Although Congress recently passed health insurance reform legislation, the real catalyst for change in the health care delivery system, in our opinion, will be changes to the reimbursement model. Health care economists almost universally agree that health care reimbursement must move from a fee-for-service model to a system that encourages accountability for both cost and quality of care. The Centers for Medicare and Medicaid (CMS) seems intent to systematically move Medicare from the current fee-for-service model to a reimbursement approach that increasingly shifts the risk to providers and encourages greater accountability both for the cost and the quality of care. This level of increased accountability can only be achieved by clinical integration among and between health care providers.
Controlling the Cost of Health Care
No one can deny that health care costs in this country are out of control, to the point of openly threatening the stability of our economy. Health care expenditures will approach 20% of our gross domestic profit by 2015. Neither can they argue against ultimately expanding coverage to all individuals living in the United States. Most of the rancor and discord generated by recent health care reform legislation centers on (1) the number of additional individuals receiving coverage under the new laws, (2) the mechanism for this expansion of coverage, (3) the costs associated with expanding coverage, and (4) the method for paying for this expansion.
The divide over these issues is deep and may not be broached in the near future. However, there is broad consensus that “bending the cost curve” of health care is an imperative that must be addressed immediately. To do so will require substantial change in the current health care delivery system that ensures greater efficiency, quality, and rational use of our resources. The foundation of any rational health care delivery system is primary care generalists with the capability and responsibility for ensuring high-quality, efficient care, especially to patients with complex chronic conditions. Unfortunately, our current educational system often is not designed or very adept in preparing primary care generalists for their new responsibilities in health care systems of the future.
Change in the reimbursement model can and is, in fact, occurring without legislation. CMS has been experimenting with a graduated series of payment reforms that systematically shift risk to providers to force more accountability. Pay for performance and refusal to pay for “unnecessary readmissions” or “never events” are the opening gambits. Experimenting with gain-sharing payment models is a more direct attempt to encourage providers to work together. CMS's Acute Care Episode Demonstration Project, which bundles physicians and facility fees for a variety of cardiac and orthopedic procedures, clearly motivates physicians and hospitals to work together to generate efficiency and savings. Moving along the spectrum, episodic bundling, which includes coverage for care from the prehospital setting to the acute care hospital stay to an extended period of posthospital care (usually a period of 30-90 days), develops even stronger economic incentives for multiple providers to improve integration, efficiency, and quality. In the Geisinger Health System in Pennsylvania, all of a patient's medical professionals work together to ensure that no mistakes are made. This model consistently results in decreases in hospitalization and rehospitalization stays for those patients. Provencare, Geisinger's coverage for acute interventions, such as coronary bypass surgery, is a private-sector example of the power of episodic bundling that reduces costs and improves the quality of patient outcomes.
CMS has substantial experience with the Physician Group Practice Administration Project, which encourages accountable care organizations to take much broader responsibility for patients' care through the entire continuum. Clearly, gain sharing between CMS and physician groups creates a very powerful incentive to reduce unnecessary utilization. Although it may take substantial time to accumulate irrefutable evidence that these various demonstration projects truly “bend the cost curve,” CMS's intent to shift risk to providers cannot be questioned. In fact, even the dreaded “C” word, capitation, has reemerged. The Massachusetts experiment providing universal health care coverage for the entire state has shown that increasing access without controlling utilization and improving efficiency naturally results in higher costs. Massachusetts is struggling with overwhelming increases in state health care expenditures and state budget deficits after expanding coverage with reform efforts. A blue ribbon panel charged with controlling expenditures has concluded that the only way costs will be controlled is through a full capitation reimbursement system.
Attempts to change payment modalities with the intent to reorganize health care delivery to emphasize efficiency and quality have several common elements: (1) all payments are value based even if the major goal is cost containment, (2) medical guidelines, standards, and quality measures will play important roles in management, (3) the systems require real-time electronic medical records, and (4) most systems use teams to provide care.
Providing Comprehensive Care
The cornerstone of clinically integrated health care systems is the committed primary care generalist physician, who organizes patient-care services across all boundaries. Primary care advocates have endorsed the concept of the “medical home” model to achieve this end. The medical home consists of an interdisciplinary team of physicians and allied health professionals who partner with patients and their families, taking responsibility for ongoing patient care, using a team approach, technology, and evidence-based protocols to coordinate and provide care. Primary care physicians serve as advocates for patients across the care continuum, ensuring that the patient's values, wishes, and directives are always honored. All patient information cycles through the primary care physician in real time to facilitate, coordinate, and integrate care. The new model requires that primary care doctors be compensated for organizing and overseeing care rather than just for delivering services in 15-minute segments in the office.
