Hospital medicine had grown rapidly and provided the platform for change in our nation’s hospitals long before there was any meaningful healthcare legislation in Washington. With President Obama’s appointment of an innovator—Don Berwick—to head the Centers for Medicare and Medicaid Services (CMS), there is increased opportunity to ramp up revisions, large and small, to provide the incentives and the impetus to create a healthcare system for the 21st century.
With that in mind, I thought I’d offer a few ideas that Don could institute on Day 1, which could start us in the right direction, or throw us all into chaos, depending on how it plays out. While most of my attention is directed to the Medicare population, all of these ideas would be equally applicable to the commercially insured population.
We all know that too few people in this country have taken the opportunity to discuss with their families and their personal physicians how they want their care managed at critical junctures, whether it comes on suddenly with an accident or with aging. The suggestion that Medicare would pay for an office visit with your doctor to discuss this imploded with the news media’s fanning of the “death panel” flames first stoked by Sarah Palin, which sidetracked all rational discussion.
Besides setting up people for unwarranted and unwanted assaults and protracted misery, mismanaging the end stages of life leads to an enormous misallocation of physicians’ focus at a time when we all need to be mindful stewards of our limited healthcare resources.
It is acceptable if, after careful consideration, anyone chooses to not have any advanced directive, but it should be a cognitive directed choice, not just a failure to engage.
Therefore, I am proposing that Medicare offer an incentive (e.g., waiving co-payments or deductibles) to have all Medicare beneficiaries complete an advanced directive annually, or sign a form indicating they were offered an advanced directive and declined to have one invoked. In addition, Medicare could set up a system that would allow physicians (or facilities) who would manage the patient’s healthcare to have access to the conditions of the advance directives. The forms could be attached to individual Medicare profiles, possibly on the Web, in addition to being held by a patient’s PCP or medical home, if they have one.
Personal Health Records
Most people in this country can access most of the information about their personal financial status in real time from any computer in the world. Less than 10% of Americans can retrieve meaningful personal medical information. This is in spite of the prevalence of Web-based personal health record (PHR) software from Microsoft, Revolution Health, and other software vendors, along with Kaiser Permanente and a handful of insurance companies.
PHRs allow for an initial baseline set of data to be recorded and updated as new tests, diagnoses, and medications are employed. It allows for a composite knowledge of what has been tried in the past and what is being utilized in the present. This can be under patients’ control, but it would allow for appropriate access at times of acute need (e.g., an ED visit or a hospital admission).
Too often, patients with a long-term relationship with a local PCP present to the hospital and all of the healthcare professionals are forced to make critical decisions in the first few hours with insufficient or inaccurate information. This leads to needless repetition of tests or inability to compare current data with previous data (wouldn’t it be nice to have the last EKG or labs?), or in retrying a treatment regimen that hasn’t worked in the past.
And if you are in another city or if you don’t have a local physician with all of your old records, the information gap is far worse.
Once again, we could incentivize patients to have an up-to-date PHR with reduced premiums, or lower deductibles or copayments. We could look for ways to incentivize PCPs and hospitals to help patients build and maintain their PHR. We could make it a matter of course that a patient’s PHR would be updated at each intersection with healthcare information (e.g., the pharmacy or the lab or each office visit).
Somehow, we have evolved into a fragmented health system. We need to repair the disconnect between patients and physicians. The professional pact between the patient and their primary physician needs to be in place until the patient and the “next” physician agree to the handoff of responsibility. As hospitalists, we see this at both ends of the continuum. Patients shouldn’t just be “sent” to the ED or the hospital, especially not when they are acutely ill. Their personal physician, their medical home, should “arrange” for an orderly transfer of care. This would involve a transfer of information (possibly facilitated by an updated PHR), but as much by the assurance that the accepting physician or institution is prepared for the handoff, acknowledges this to the PCP, and that the patient understands the handoff has taken place.
In the same way, patients would not be just “sent out” from the hospital. The treating physician (it could be the hospitalist, but also the surgeon or cardiologist) would remain the doctor of record—the first resource for patients’ question and issues—until another “receiving” physician has accepted the handoff, acknowledges this role, and the patient agrees.
We could rapidly shift this process by allowing the patient to decide when the hospitalization has ended. We could change the system overnight by making one of the conditions for payment for a hospitalization (to the physicians and the hospital) that the patient has signed off that indeed the hospitalization has ended.
This might include a discussion of chronic medications to continue, acute therapies to complete, understanding by the patient of where and when to receive follow-up testing and evaluation, and a clear understanding of which physician is now accountable for future issues and questions as patients travel from acute illness to normal function.
There certainly are economic and societal issues. Not everyone has a PCP or can pay for their outpatient care, and this could be a full-employment plan for liability attorneys, but in the end I am confident medical professionals would create the linkages that would minimize the deep white space patients find themselves in once they are wheeled to the front door of their hospitals.
Creatively Complete the Hospitalization
In a perfect world, everyone would have a functional, robust medical home to return to after an acute hospitalization. Unfortunately, a patient-centered medical home (PCMH) is much more of a hope than a reality for most Americans. While we are working to create a better “horizontal” hospitalization, there are clear gaps in the vertical-care world.
If we are going to be responsible for bundled care that encompasses pre-admit and post-discharge care (e.g., 30 days after discharge), then we must beef up our outpatient capabilities.
Hopefully in the long run, this can be supplied by a reinvigorated and reinvented medical home, but it is still a long way off. If payment and accountability continue to blur just when the hospitalization ends, then hospitals (and hospitalists) and Medicare and insurers will need to be creative in how and who will manage the patient. We’ll need to solve the issues around patients who are no longer sick enough to require a hospital bed but clearly are not back to their steady state.
This ties in with the accountability gap that vexes our patients every day. Very likely, hospitalists will have to assume a role in managing the patients after hospital discharge. This might take the form of a few follow-up visits and continued support systems via the Web and telephone. It will probably require a new class of hospitalist—the ambulist or the subacutist—supported by dedicated ancillary staff and systems.
Once again, Medicare and insurers can drive to a better system of post-acute care by supplying incentives: a more robust discharge payment or rewarding successful completion of a hospitalization, possibly by bundled payment incentives. In addition, there could be clear standards set that would define when this is done well with associated rewards.
I know some of these ideas are radical and make us uncomfortable. They seem to assign more responsibilities to an already overburdened profession. To be successful, these innovations require an active participation and accountability of our patients. We as the providers of healthcare cannot do this alone. It also requires the evolution of the hospital as an institution from just the healthcare provider for the acutely ill, horizontal patient, but as more a part of a continuum from acute illness to return to function. And it cries out for a robust, capable, outpatient partner in a medical home or accountable care organization (ACO) that is equally dedicated, incentivized, and accountable.
We won’t get there tomorrow, even if Dr. Berwick reads this and acts on all of the ideas on his first day at CMS.
But if we don’t get started, we know we definitely won’t get there at any time in our future. TH
Dr. Wellikson is CEO of SHM.