How About Team-Based Care AND Experts?

Disease Management Care Blog readers may recall this snarky "It's Team Based Care, Not More Experts" speechifying that challenged a John A Hartford Foundation report on the growing need for expert geriatric care.  The Foundation's Program Director Christopher Langston responded and, rather than let it languish as a bottom-of-the-page-comment, the DMCB thought it warranted its own separate posting. Dr. Langston makes some good points:

The John A. Hartford Foundation has long recognized (here's an example) that there are only 24 hours in the day and that teams are critical to delivering quality care in a cost-effective way.

So when we reported the results of our recent poll showing that despite the existence of the new Medicare Annual Wellness Visit benefit, older adults still aren’t getting important assessments (like fall risk, mood screening, or medication review) at adequate rates, we weren’t trying to doctor bash or even suggest that MDs should work harder. They just need to be sure that the work gets done by someone.

We are in favor of organized, team-based systems of care and the poll results should include services delivered by non physician-providers.   The cognitive interviewing that the survey firm did as part of question development assured us that respondents were saying "yes" when they got services/assessments from a practice regardless of who exactly delivered them (MD, RN, MA, or ??).

So, I don't think we have a real disagreement on this team/delegation issue.

I also tend to agree with the Disease Management Care Blog that we can't really tell from the poll if MORE geriatrics expertise would help or not -- BECAUSE we aren't really using even the limited expertise we have. Models like IMPACT or Guided Care mostly use generalists and incorporate "expertise" in the team model and the protocols they use. Unfortunately, these models are underused.

Perhaps the role of geriatrics expertise is to help practice leaders redesign their work? Respondents on the poll did endorse items  that more health professional education would help and even improve their care, but any one perspective, even patients’, on this issue is limited. It was also very interesting that in question development, our polling firm kept trying to focus on the work of the MD. Perhaps the public needs some education too before it buys into the team concept?

Regardless, the Foundation supports more education in geriatric care that can at least teach providers take this part of their work more seriously.  I don’t think that we really need to teach MDs HOW in a mechanical sense to do a “get up and go” test of mobility and balance, but we do seem to need to teach WHY they should do one as well as find ways to incorporate such assessments into the work of the team.  Ageist attitudes seem to stand in the way of many providers understanding that their care of older adults makes an even bigger and more immediate difference in outcomes than the care of younger adults.

The Latest Cavalcade of Risk Is Up!

FreeMoneyFinance is the host of the latest Cavalcade of Risk.  This insurance and enterprise risk management summary offers up some of the best bloggery on data sharing, health care policy, workers comp and, last but not least, an unusual type of life insurance claim.

For your learning pleasure. 

Prospective Payment Good, Fee For Service Bad, Right? Unless You're a Patient That Is.....

Applying the brake in the name of patient care?

The Disease Management Care Blog poses a simple question: knowing that, despite the best of care, things can occasionally go wrong following surgery (for example, inpatient MRSA infections can still happen and readmission rates will never go to zero), do you really want your doctor or hospital to not be paid for the additional care that you may require?

Go to the websites of organizations like Robert Wood Johnson or The Brookings Institution and you'll find impressive expert papers that extol a variety of "payment reforms" designed to "align incentives," "reduce waste" and "achieve cost savings."  Dig into these reforms and readers will encounter admiration for payment approaches like "prospective payment," case-based," "bundling," and "shared savings."  You'll also find a deep disdain for "fee-for-service" (FFS). 

Prospective good, FFS bad, right? 

"Not always," replies the DMCB. It depends on your point of view. Like, if you're a patient.

The DMCB explains.

The DMCB learned long ago to simplistically think of provider payments in terms of "gas" and "brake" pedals.  FFS applies gas and accelerates provider services; that's because each time a "service" is provided it subsequently generates a "fee." 

In contrast to FFS, case payment, bundling and capitation apply the brakes, because providers receive the payments up-front. Since the money is in hand, providers have an economic incentive to preserve it and withhold services.  The DMCB thinks of "shared savings" in terms of brakes because the up-front payment is essentially held in escrow until the savings (versus a targeted level of utilization) are achieved.

The simplest example of how this can be applied is to hospitalization.  If hospitals are paid for each day that the patient is in a hospital, that's FFS (otherwise known in the industry as "per diem"). 

Instead of per diems, most hospitals are paid with a different payment mechanism based on "diagnosis related groups" (DRGs). Every time a patient is admitted, that generates a payment (similar to FFS).  That payment, however, is not pegged to the number of days the patient stays in the hospital. Instead, the payment is bundled to pay for the entire hospitalization.  That's why hospitals are always willing to admit patients (the gas) and then in a hurry to discharge them (the brakes).

Under the payment reforms championed by Robert Wood Johnson or The Brookings Institution, the inpatient payment bundling would be expanded to pay for the entire case after discharge from the hospital.  Under this system, if the case had to be readmitted, the hospital and providers are SOL.  After all, why should they be rewarded for shoddy care?

Unless, of course, you're the patient.  The DMCB worries that a one-size-fits all approach to payment policy could have unintended consequences. Patients battling unanticipated outcomes would likely prefer that their providers be incented to give additional care.  They want to be back in the hospital.

The payment policy may be good from the point of view of health reform, but it can be bad for patient care. 

The DMCB asks if we are on the verge of another round of unintended health care consequences.

We'll know soon enough when anecdotes of patients being inappropriately denied readmission begin to appear.

Population Health Management and Readmissions

A physician welcoming the
patient back to the hospital

Years ago, the Disease Management Care Blog had to readmit a recently discharged elderly patient back to the hospital.  It paged the colleague who originally discharged the patient and she offered up an important insight: the patient was so ill and feeble that it was remarkable that the patient made it out of the hospital in the first place.

Later, when the tut-tuting hospital quality assurance nurses started to swarm, the DMCB provocatively informed them that readmissions were the price of doing business.

That's why the DMCB liked this New England Journal of Medicine article that questions the overall wisdom of Medicare's national focus on reducing readmissions. Authors Karen Joynt and Ashish Jha make some good points:

1. What is the evidence? While a "readmission" is widely viewed as a failure of not having gotten it right the first time, in-depth chart reviews of readmitted patients reveal that only 12% - 25% are truly preventable.

2. Multiple causes: Not getting it right the first time is less of a cause than absent families, poor community supports and lingering poverty.

3. Death is the most effective solution: Hospitals that perform well in keeping patients with end-stage illness alive are ironically destined to have higher readmission rates.

4. Priorities: Trying to reduce readmissions will consume hospitals' time and resources better spent on other patient safety initiatives. 

Drs. Joynt and Jha have two good recommendations:

1. Focus on those readmissions occurring within 3-7 days.  Those patients are more likely the victims of poor discharge planning that is under the hospitals' control.

2. Alter diagnosis related group payments to include a "warranty" that covers the likelihood of readmission within a few days of discharge.

And, as is common among the health care academia, one good recommendation was missed:

3. Medicare should learn how to adopt, incent and pay for "best practices" from population health management interventions like this and this that lead to meaningful decreases in readmissions for the patients who are at greatest risk.  What's more, the DMCB believes that if hospitals (and their spawn, ACOs) can "outsource" this to a third party who can provide this on a turnkey basis, they can better devote their attention to other critical patient safety needs.