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Towards Accountable Care Cultures: Minding Our “Clinical Footprint”

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If , while reading this blog, you have a medical emergency, please stop reading and dial 911 or go to a nearby emergency room. Because sometimes you just need help from a doctor or other medical professional. But what about all of those other times—that aren’t emergencies—where you aren’t sure you really need to see someone, just need a little information, or have a small worry where a nurse or doctor might ease your mind? Can an advice nurse help triage and assuage your healthcare concern over the phone? Does a quick search of the internet help or harm your confidence in knowing what to do? Is it worth making the appointment, trip, and co-pay (assuming you have insurance) to visit your care provider?


I recently wrote about the hype cycle around the topic of “mHealth.” But it’s certainly not the only hot topic making the rounds in the U.S. marketplace of healthcare ideas right now. Perhaps running a close second for the most-hyped award is “accountable care organizations,” or “ACOs” for short. I’ve just landed in Washington, D.C., where I know of no less than five workshops this week on ACOs, yet few consumers (or clinicians for that matter) understand—or have even heard of—this concept, which is a pretty significant aspect of the healthcare reform bill here in America.


ACOs refer to models of care, payment, and governance whereby different healthcare entities in a community (physician groups, hospitals, home care providers, specialists, long term care providers, etc.) come together to form a new kind of organization that is accountable—and paid collectively—for the annual, holistic care of a large group of patients. There are many different kinds of ACOs being proposed and explored, especially via the newly-forming CMS Innovation Center (CMMI) set up to pilot these kinds of approaches. I found the Deloitte whitepaper on the topic to be a helpful summary of the ACO concept.


The bottom line is that, importantly, ACOs are one way of trying to shift our payment model for healthcare in America from a “fee for service” paradigm (doctors and nurses get paid for each office visit, lab, or prescription they generate) to a what I think of as a “fee for results” (medical professionals get paid for delivering great quality care and improved outcomes for their patient panels). Think value, not volume of visits. It’s ultimately about setting up incentives that move us beyond this factory-line, fix-it, fee-for-service, face-to-face care mentality that has dominated our conceptualization of healthcare for a long, long time and that no one—providers, patients, payers, or politicians—is happy about.


I am certainly guilty of adding my voice to the echo chamber on this one as I fly around giving lectures and helping healthcare providers develop their technology strategies for becoming an ACO. But I fear we may be missing the real opportunity for meaningful healthcare reform if we focus too much on the “accounting”—the numbers, salaries, bonuses, and quality measures that will certainly be controversial and suspicious to a lot of healthcare professionals—and too little on the “accountability” that these new care models must instill in all of us. Yes, we must figure out fair, sustainable ways to do clinical payment, governance, and liability as we try out ACOs, but we must also foment a shift towards a culture of accountability for care on the part of patients, clinicians, payers, and everyone involved in healthcare.


At the end of the day (and as much as we don’t like to think about it, especially when we face a medical catastrophe and want every test, procedure, and drug in the book thrown at the problem), healthcare resources—doctors, nurses, bed space, drugs, equipment, education/training resources, and dollars—are limited. Our workforce of trained healthcare professionals—especially primary care doctors and nurses—is dwindling in the midst of global retirement and demographic trends. And somehow—perhaps the bureaucratization of care, perhaps the actual and perceived declines in salary and status for healthcare providers—we’ve not filled the pipeline of healthcare workers fast enough to keep pace with the age wave that is producing a large number of older, often sicker patients.


As with “natural resources” that are scarce or declining, we as a society have to figure out more effective and efficient ways to use and sustain these precious healthcare resources. We need an accountable care culture, in which we all play our part to nurture, sustain, and improve the care resources we have around us. We will have to all change our attitudes and behaviors about how we utilize healthcare resources. In the midst of Global Warming and worldwide conflicts around natural resources like oil and natural gas, we have seen new behaviors, industries, and consciousness emerge. We have become more accountable for our energy use—as individuals and institutions—to reduce our “carbon footprint” whenever possible. So, too (and with surely as much debate, disagreement, education, and struggle as we have faced with energy consumption), we must come to be more conscious and conservationist in our clinical consumption. We must learn how to reduce our clinical footprint.


So what would it mean for us to mind our clinical footprint? I honestly don’t know, entirely. But I am pretty sure that if we only use things like ACOs to change the behavior and payment paradigms of clinicians without also changing how consumers, companies, and cultures manage their own health and resources, then we are doomed to fail. Certainly, doctors, nurses, and other healthcare professionals need to at least be open to these new models of care coordination and accountability for managing the whole patient population with more attention to the costs and benefits—to the value—of different procedures and therapies. And we as patients need to be conscious of at least the days, dollars, and drugs we consume in our quest for health and wellness.


But there is more to accountability than making all of us healthcare accountants, tracking every dime and minute we use the healthcare system. “Accountable” also means taking personal responsibility for something. It means patients will need the means—and the mandate—to take personal responsibility for our health and wellness with more consciousness of—and commitment to—healthier behaviors. And it means medical professionals will have to shift into a mode of coaching and teaching us more about those preventive behaviors, not just putting us back together again when we’re broken or sick.


Some skeptics will say that we’re simply making everyone a healthcare “bean counter” or fomenting a “nanny state” whereby the government controls our behaviors, but I believe we can become more accountable as a culture without going to those extremes. Today’s volume-driven paradigm has made us, as patients, too passive about owning our own health and care, too ignorant of the costs and benefits of the things being done to us in the name of healthcare, too divorced from the financial aspects of care, and too ignorant about whether or not those procedures are likely to prove beneficial. No one should hesitate to dial 911 when help is needed, but nor should we be absolved from trying to minimize our clinical footprint of the healthcare resources we use. If the current hype around ACOs can help stir up that kind of consciousness and personal responsibility, then it will have created healthcare reform, indeed.


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NOTE:  ERIC DISHMAN'S 'HOME BLOG' PAGE HAS MOVED TO:  blogs.intel.com/healthcare