Medicolegal Issues

Performance Partnership


 

With 37,000 individual members and nearly 5,000 hospitals and other provider groups on its roster, the American Hospital Association (AHA) is a major player in national healthcare debates and in shaping policies aimed at improving quality.

John Combes, MD, AHA senior vice president and president and chief operating officer of the association-affiliated Center for Healthcare Governance, serves on several national advisory groups on medical ethics, palliative care, and reducing medication errors.

Among his many duties, he is a principal investigator for a national project aimed at reducing hospital-acquired infections called “On the CUSP: Stop Bloodstream Infections,” sponsored by the Agency for Healthcare Research and Quality (AHRQ). (CUSP is the Comprehensive Unit-based Safety Program, developed by Johns Hopkins University and the Michigan Hospital Association.)

Dr. Combes recently talked with The Hospitalist about the AHA’s vision for healthcare reform, integrated care, and the role of hospitalists in redesigning hospital-based care.

The promise is that if we can integrate the delivery system, we can then get focused on improving care and then rewarding high-quality delivery of care.

Question: What are the AHA’s biggest priorities over the next year?

Answer: Healthcare reform and making sure that we can increase coverage for patients without insurance. There are 48 million uninsured in this country, and we are very supportive of increasing that coverage to make sure that people have good access to healthcare.

Q: The AHA has stated that “clinical integration holds the promise of greater quality and improved efficiency in delivering patient-centered care.” What’s your vision for clinical integration?

A: What we recognize is that in a reformed delivery system, we have to have a lot of partnerships between hospitals and clinicians—physicians in particular—and between hospitals and other facilities, such as long-term care facilities and post-acute facilities. We need to be able to bring better-coordinated care that meets the patient’s needs, and we need to work with each other to constantly improve that care. So that’s why we’re looking at an integrated delivery system. In our minds, it really means one registration, one bill, one experience for the patient.

Practically speaking, if you look at the healthcare reform legislation … there are pilots in there for accountable-care organizations (ACOs) and other payment reforms. And we’re very interested in making sure that hospitals can participate and take a leadership role in the development of those kinds of new structures.

Q: What role do you expect hospitalists to play in the continued drive for higher quality and more efficient care?

A: I think hospitalists can become a critical partner with the hospital in helping us redesign inpatient care to make it more efficient and effective. Additionally, hospitalists have a key role in engaging and keeping involved the community-based PCP, and making sure that they are considered part of the care team, even though they may not be present in the hospital, since they have the continuing responsibility for the patient.

I think as we look at other models of care delivery, such as the patient-centered medical home, it’s critical that hospitalists really develop some strong relationships and communication networks with those groups as well, so that the care for the patient can become seamless and transitions are not as dangerous as they’ve been in the past, in terms of missed opportunities and missed handoffs.

It’s critical that hospitalists really develop some strong relationships and communication networks with those groups as well, so that the care for the patient can become seamless and transitions are not as dangerous as they’ve been in the past, in terms of missed opportunities and missed handoffs.

Q: What are the necessary ingredients for any successful quality incentive payment program?

A: One of our big concerns is that there are lots of regulatory obstacles to true integration, where you can design some of those payment structures in terms of gainsharing and also in terms of payment for high-level-quality performance. One of the concerns of the AHM is to make sure that as we pursue these new models of care that require high levels of integration, we also look at some regulatory relief.

The promise is that if we can integrate the delivery system, we can then get focused on improving care and then rewarding high-quality delivery of care. And that can come through incentive programs or pay-for-performance programs and things of that nature that can be worked out between the hospitals and the physicians.

Q: What can be done to reduce the rates of hospital-acquired infections?

A: The idea of CUSP is that you create teams and a culture on units that will then implement the evidence-based intervention—in this case, eliminating central-line infections.

Hospitalists can play a critical role in helping create that culture of mutual accountability at the team level [and] holding each other accountable to use the evidence-based techniques for, in this case, line insertion, or for any kind of safety intervention. I think eliminating infections is a goal that’s achievable. I think we have come to the understanding over the last five or so years that these complications are avoidable in many, many cases, and that it takes teamwork, communication, and use of evidence-based procedures to get the work done.

Q: What can be done to help reduce preventable hospital readmissions?

A: There are so many things that go into readmissions. And the issue is: What is truly preventable in terms of treatments within the hospital, the coordination of discharge, and aftercare followup? A lot of readmissions are related to social determinants of health. And those have to do with people’s ability to afford their medications, people’s ability to access care, people’s home environment, and things of that nature. It’s going to take an approach by hospitals on those things that are controllable in partnerships with the physicians. But for many, many readmissions, it’s related to other issues that we as a society really have to hold ourselves accountable to.

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Q: Some critics have charged that the overuse of medical technology is helping to drive up healthcare costs. Would there be more of a role for hospitals in decision-making about the appropriateness of tests within a model like an ACO?

A: In an ACO, that’s a partnership between hospitals and physicians operating as one entity. So that’s the difference, because there, everybody is aligned to make sure that we deliver the most effective care. There’s going to be much more time spent on physicians ordering the most appropriate technology or treatments for that condition that will deliver value to the patient and to the payor of that care.

But that’s in a totally integrated system. Right now we don’t have that. So where the interests of the physicians may be different from the interests of the hospital and the intentions are not aligned, it’s very hard to get at talking about what’s the most effective care.

Q: Is there a measure that hasn’t received as much attention that you would like to see more focus on to help improve the quality or cost-effectiveness of healthcare?

A: I think the one area that we’re always challenged with—and I think we’ve seen it in the healthcare debate, and I think it’s an appropriate role for us as healthcare providers to pay attention to—is palliative and end-of-life care. I don’t think we’ve done enough work, as a profession, to make sure that we deliver very-high-quality care of patients with chronic and acute catastrophic illnesses.

We need to better understand what the needs of those patients are, to ask them to work with us to set the goals with them, what they want from us.

So I think it’s an opportunity for us to have a real partnership with patients at a critical time in their lives. TH

Bryn Nelson is a freelance medical writer based in Seattle.

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