The current national healthcare system can be seen as a pay for procedure ‘Sick Care’ network where most contacts with the system deal with health problems that have progressed to a serious enough level as to require procedures and treatments paid for under the CPT coding system for procedures ( Level 1) and durable medical equipment and supplies (Level 2).
Physicians and treatment centers receive little for disease prevention and much for heroic efforts to treat problems that are often preventable or at least have lower costs and better outcomes when seen and managed earlier in their development. We have been operating on a fee-for-service basis that encourages high cost and discourages preventative medicine. We are just now seeking to implement a system based on value for expenditure.
We have significant experience with public expenditures that have had tremendous impact on population health in the past. Installation and maintenance of clean water supply and waste removal and treatment though seldom noticed and provided massive health returns for the dollars spent as has the efforts of the Centers for Disease Control and Prevention to rapidly respond and diffuse public health threats.
Achievement of the first stated goal of the Triple Aim focus implies improvement in the baseline health status on the entire community served by an Accountable Care Organization (ACO). Each patient is supported and guided by a care manager who oversees their interaction with all levels of the ACO and receives full communication back from each level of the treatment community. Let’s assume that the patient community includes 1,000 persons with diabetes. Under traditional medical practice each of these patients might see a primary care physician who would address some issues of their care, an endocrinologist who might manage the insulin issues and a podiatrist or Emergency Department if they discovered a foot ulcer. Each treatment location would probably run their own tests and recommend their own approach based on local standards or personal experience. Basically each location starts over and provides often conflicting advice with or without scientific merit. Real world reports indicate that this process leads to high costs and questionable outcomes.
Under the Triple Aim / ACO model each diabetic patient would be followed by a care manager who would insure each visited the appropriate physician or center for each of their conditions. Tests and data would be shared within the ACO though Electronic Medical Records and coordinated to minimize repeat testing. The treatments administered would be science-based with active follow up at the appropriate level of facility. A greater part of medical care would include coordinated patient centered education to induce behavioral change and provide information on when and where to interact with the ACO as different issues arose. Instead of falling back on the ER or readmission to hospital patients would be directed to the level facility for problems easily handled by other members of the ACO. As the patient population spends more time within the system the ability of the ACO to work on prevention and the increase in general patient education and motivation is expected to improve general health insuring less use of the most expensive facilities and procedures.
For the diabetic population, better diet, reduced medication errors, and care coordination could quickly reduce the incidence and prevalence of diabetic ulcers while insuring they are detected earlier (duration correlates negatively with healing) with smaller size and less tissue involvement (superficial vs involving bone). All members of the ACO would be aware of the latest science based treatment protocols or where to find them to benefit from the best outcomes at best cost. Electronic Medical Record sharing and adherence to Science Based Treatments and products can insure wound bed preparation, offloading, initial use of advanced wound care products instead of gauze and quick progression to expensive alternate therapies for those not responding to conservative care.
Similar coordinated management of the VLU patient would insure early identification of smaller ulcers and treatment with consistent guidance on the use of compression products to support advanced wound care dressings. Adjuvant therapies like growth factors or cellular and tissue based modalities would be started earlier but only on those who do not demonstrate significant early healing with conventional therapy.
In an ideal situation the population managed within an efficiently functioning ACO should evolve from the current high incidence, large ulcer, ulcers of long duration, to one of early detection, early effective treatment of fewer and smaller ulcers that cost significantly less to treat. The payers would note the reduction in cost due to population health improvement and reward the ACO with a proportion of the savings to be distributed amongst its members.
Success in achieving the first of the Triple Aim Aims will depend on the ability of the ACO to provide top rate data (EMR) that confirms that their efforts to improve population health are moving towards demonstrable results and that healthcare costs are being reduced as a result. Payers must be motivated, able to recognize and support the Pay for Performance model and financially reward each facility and provider within the ACO to insure the prevention and population health model grows to become the dominant model for healthcare delivery.
Alan Neil is the founder and CEO of ASN Associates.