Leading New Models of Practice - Accountable Care Organizations

ACO - the newest mysterious acronym from Washington. Just when most of us were getting familiar with the last big organizing acronym, PCMH. Maybe we weren't actually familiar with the 7 joint principles of the Patient-Centered Medical Home (PCMH) and their implications, but we were at least getting comfortable throwing the term around in discussions, networking sessions and conferences, hoping that no one would ever ask us: "So, what is a PCMH?" Now we've been hearing about the Accountable Care Organization (ACO)... is this just the newest street language in health policy or is there more to it than that?

Last Wednesday, I attended a full-day workshop sponsored by the Society of Teachers of Family Medicine on the ACO. We started by reviewing the basic premise of the PCMH: central places to coordinate care focused on patients’ needs and relationship-building. Industry leaders who were fed up with poor care options in America created the concept of the PCMH, which was jointly supported by all national primary care organizations. The PCMH model emphasizes a strong primary care foundation in which primary care providers take responsibility for providing, coordinating and integrating care across the health care continuum. Pilots of the PCMH have shown improvements in quality and reductions in spending when implemented in large provider settings.

The conceptualization of ACOs is separate from the PCMH but there are many parallels. ACOs are organizations that can use payments:

• to incentivize physicians and hospitals to provide care coordination,
  
• to invest in infrastructure and redesign care processes and
  
• to provide high-quality and efficient services.
  

Patient-specific metrics are being developed to evaluate outcomes and quality. An example of a metric would be A1c <9% in those with diabetes or providing a post-discharge physician visit. Participation in ACOs is optional. Providers and hospitals that participate would be accountable for a defined population across care continuum. Benefits for participating? You would also get a share in the cost-savings from this model.

You may be thinking right now - this all sounds great. But what you've given me is a bunch of fancy concepts. Where are the examples? Well, the answer is that there aren't really any good examples yet. The ACO is a new model that was outlined in the Affordable Care Act. ACO rules were just released last month by the Center of Medicare and Medicaid Services (CMS). These rules are still open for comments until June 6, 2011 and then are to be implemented by January 1, 2012. Providers and hospitals at that point can apply to be ACOs.

What does this mean for family medicine and for the PCMH model that we helped develop?

It’s an opportunity to get involved! The weakness of the PCMH model is that there is no incentive for specialists and hospitals to get involved because they don’t participate in the savings. Secondly, there’s little financial incentive for even primary care doctors to get involved because the money saved on emergency room visits, tests and procedures isn’t reflected directly in the pocketbooks of primary care doctors unless payment structures are transformed from the traditional fee-for-service to more innovative payment mechanisms. The ACO model helps align these incentives to achieve much of what the PCMH model desires.

However, the ACO model makes no explicit mention of the centrality of primary care. As future primary care doctors, we must lead in the development and implementation of ACOs if we are to remain relevant in the 21^st century and to continue serving our patients.

Retooling the MCAT, Rethinking the Goals of Academic Medicine

Think quick –

If a man running at 12 miles per hour in a northern direction on a horizontal plane grabs hold of a bird traveling at 18 miles per hour moving in a westward direction at 45 degrees above horizontal, what will be the final speed and direction of the pair? (just typing this was exasperating, phew!)

The better question should be, what does this have to do with medicine, or the training of an able-minded and bodied physician? In all honesty, I couldn't answer that directly. For good measure, I couldn't answer a very similar question to the one proposed above on my official MCAT, either.

I'm sure some would argue that this sort of questioning tests critical thinking skills, determination, and the ability to work under pressure and time constraints. That is reasonable. But then again, I also spent countless hours memorizing physics equations in college - hours that could have been spent studying pharmacological interactions or anatomic details. Or better yet, hours spent studying medical ethics, health law, health policy, communication skills, or the history of medicine. Wouldn't intense courses in those topics push critical thinking skills? I'm not arguing that there is a perfect system. But then again, I haven't needed to measure the work and force of a spring anytime recently.

Without a doubt, questions like this weed out the competition. I can recall countless classmates that fell to the wayside during physics, organic chemistry, and MCAT preparation. Some that I thought would have otherwise made excellent physicians. So, is our system weeding out the right students? Well, it looks like the AAMC might not think so. A recent announcement indicates that a change in the emphasis of the MCAT examination may be in the works.

“In the next several months, the MR5 Committee will continue its dialogue with stakeholders on the proposed recommendations, leading up to final approval by the AAMC Board of Directors in February 2012. If approved, the recommendations will be introduced with the 2015 MCAT examination.”

The overall goal of the proposed MCAT changes would reflect a greater emphasis on the social sciences, medical ethics, and evaluation of thought processes.

If the AAMC believes that the MCAT may need modification – what other areas of academic medicine could be addressed? How about the requisite pre-medicine courses? Or lecture topics and areas of focus in medical school? Residency structure? CME and physician licensing? I believe that the success of the future of medicine demands a robust review of each of these areas of medical training.

Our health care system must embrace a new academic aim of integrating longitudinal experiences and enhancing the team-based approach. I believe that the future of health care leadership is dependent upon development of leaders now that are adept at both technical and non-technical competencies - communication, effective team-management, time-management, emotional intelligence, awareness of policy and current affairs, to name a few.

Along these lines, MedPAC has laid out recommendations in their June 2010 report to Congress to modify GME payment schemes to create incentive toward just this sort of health care development at the residency level. Their is some indication that MedPAC will go even further in more specific terms for these recommendations in their coming June 2011 report.

