Jan. 1 marked the official start of the Accountable Care Organization (ACO) era, with 32 Pioneer ACOs across the country beginning a three-year program embracing the “three-part aim” of improving the health of the population, enhancing patient experience, and making costs sustainable. Later this year, many more ACOs will come on line around the country under the Medicare Shared Savings Program. Perhaps the biggest challenge to ACOs will be the management of the complex medically ill, or those individuals with two or more concurrent chronic conditions that require ongoing medical attention and/or limit activities of daily living.
In 2011, SHM embarked on a groundbreaking project to improve care coordination between hospitalists and primary-care physicians (PCPs). The Complex Medically Ill Project is being carried out at three health systems and has already had a positive impact. As part of the project, SHM is working with a mobile and online physician community, QuantiaMD, to both learn and teach during the one-year project. Parenthetically, in a short time, the collaboration has yielded glimpses of the potential of mobile technology to improve healthcare, or at least learn about physician attitudes and preferences.
In November 2011, SHM queried hospitalists and PCPs about communication and care coordination between the two specialties regarding treatment of the complex medically ill patient. Remarkably, 4,000 PCPs and hospitalists responded to the survey. In less than a month, we collected more information on this crucial topic than at any other time in the past.
SHM has prepared a white paper that will provide a full picture of what we learned. Here is a preview of the survey findings:
- Improvement efforts in hospitalist-PCP communication should focus on 1) the hospital discharge and 2) the “black hole” —the time between hospital discharge and first follow-up with a PCP;
- Hospitalists and PCPs feel that the telephone currently is the best communication tool, but both groups agree that technology solutions will improve care coordination more than human resources (e.g. a transitions coach) or process improvement (e.g. checklists or discharge bundles);
- PCPs should be more involved in the inpatient care of the complex medically ill; and
- There is a high degree of alignment between PCPs and hospitalists regarding the importance of robust communication for complex medically ill patients.
As ACOs and other approaches to payment innovation expand to effectively manage the health of a population, HM must evolve its focus away from just managing the individual patient during an acute hospitalization and toward a true collaboration with PCPs and the medical home. What will this look like? In pockets across the country, there are hospitalist systems that have enabled 1990s-style managed care to survive and thrive under Medicare Advantage programs (physician groups and hospitals that have aligned incentives under capitated or global payments). They provide some of the best insight into how HM can embrace population health management. The key elements of these hospitalist programs include:
- Aligned incentives with PCPs (and in some cases specialists) and the hospital under a global payment for a population of patients;
- Active participation in disease-management programs for patients, especially the complex medically ill, across the care continuum, including the home and post-acute-care venues;
- Use of “front-end” technology to coordinate care with the PCP and other members of the care team; and
- Use of “back-end” technology to 1) track key measures of healthcare quality and population health, 2) measure and manage utilization of resources, and 3) accurately capture severity of population illness.
SHM’s Complex Medically Ill Project will be one of a number of “test tubes” for care coordination in HM as it transitions from fee-for-service to global payment and population health management. The coming months will see the start of the ACO voyage for a few hundred health systems and their hospitalist programs.
Additionally, Medicare Advantage programs continue to grow, fueling efforts at better coordination and disease management, with hospitalists squarely in the mix. Surely, each of these will represent an experiment in the design of systems for population health management.
While it is anyone’s guess as to whether these policy initiatives will have a major impact on cost containment while maintaining quality and access, it is hard to imagine the brave new world without a retooled hospitalist model that plays an integral role in population health.
Win Whitcomb, MD, MHM is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at email@example.com.