The Independence Day holiday is understandably one of my favorites. It had a lot more meaning to me this year and I have my clients to thank for it.
During the last 12 months, I’ve had the privilege of performing consulting engagements in locations key to our nation’s history. I started in Boston, followed by Philadelphia, then Washington DC, and back to Philadelphia. For someone who is a bit of a National Parks junkie, it was like winning the lottery.
Fortunately, many of the monuments are open late. If you hit Independence Hall at the end of the day, there’s an “express” tour that doesn’t require tickets. You don’t get to see everything, but when you’re on site with a client and trying to squeeze in some sightseeing before your flight, you take what you can get.
Of all the monuments and memorials, my favorite is the National WWII Memorial in Washington, DC. During the day, you can often catch an Honor Flight group visiting. It’s certainly something to see the veterans reacting to their memorial. Sometimes I can’t turn off the physician side of my thought processes – not only did they survive the war, but they’ve experienced first-hand many of the medical advances of the past century. Things we completely take for granted were revolutionary during their lifetimes. At night, the Memorial takes on a supernatural quality. Each of the memorials has its own special quality, but for some reason, this one particularly resonates with me.
As much as many of us feel we are living in a word full of turmoil, thinking about what we’ve been through as a society during the last 200+ years puts it somewhat in perspective. Although we may be dealing with crises in healthcare delivery that consume us on a daily basis, we’re not dealing with smallpox, polio, or whooping cough. Many of the diseases we’re fighting are somewhat self-inflicted. We don’t need a so-called “moon shot” to cure them, but rather could make a huge difference with public health initiatives, preventive services, and individual lifestyle changes.
Population health has a lot of promise, if you can get through the hype. The ability to reach out electronically to hundreds of patients based on easy-to-access data points is huge. We can do in seconds what it would have taken days to do with paper charts. For most practices, though, the focus is on the sickest of patients because we’re targeting costs as a primary indicator. We’re trying to manage the top 10-15 percent but are losing sight of the rest of the population. For those organizations that have figured out how to expand their reach into the next quartile, the long-term returns on health promotion and disease prevention could be tremendous.
As a young physician, I used to rail at the fact that Medicare would pay for insulin but didn’t have adequate coverage for diabetic education. It felt like we were spending our money in the wrong place. We also weren’t paying for preventive services, but were happy to pay when people were sick. The Affordable Care Act has changed that for the better, as has the push to look at value rather than volume.
I’d like to see it go even farther, though. Rather than focusing primarily on diabetics with the worst control, how about we focus more on the pre-diabetics and newly-diagnosed individuals who we can truly impact? It may not bend the cost curve in the short term, but it certainly will in the long term. I think organizations are trying to move in that direction, but it’s hard to find the right mix of patients to target given the typical resource constraints in care management.
There are some solid programs to look at how we do this. I’ve been following the Comprehensive Primary Care Initiative (CPCI) and its evolution into the CPC Plus program. It’s been great to see the way they looked at the program and how it worked and are now creating two different paths moving forward. Hopefully we’ll have enough practices truly embrace the program that we will be able to see how effective the different approaches are in achieving health outcomes. I’m eager to see what regions will be chosen, what payers will participate, and whether any of my clients will decide to move forward with the programs. I’d love the opportunity to be hands-on with the next generation of comprehensive care.
One of the reasons I think programs like CPCI work is that they’re voluntary. Practices self-select if they want to be a part of it — they know from the beginning what they are getting into. They’re not doing it because they feel pressured or because they’re trying to avoid a penalty, and I think that’s the point we’ve collectively missed with Meaningful Use and now MACRA/MIPS/ACI etc. We all understand the psychology of the carrot and the stick, and even though we know some people will never get moving until the stick is approaching, the carrot is a more powerful motivator for many. Programs like CPC+ also speak to the reasons why physicians went into primary care in the first place.
As we all wait for the MACRA final rule, many organizations are trying to figure out their strategies for the next few years. Do we want to be the kind of practice that just aims to check the box, or do we want to try to do more? How can we get our nation’s best and brightest focused on solving these complex healthcare problems? Can we start to focus on the patients in front of us as much as we’re focusing on scores and numbers?
Unfortunately, these aren’t easy questions to answer. Eventually we will get through all of this, much as our forefathers have gotten through so many other challenges that were different and yet the same. Although it may not seem easy, we’re fortunate to live in a time and place where there are many opportunities to make things better for the people we serve.
Rather than focusing on the daily chaos that surrounds us, let’s remember to think about the promise that our technology holds. Who’s with me?
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