Healthcare delivery system reform: Moving beyond King

The national spotlight on health reform has been focused for the past few years on political battles over the fate of "Obamacare," including two Supreme Court decisions and numerous failed Congressional attempts to repeal the legislation.

The recent King v. Burwell decision preserved federal subsidies for Americans receiving insurance coverage in state-based exchanges, allowing a fundamental pillar of the legislation – near universal coverage – to stand. With the King v. Burwell decision fading into the background, the conversation on health reform is now turning towards the delivery system itself, and how best to structure it to achieve superior quality, personalized service and lower costs.

Obtaining the best medical care is far more than choosing outstanding physicians and safe hospitals. The quality of care is dependent on how those doctors and inpatient facilities work with each other and the technology they use and offer to their patients. Some medical groups are able to achieve better outcomes for patients than others. Some are better able to collaborate in order to provide superior care to the sickest of patients. And some groups are leading the movement from a "sick care" system to a "health care" system.

Well-organized multispecialty medical groups are the gold standard in healthcare delivery today; achieving higher quality in more efficient and effective ways than the typical fragmented, community based delivery system. The Council of Accountable Physician Practices (CAPP) brings together twenty-eight of the nation's highest performing health systems to collaborate on shared learnings and serve as models to the rest of the nation. These groups have been successful at achieving superior clinical outcomes for patients by supporting a vision of a healthcare system designed on five key pillars.

1. They enlist and support physician leaders to lead true system change. Physician leadership is key – in both care teams and medical group leadership. The best outcome for the patient becomes possible when the medical care team is led by a physician and includes a variety of providers, like nurses, medical assistants, care managers, and physical therapists. As part of an integrated delivery system, they focus on maximizing prevention, and intervening early both for patients with chronic and acute illnesses. Together, they make the transition from hospital to home smooth and ensure no patient falls through the cracks. When a physician chosen by the physician group helps lead strategic planning, decision-making and systems improvement efforts, real trust is built and change is possible. Physicians will follow a colleague who they are convinced is committed to helping physicians provide the best care to their patients. But they are wary and more cautious with a "chief medical officer" employed by a hospital or health plan administrator whose motivation and incentives may not align with theirs.

2. They make care coordination real. Care coordination requires the care team to have all of a patient's clinical information available at all points of contact, regardless of their physical location in the system. This allows their physicians to work as one to maximize quality outcomes. This robust care delivery design goes much farther than an ad-hoc care manager or coordinator focused only high-cost patients with chronic conditions. To truly provide the benefits our nation requires, health care systems must be improved to provide accountable, coordinated care to all patients across the entire care continuum, and integrate their efforts with those of the treating physicians on a daily basis.

3. They implement population health practices system-wide. As scientists, physicians and clinicians know that you can't improve what you can't measure and monitor. The increased use of electronic medical records also creates increased opportunities to aggregate, analyze and utilize data to identify areas where health can be improved. If the American medical system truly wants to shift from system that focuses on sick care to one that focuses on health and prevention, then individual healthcare organizations must make comprehensive preventive health tools available to clinicians and patients through both primary and specialty care channels. With those tools in hand, physicians and their patients can work together to monitor and improve health. Ideally, needed services can be scheduled whether the patient is seeing a primary care physician or coming to have their eyes checked by an ophthalmologist.

4. They provide 24/7 access to coordinated care. Twenty-four hour medical care is not a novel idea. But physicians working alone in their own offices can't provide that level of service or availability. As healthcare providers, it is our obligation to ensure that our patients can get care whenever and wherever they need it. The problem for physician organizations has always been how to provide this to patients without relying on the emergency room. However, currently available technology, including video, secure e-mail, and other digital technology solves many of these situations and allows patients to get the right care at the right time. When health systems utilize technology in an appropriate way, patients can rapidly access medical care and maintain the critical relationship with their personal physician and care team.

5. They expand outcomes-based payment methodologies. We know that changing the financial incentives motivates real change among care providers. The fee-for-service payment model rewards volume, not higher quality clinical outcomes. Only when payment is tied to improved health outcomes and evidence-supported quality measures will care activities and innovations align. The question that faces us today is what are the best payment methodologies to achieve those goals? For some situations, it can be bundled payments and in other capitation for an entire population. But regardless of the approach, it must align payments with the excellence of the result and the level of patient satisfaction.

Now that the most significant challenges to universal coverage through the ACA have abated, the time has come for all physicians and care providers in this nation—working with payers—to make the adjustments and changes necessary to achieve real healthcare reform. In our view, the focus must remain on these key five pillars -- the real "true-north." The 28 multi-specialty medical groups that comprise CAPP welcome the opportunity lead the way.

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