Healthcare systems are valiantly seeking to break out of the old paradigm and into a new one based on caring for populations. Health care reform efforts are still tragically focused on access and the payment system. While both are important, I think they miss the mark by getting us into the details of payment before we redesign the care.
Don’t get me wrong – most of my doctoring career as a primary care physician was spent trying to balance my patients’ needs with the wacky payment system; that meant I needed to see as many people as possible in the shortest time to bring in enough revenue to sustain the practice. I insisted on seeing folks in the office when I could have advised them by phone or e-mail because that was the only way I could have gotten paid for my professional services. We are finally on the brink of changing that model.
Of course health systems are responsible for the care of the people they serve. Who is that exactly? Is it those in the service area of our nonprofit health system? Those who choose us? People who sign up for insurance that we accept? I welcome your definition so we can get on with the care. One of the important lessons of the managed care era was that caregivers were responsible for people “on their panel,” even if they never came to the office. The new system is described as allowing people to choose rather than be assigned, and for organizations to be responsible for those that choose them.
Our primary responsibility is to design better systems of care to deliver more value. I believe we need to spend our effort on the redesign to improve value and the payment will reward those who figure it out best. The transition will be awful for providers and patients as confusion and mixed incentives will be the norm until we settle on most of the payment being for a better system. It’s time to design the system.
So a giant need is to improve transitions. Quality declines and safety is jeopardized when people transition from one care setting to another. A recent review (to access the review, see the attached PDF) of the past decade of research on transitions points out that there are a small number of interventions to change transitions that can make a big improvement. In particular, three are highlighted for patients in the big transition from the hospital to home:• a follow-up visit in the home;• use of “telemedicine” methods for patients to remotely measure key parameters of their health and transmit them to their doctor. (Examples of key parameters include blood pressure, blood sugar and daily weight ), and have daily videophone or telephone visits with a caregiver; and • comprehensive discharge planning that is individualized, and focused on self management and goal setting.
Those who invest time and resources in these kinds of evidence-based improvements in transitions, along with community based improvements in chronic care, will be better positioned to improve value and will be successful for patients and populations while being rewarded financially.
Cooley Dickinson Hospital • 30 Locust St. (Route 9), Northampton, Mass. • (413) 582-2000