Hospitals, MedCity Influencers

Realizing changes in health care delivery – new structures for providers, more hand-holding for patients

There is some good news for patients when it comes to the changes underway as […]

There is some good news for patients when it comes to the changes underway as part of the Affordable Care Act (ACA). The reforms and transitions have started a national discussion about how to deliver care in a different way – and we are headed to a system built more on collaborative, patient-centered team care.

With all the different moving pieces of the ACA and the development of accountable care organizations (ACOs), both healthcare providers and patients are adjusting to the new approaches for delivery of patient care. Some are good, some are unknown and most are complicated.  But as a physician anesthesiologist that plays a pivotal role in the perioperative care spectrum for all patients, I welcome the new emphasis on collaboration.

The past focused on “managed care” and the HMO model.  The ACO, unlike the HMO, is all about “coordinated care”. But there is much confusion about what this coordinated approach really means when it comes to hands-on patient care, and how healthcare providers should do things differently.

Brett Simon, M.D., Ph.D. and Sharon Muret-Wagstaff, Ph.D., M.P.A. state: “Payment reform and the move toward accountable care organizations and other integrated delivery systems enable a renewed focus on improved patient outcomes and interdisciplinary collaboration to achieve high-value care that is safe, effective, patient-centered, timely, efficient, and equitable.” (Simon BA: Leading departmental change to advance perioperative quality. Anesthesiology 2014; 120: 807-09).

In practice, the goal is to be more collaborative and coordinated in order to reduce the amount or level of care that a patient actually needs.  Think of it this way: a patient with various health issues is standing on a balcony about to fall over the edge. It is the job of the ACO to move the patient from the balcony down to the front door step BEFORE he falls. If the risk is reduced on the front end, the fall is much less severe and the resulting treatment needs are minimized. We accomplish this through improved communication, shared information, early identification of problems and implementation of measures to address them.

The ACO model will serve as one driver toward this more coordinated care approach. Another driver is what’s known as the perioperative surgical home – an interdisciplinary model of care being promoted by the American Society of Anesthesiologists. In this approach, the physician anesthesiologists act as “conductors” for an “orchestra” of surgeons, hospitalists, nurses and other care providers. They are there from beginning to end, with a comprehensive view of the patient’s entire perioperative course and are positioned to gather the appropriate preoperative testing and consultation, design a very personal anesthetic plan, manage health issues, identify and treat complications, and maximize pain control through to discharge.

When you take a step back and look at this increased provider involvement, the system can seem more intrusive. But for higher risk patients, some extra hand-holding will keep them healthier, reduce hospital stays, improve recovery times, and lead to earlier interventions when problems arise.

So what’s shifting behind the scenes with responsibilities and requirements on healthcare providers to change this dynamic for patient care? Some of these factors include:

  • Reporting and reimbursement requirements: ACO reporting and Physician Quality Reporting System (PQRS) measures are a new way of monitoring and reporting outcomes.  The ACO PQRS system includes 32 quality measures that will help protect long term health – such as ensuring the correct lab tests for diabetics, making sure patients receive preventative mammograms and colonoscopies and that smokers receive non-smoking counseling to name a few.  We shift from payment for volume of services to payment for value of services.
  • Cost savings: Healthcare systems aim to make better use of non-physician providers. The concept is to do more with the lesser licensed, lower cost providers. This can be a good thing, as long as it is done safely and maintains physician involvement.
  • New business structures: Physician practices are being structured differently today than in the past.  The use of electronic medical records is changing the way practices communicate with each other.  Care transition nurses are now in constant contact with physician offices and practice managers.  Physician extenders are employed by both primary care and specialty practices.
  • Increased and targeted intervention: There is a definite benefit to not treating all patients equally. We need to identify the patients who are more likely to get sick, and then do more to intervene through reminders, check-ins, and tailored care that includes managing medicines and appointments. The use of predictive modeling software allows us to intervene sooner for patients who are at high risk of developing serious illnesses.  This hand-holding is what brings the patient from the balcony to the front step.

The healthcare system is evolving with a new focus on long term health, and an emphasis on harnessing a team of experts to identify and treat patient needs in a more collaborative fashion. As a physician anesthesiologist, I encourage this coordination and look forward to working through this new approach with my peers. And as a future patient myself, I will certainly welcome the heightened efficiency, reduced cost, increased communication, and even a bit more hand-holding.


Keith Chamberlin

Keith Chamberlin, MD MBA, is Vice Chair of the California Society of Anesthesiologists’ Legislative and Practice Affairs Division.

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