Care from the "Home Care" industry, housecleaninig, companionship, etc, is trying to move into the Hospital at Home space, but…
Bruce Bethancourt, MD is chief medical officer of St. Vincent Medical Group of Indianapolis, IN.
What are the biggest challenges for the medical group?
The biggest challenge is that with the Affordable Care Act, not so much now but in the near future, so many more people that will have access to care. We really don’t have an increase in provider base. We need to move — and we’re in the process at St. Vincent’s in moving — from a traditional model of “one physician, one patient at a time” to more team-based care.
Moving to the patient-centered medical home model, where it’s team-based as opposed to one-on-one, is a challenge. In the long run, once we’re there, we’ll be able to provide the right care at the right time and at the right place.
How are you positioned in terms of electronic medical records?
I think we’re OK. We’re moving from one EMR to athenaclinicals, which will be a huge advantage for us in the near future. Athena’s ability to track things and to improve gaps in care will be a big advantage for us as soon as we get fully implemented. We’re about 50/50 right now.
What technologies do you see as being either necessary or promising for how you see the care model changing?
Many of us thought that the EMR was going to be the end-all. It would provide all the analytics that we need. I don’t think there’s any one product out there, as far as EMR goes, that provides what we really need.
What we need, there are a couple of things. One is predictive analytics. There are several products out there. Milliman MedInsight is one. The Advisory Board Company’s Crimson is another. Optum is another since they and Humedica came together.
What we need to know is not just the patients we know that are at higher risk, but those patients that are out there that are the second line to be high risk. The example I use frequently is a 75-year-old woman who has an eighth-grade education, who has COPD and smokes, who doesn’t really like going to her doctor, doesn’t get a flu shot, gets pneumonia, is on a ventilator for a month, and then is discharged to a SNF and dies six weeks later.
If we could just reach out to that person, if we had the analytics to find that person and bring them in to the fold, so to speak, before she reaches the tipping point … that’s going to be critical when we’re at risk for all these patients.
The other, much like Acupera that we’re piloting, helps physicians close the gaps in care. That’s the big problem. There have been several studies that show that if a primary care physician with an average patient population or panel size of about 2,400 were to provide all of the evidence-based predictive health and all the evidence-based treatment of chronic disease, it would take that physician 17.5 hours a day just to meet those needs, not counting all the acute problems when they come in.
We really need those analytics to figure out which patient hasn’t had the appropriate preventive health — mammography, colonoscopy, etc. The Acupera model we’re piloting picks up those gaps in care. It doesn’t have to rely on the physician to remember or to even order. The staff can order for the physician and close all those gaps in appropriate care.
Will you put the same resources towards those patients who are still fee-for-service as you do for those who aren’t?
Yes. It’s the right thing to do. If you look at it, the ones that are fee-for-service that we’re closing gaps in care are actually bringing revenue into the system.
Even though you can save money on the patients you’re at risk for, you can make money on fee-for-service patients by being more aggressive about their ongoing needs?
What are the building blocks of getting from a purely fee-for-service, volume-based practice to a more at-risk model?
It’s what we’re going to right now. You can’t just develop a complete team-based care and have open access and non-traditional hours in that physician’s hours to the nth degree and be able to meet the bottom line.
We’re asking our physicians to grow their panels. As we see their panel grow from the 50th to the 75th percentile, we’re implementing an advanced practice provider into that practice. We may even have to split some of our larger practices up because there’s not enough room in the office that they’re in. We’re going to have to, in some cases, open up the access so we can have team-based care, but it’s a gradual process. You just can’t do it overnight.
People talk a lot about patient engagement. Are patients are pushing you to engage differently with them and are you considering any technologies that would help you do that?
We really are in an era of convenience. There was a study last summer where they contacted patients that, when they had an immediate need, would not even call the physician. They went to Walgreens or they went to CVS and they went to some retail provider because it’s convenient. Patients want to be able to get in in a very convenient manner. They didn’t even want to wait on the telephone to find out if they could see the doctor. They didn’t bother — they went directly.
We need to have the ability to have open access, but still be able to meet patients where they are and meet the bottom line. It’s a balance between having enough open access, doing it gradually, and getting the patients where they need to be.
One of the things we’re working on right now is a call center, so that when a patient calls, the call is answered immediately. If they can’t see their physician, at least get them in to a member of the team. A two-way call center is very appropriate.
The other thing is in dealing with predictive analytics and closing the gaps in care. If we have the two-way call center, so that not only calls are coming in, but calls are also going out to find those patients that are missing those gaps in care, whether it be mammography or a colonoscopy or they have to have their hemoglobin A1C checked in six months. We can reach out to them and bring them in. It’s going to take the predictive analytics also with an appropriate call center to do that.
Will you run the call center in-house or will you outsource it?
We’ll run it in-house. What we envision is really not even hiring more personnel. We’ll take the person that’s in the office right now answering the calls and put them into a call center.
Are patients approaching you about being able to see their medical records or the OpenNotes project?
For Meaningful Use, patients can have a summary of care within 72 hours. To be honest, we really haven’t seen a lot of demand for that yet. We’ll have it there when it’s ready.
What are physicians looking for when you recruit them?
Most of them in today’s world are looking for a work-life balance, specifically the younger doctors. They want to be employed. They’re not into working 50 or 60 hours as we did when I was coming up the ranks. They’re looking at a 40-hour week and they want that. They want the electronic medical record. They’re looking for a work-life balance.
What will be the group’s biggest challenges and opportunities in the next few years?
Where we become fully at risk, we may reach the pinnacle of where we want it to be. That is, that it isn’t about how many patients we churn or see to be compensated or reimbursed for our services, but physicians and providers will be compensated on a population of patients. They will be responsible for that patient from birth to death, from preventive health to acute illnesses to end of life.
For example, if you have a panel size of 5,000 and your patient satisfaction scores are excellent, your readmission scores are low, and your quality metrics are in the 90th percentile, you may be compensated X-squared dollars. If you have 3,000 patients and your patient satisfaction scores are low and your quality is low, you’re going to get X-squared minus Y-squared dollars. It will really be about how well you’re taking care of your panel of patients. To be honest, I look forward to that.
In order to do that, it’s going to take the appropriate EMR, but it’s going to take predictive analytics to take care of all those patients. If you think about it, we have not increased the number of physicians substantially at all since 1997, since the Balanced Budget Act. It just recently increased the size of the medical schools, but we really don’t have the appropriate physician workforce to manage 40 million newly insured citizens of the United States. We’ve got to have team-based care. We’ve got to take care of the population. It’s going to take appropriate analytics to do that.