Redesigning Care to Be Proactive in the Move to Value

Transforming a practice to become proactive in delivering care, rather than reactive, will be crucial in improving patient care and reducing costs, said Thomas Graf, MD, president, Ascension Medical Group, at the spring session of the National Association of Accountable Care Organizations, held April 24-26 in Baltimore, Maryland.

Physician buy-in is not enough, Graf said. Transformation requires physician engagement, with the physicians truly feeling like they have a seat at the table. The old way of doing things was for a group of executives to make a decision and have “the token physician leader” get buy-in from the other physicians.

“We don’t need the physicians being passengers in the boats anymore,” Graf said. “We need the physicians pulling on the oars, getting us to where we need to be, and the only way that’s going to be achieved is if they have a legitimate seat at the table where those decisions are being made.”

Another differentiator of success is quality. Discussions of quality that try to boil everything down to the perfect small handful of measures is “disingenuous,” he said. Physicians are struggling to boil down all of their care delivery and decisions to just a few measures. Graf likened the situation to only boiling diabetes care down to glycated hemoglobin (A1C). While it is important, A1C is hardly the only important part of care for a patient with diabetes. Blood pressure, cholesterol control, and weight are all equally important, he pointed out.

Boiling down care to a single measure or a single small set of measures across multiple diseases will result in a lot of “teaching to the test.” Providers will rush out at the end of the year to meet screening goals or get the last flu shots in.

“We haven’t improved care if we just teach to the test,” Graf said.

For example, if a payer is trying to improve breast cancer screening rates, it might provide a monetary incentive. After a few years, when breast cancer screening rates reach a point where the payer is happy, it might stop paying for those screenings and start paying for colon cancer screening to improve those rates. What happens? Breast cancer screening rates drop while colon cancer screening rates increase.

“Have we created a sustainable solution?” Graf asked. “Not so much.”

If the payer chooses to pay for everything, the doctors won’t necessarily be happy then either—they’ll feel like they’re being forced to chase too much.

Graf suggested identifying the things that are most important in disease states to create consolidated lists of 5 or 10 items that are viewed in an all or none fashion. Either providers and systems did provide the healthcare they were supposed to by meeting all those items, or they didn’t.

He provided an example with Geisinger, which treats 20,000 patients with diabetes and decided on 9 elements that were important and would be reported, recorded, and reviewed for all these patients. At the beginning, only 2.4% of physicians had all 9 measures completed. When Graf was at Geisinger, the system empowered patients by engaging them in their care and leveraged the power of nurses. The system had doctors focus on the 10% to 15% of patients for whom they could make a real difference in their care rather than having the physician focus on everything.

“If you suddenly don’t have to worry about 100% of the things that have to occur for the patient but only 10% or 15%, you have 8 to 10 times more time with the patient,” Graf said.

He also highlighted the importance of informed consumerism. Over the last few years, consumerism has been having a larger and larger impact on healthcare and it will only continue to grow. However, there is evidence out there that shows when patients are in charge of their healthcare, “they screw it up every time” by either spending money on things that don’t provide value to them or not spending money on things that would provide value.

Providers and health systems have to be able to understand the individuals they care for in order to help them make the right choices. He used the example of getting from the airport to a hotel. Everyone needs to do it but there are a variety of ways to get there: get a taxi, rent a car, call an Uber, take the train.

“We need to be that GPS, that navigation system that gets them from where they are to where they need to be in whatever way makes sense for them to do,” he said.