"The standards established by the Secretary should, in particular, specify ambitious goals for practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice, including integration of community-based care with hospital care."1

I am encouraged that groups like AAMC, MedPAC, and others recognize and support these needs. This demonstrates a recent shift in ideals of physician character and workforce expectations. In the past, the four year academic medical track focused almost entirely on the preparation of physicians that could meet the myriad of pathologic disease. While bedside manner and patient communication were emphasized in this training, left out were business skills, political awareness, health system development, personal leadership, and development of non-technical competencies.

All of this speaks to what I believe – that there is a fundamental difference between developing clinicians for the sole focus of patient care, and developing physicians that have the skills to be both team-members and leaders in the future of health care. Clearly, in the past, academic medicine has focused on the former. The modern health care climate, and the rapid transition of health reform demand attention to the latter. In the future, we need to more fully consider this balance between service and education.

This begs the question - are we developing great clinicians or are we training health care leaders?

Considering this question is absolutely imperative for the success of the future of family medicine. As we look towards advanced systems of health care delivery – the ACOs and PCMHs of the world will hinge their success on the leadership of those family doctors at the center of patient care. Family physicians in these models MUST have strong communication skills, the ability to manage a team, an appreciation for the business of medicine and health system development. Ever increasing political involvement in health care necessitates a comfort with health policy, legislation, and the political process – not to mention advocacy. Single-minded family physicians cannot expect to be efficient and successful providers of care for their patients. And I believe it is up to our academic institutions to encourage development and growth in these areas.

The problem is that I do not necessarily see these characteristics in many of my classmates, or in the residents with whom I train. My colleagues remain content to stick their heads in the proverbial sand for the duration of their medical school and residency years – with the expectation that they will peek out at the end of the hibernation and everything will be perfect. This is largely a product of a medical education and residency structure that encourages these sorts of behaviors. Textbooks, tests, and H&Ps are the name of the game in these outdated models.

We need to continue to encourage efforts like those of the AAMC's and MedPAC. We should embrace medical school projects such as Dartmouth's approach to engaging students in systems development and quality improvement. And we should look to continue to find ways to balance service with education in the longitudinal structure of residency programs. These goals will continue to streamline and advance the process of developing a successful and productive family physician in modern health care. The kind of family doctor that is best for his patients, his community, and his profession.

1. MedPAC Report to Congress, Aligning Incentives in Medicare. June, 2010. Pages 103-125

Bringing It All Back Home

In the scope of history, medicine has a definite tendency towards cyclical trends through generations. Recently, I've been considering the moves to incentivize preventative medicine, as well as those to reduce admissions and lengths of hospital stay. These factors are driving health care out of the hospital, and into the home. But looking though the lens of the past – we've been there before.

For the overwhelming majority of American history, health care delivery was centered around the home. Only recently, with the rise of the hospital system, have we witnessed an explosion of inpatient care. Far from this, the only care done outside the house was in charitable centers for the destitute. Further, physicians rarely maintained private offices. Early American medicine was a diminutive practice, and professional physicians viewed as a whole, were considered inconsistent at best.

Throughout the 18th and 19th centuries, the center of health care delivery was definitively the home. It was considered a familial responsibility to care for the sick of the household, and it was often beyond thought to send an ill family member outside for care. There was great tradition in caring for one's own family and considerable comfort and dignity in dying in one's home. In rare or advanced circumstances, a doctor could be summoned to the house to offer guidance. But, by and large, patients remained in bed and the extent of care was entirely within the confines of the family house.

The rise of the professional hospital system and the association of physician licensing to health facilities did much to initiate the movement of medicine outside of the home. Increased urbanization and longer work hours also limited the ability for families to care for themselves. The final blow was cast by the rise of individual health insurance, and the co-committal necessity to seek professional care. By the 1930s and 1940s, the public perception had shifted and American expectations aligned with hospital and office-based care. Since that time, health care delivery has become overwhelmingly associated with these entities.

Modern medicine is now seeing a rejuvenation in health care in the home, and a movement away from the hospital and office. Equipping patients with home blood pressure cuffs, glucose monitors, and sensitive scales allow regular monitoring of health. Many large health systems have developed integrated patient tracking programs, in which these devices automatically transmit information into the system database for that patient. Red flags are recognized by the system, and a phone call to the patient allows immediate evaluation and intervention. Further, the rise of direct care physicians has seen a sharp return to “house calls”. In the near future, a continued increased emphasis on preventative care will keep patients out of waiting rooms and tele-medicine will allow many to confer with doctors from the comfort of own living rooms.

Looking at the cyclical nature of American health care, I am reminded of the importance of remembering our roots. With the current debates and projections in health reform, perhaps it would be prudent to more fully consider the past as a means of plotting the trajectory of the future?

Another thought, which may be somewhat tangential, is no less important for the future of family medicine. As we move into this increasing technological world of health care delivery, it becomes ever more paramount that we stick tightly to our foundations. We must be resolute in our commitment to our patients and present in our compassion. We must practice a delicate and humanistic bedside manner. For that is the one thing that computers and precision medicine can never replicate – a comforting hand, a warm heart, and the dedication and trust of a life-long family physician.

1. For an extensive and enjoyable review on this subject, I would encourage EVERY medical student to read Paul Starr's The Social Transformation of American Medicine. If we understand where we are coming from, we can better be prepared for where we are going.

2. Quality of care and patient satisfaction seem to be hot topics in medicine at present. Certainly, the importance of a bedside manner cannot be underestimated. However, I find it intriguing that we are still striving for perfection in this area in the 21st century. After all, the basics of bedside manner were outlined 2000 years ago in the works of Hippocrates. Nearly 400 years ago, Thomas Sydenham wrote extensively on the details and the art of patient care. Again, with the cyclical nature of health care – before so eagerly looking toward the future and waiting for new solutions to arise, perhaps we should more often delve into the past.