-friendly interface

  • Providing capacity to facilitate chronic disease management

The obvious precedent for this type of action is, of course, the Medicare and Medicaid EHR Incentive Programs which provide financial payment for the “meaningful use” of certified EHR technology. While that initiative has made some strides toward increasing electronic medical record use and overall effectiveness, the ability of one system to speak to another is vital for the successful exchange of information. Any obstacles in the way of that objective will have to be overcome, especially as we move toward new delivery and payment models.

Without interoperability, the health information system, and in large part our healthcare system itself will remain fragmented.

Leonard M. Finn, MD, an AAFP board delegate from Massachusetts and author of the resolution asked a recent Academy board member audience of more than 100 people if they were happy with their EMR. About four or five individuals raised their hand.

In response, he said that in over the decade since they came into relatively common use, “Electronic medical records still fail to help us do what we want them to do – provide a truly higher level of care for our patients. No bank, no airline, no major manufacturing concern would tolerate the quality of the software that most of us have to work with. In particular, interoperability and standard formats for patient health information should have been present when EMRs first came on the market.”

We can’t change that past, but we have a good shot at the future. Our hope now is that the problems of healthcare information exchange, which Dr. Finn mentions, can be rectified as lawmakers listen to our combined voices. Please join with the AAFP in helping to move this initiative forward.

Team Building vs. Building a Team

The Difference Between Building a Team and Team Building

In The Boys in the Boat, a masterful account of the University of Washington’s eight-oar crew in the 1936 Olympics in Berlin, author Daniel James Brown offers an insight into what it takes to develop a gold medal-winning team. He also describes the frustration of the university’s rowing coach who kept trying to put together the best combination of people, a task he finally realized relied on temperament, personality and other intangibles as much as it did on physical strength and rowing skills.

Each time he assigned nine young men to a racing shell – eight rowers and a coxswain – he was fulfilling the basic requirement of building a team. But only when he found people who shared common goals, and then sublimated some, but not all, of their personal interests toward those goals, did he engage in true team building. Simply put, he learned that building a team was an action while team building was a concept and a vision.

As you’ve probably already guessed I think there’s a strong analogy between a well-rowed racing boat and a team approach to primary care medicine.

For over a decade, team building has been at the core of our efforts to help clinical practices transition from a traditional physician-centric model of work distribution to a shared-care approach like Team Care Medicine. Toward that end we are inspired by the work of Thomas Bodenheimer, MD, a Family and Community Medicine practitioner and faculty member of the University of California-San Francisco Medical Center. In his study of high functioning primary care practices, Dr. Bodenheimer shared what he considered to be the key elements of team building:

  • Defined Goals — overall organizational mission statement and measurable operational objectives

  • Understandable Systems — both clinical and administrative

  • Labor Division — clear definition of tasks and clear assignment of roles

  • Training and Cross-Training — for the functions that each team member regularly performs and for other roles

  • Solid communication — structures and processes

In keeping with those elements, and in order for our training strategy to be as effective as possible, it needs to go beyond re-engineering the patient-physician interaction in the exam room. That’s why we also support and guide the physician’s participation in mentorship, delegation, communications, role playing and other team building initiatives. In the new model of primary care that’s built around patients and delivered by teams, these skills are becoming more and more essential.

Because whether you’re racing an eight-oar racing shell through the water or providing primary care that’s comprehensive, preventive, efficient and effective, there’s no substitute for pulling together.

Teamwork in the Exam Room

Going Solo Doesn’t Work in the Operating Room

It Doesn’t Work in the Exam Room Either

This surgeon walks into an operating room and nobody is there except the patient. If that sounds like the beginning of a joke consider that the patient waiting for the procedure wouldn’t find it very funny.

A successful surgery requires the close cooperation of a number of operating room personnel. It relies on their familiarity with their specific roles, their preparedness and their ability to execute their responsibilities quickly and confidently. On the most basic level, they’re working together as a well-trained and experienced team.  As it turns out, the primary care exam room responds well to that same scenario.

What’s been taking place in what I have referred to as the “primary care operating theater of performance” is all too often a solo act with the physician spending much of his or her time collecting and verifying relevant medical data, completing documentation, implementing the treatment plan, carrying out any needed patient education and closing the visit.

By re-assigning these important but essentially routine tasks that don’t require direct physician involvement to appropriately trained members of  a coordinated care team, doctors can focus on direct interaction with patients – instead of keyboarding EMR data – while using their specific expertise and training for vital medical issues. The results are physicians who experience more challenge and greater satisfaction as well as more satisfied patients and staff.

The team care approach also provides the foundation for increases in the number of patients seen in a day with subsequent increases in revenues. The other important benefits reported by practices using a team care model are reduced stress levels among physicians, a restored or new sense of joy with practicing medicine and the always appreciated increase in personal time.

There are a number of activities that lend themselves well to the lone wolf approach. Things like reading, painting, writing, cooking, certain types of exercise or reflecting on the greater meaning of life come to mind. But when it comes to exam rooms, it’s becoming increasingly evident that the team care model is the way to go.

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