By Scott Rollett, M.B.A., C.M.P.E
As they say, we live in interesting times. As anyone who works in the healthcare industry can attest too, nowhere is this more true today than in healthcare. Probably unbeknownst to most healthcare consumers (i.e. patients!), there is a quiet revolution underway to transform the United State’s costly healthcare system into one that is both more effective in terms of health outcomes and less expensive to deliver. It goes by many names and has many parts and pieces, but all are designed to work together with those ultimate goals in mind. Perhaps you have heard of some of the latest “buzzwords”. The Triple Aim. Value-Based Care. Accountable Care. Outcomes-Driven Care. Or one of the most popular, the Patient-Centered Medical Home.
Many of these are not new concepts and have been around for decades. I began my career in healthcare in the early 1990’s when Managed Care and HMO’s first came upon the scene in Indiana. You may remember how your Family Doctor was your “gatekeeper” and how your access to specialty care and diagnostic tests was directed by him or her. It was seen as an efficient model of care and there are many studies that do report a “slowing” in the growth of health care costs during the 1990’s.
Then things kind of got crazy again. Patients pushed back against some of the restrictions that limited their access to care. New technologies came into existence. More effective drugs and treatment options became available. More specialists came onto the scene and some specialists became sub-specialists. All of these things and more created the most advanced level of healthcare available to anyone in the world - - but also the most expensive. The harsh reality is that American healthcare has become so expensive that it is breaking budgets. But not just your budget and mine! Also State and Federal budgets as well the budgets of third party insurers which likely trickles down to the budget of your employer if they offer health coverage as a benefit. The bottom line is that health care costs are skyrocketing at an alarming rate for all of us and no one can stand idly by anymore and do nothing. As consumers, as employers, as taxpayers, we can no longer afford it.
So this latest permutation of “managed care” is back and it needs to succeed more than ever before. One of the key differences this time, however, is that Primary Care Providers (PCP’s) are no longer asked to be simply “gatekeepers” for your health care. Instead, governmental payers and third-party insurers are requiring PCP’s to be “accountable” for your health outcomes. They want PCP’s to make sure your health is either improving (or at least not deteriorating!). They want us to make sure you are getting recommended preventative health care services. They want us to use evidenced-based medicine and hit certain quality metrics. They want to make sure that we address any “care gaps” that might exist. They want us to screen you for depression and substance abuse. If you are elderly, they want us to asses the probability of you falling in your home. If you’ve been recently discharged from the hospital, they want to make sure that you understand your discharge plan and also make sure that you follow up with your PCP at the appropriate time.
These all seem like good things and, when done right, they do, indeed, meet the goals of the Triple Aim (Better Care, Better Health, Lower Costs). But in today’s healthcare environment, this can present some unique challenges. One of the biggest challenges, of course, is: Is this what the patient wants?
It seems like a silly question, right? What patient would not want better health, better care, and lower costs? Everyone does want that, right? But the real question remains, do they want it enough to do anything different? Do they want it enough to get that colonoscopy once they turn 50? Or their annual mammogram or PAP test? Do they want it enough to stop smoking? Do they want it enough to try to lose weight? Do they want our offices calling them every few months to remind them of things they need to come in and have done?
What we are finding at Windrose Health Network is mixed. Some patients like the reminders and really appreciate that someone is looking out for their health. But others don’t like it one bit! They want to be in control of their health-care decision-making and resent the fact that we are calling to remind them about things they don’t want and have no intention of pursuing. Further, since some of these things will cost patients money out of their pocket, we’re asking them to spend money that they may have set aside for other things.
Such exists the dichotomy of Healthcare in the Accountable Age. Whether patients want it or not, commercial and governmental payers are beginning to hold Primary Care Providers accountable for positive health outcomes for their patients. For many years now, medical practices and other healthcare organizations have been incentivized to take proactive steps to ensure good health for their patients. Beginning in 2017, however, reimbursement mechanisms will begin penalizing medical providers who are not able to demonstrate that they are effectively influencing the health of their assigned patients.
So, as 2017 approaches, Windrose Health Network will continue to operate as we always have: by helping patients become active participants in their care and creating a partnership in which the patient remains firmly in the driver’s seat.