For these physicians to have maximum impact, they must be engaged in the comprehensive care of their patients not only in the ambulatory setting but in all aspects of care, including specialized units, such as the critical care unit and the emergency department. Though the direct care responsibility may be delegated to a specialist during a given episode of care, the primary care generalist must remain intimately involved in his or her patients' care. The current efforts to master the perfect virtual handoff between the various providers during any episode of care is likely to fall short in meeting the needs and expectations of these often very ill, frightened, and confused patients and their families.
The need for these comprehensive primary care physicians (“comprehensivists”) is most striking in the care of the rapidly growing patient population with complex chronic conditions who require the reassurance and wisdom that only the long-term relationship with their personal primary care physician can provide. These comprehensivists will need to be experts in (1) anticipating, preventing, and managing the progression and/or complications of common complex conditions, (2) the management of complex pharmacology, (3) end-of-life issues and medical ethics, (4) the coordination of care, and (5) leading health care teams. Their practice environments will need to contain the elements and systems to support their comprehensive care, such as advanced information and e-health systems. Comprehensivists will also need to be able to direct and coordinate a health care team that includes expertise in patient education, mental health and behavioral modification, physical and occupational therapy, pharmacy, home health, etc. Their responsibility is not to ration care but to make care rational, consistent with best practices and evidence-based medicine, while incorporating the patient's values.
Given the anticipated critical role of the comprehensive care doctor in our future health care system, we must ask several questions. Are there enough of them today, and will there be enough of them in the future? Are we training them appropriately to accomplish their critical roles?
Researchers in health care manpower have documented that interest in generalist careers, including general internal medicine and family practice, has been in steady decline for a number of years. Many reasons are put forth to explain this lack of interest, from excessive paperwork and bureaucracy to issues of compensation to a sense that generalist careers lack respect and prestige. Excessive medical school debt adds another disincentive to choose lower-income primary care disciplines and must be addressed. Reorganizing the system to minimize administrative, bureaucratic hassles and to maximize time for cognitive functions and time with patients is critical. Clearly, a compensation model is required that rewards generalist doctors to coordinate and integrate care, actions that are expected of them now and that will be demanded in the future by their patients. Generalists must also be empowered by the medical profession to help patients make judgments that may, in fact, defer, postpone, or refuse care suggested by advanced specialists.
Educating the Primary Care Physicians of Tomorrow
Are we training the types of physicians that the profession needs? Our concern is that we are not. Our system of care in the current training model reinforces fragmentation of accountability and responsibility. The organizational response to the 80-hour resident workweek has created a “shift-work” mentality, leading to a failure of the residents to develop a sense of ownership of their patients. This shift-work approach generates many handoffs that represent real opportunities for failure and eliminates the valuable educational experience that continuity of care provides. Without question, we cannot go back to the training system that demanded >100-hour workweeks, but we must create a more innovative approach to training that will promote a greater bond between trainees and their patients.
Our clinical mentors and role models may also be sending the wrong message to prospective generalists. We have generalist doctors or office-based providers, who hand off their patients to hospitalists for inpatient care. The hospitalists, some of whom work nights, staff inpatient care in shifts, further fractionating care. Often when patients are admitted to the hospital, their primary care doctor is not involved in their care. Patients are handed off between hospitalists working day and night shifts, and occasionally intensivists, all of whom are responsible physicians but do not have a long-term relationship with the patient that commits a sense of responsibility and accountability to the care. We must return to the model in which generalists are involved in the patient's care across the continuum, including the ambulatory office (their medical home), the emergency department, the hospital, the critical care unit, indeed anywhere the patient presents for his or her health care. The generalist who knows his or her patients best acts as a senior consultant (reducing unnecessary, redundant testing), is a valuable resource to consultants who can improve their efficiency, and reduces excessive utilization that is inherent in the current fractionated model.
The educational issues go deeper than graduate medical education and the 80-hour workweek. Undergraduate medical education is also fragmented, interventional, and faculty centered. Even if generalist workforce issues could be alleviated, the educational enterprise is unlikely to produce generalist physicians suited to practice efficient health care. Ironically, much as “fee for service” dictates substantial structure in health care delivery, traditional, department-based educational funding also contributes to fragmented, faculty-centered education. A pay-for-educational-performance and outcomes model, with organizational bundling of educational costs, may need to be piloted in a similar way to the piloting of new care delivery models.
Several elements are essential if we are to train excellent generalist physicians for the health care system of the 21st century. Education must be more efficient, integrated, and longitudinal. Time must be created for students and housestaff to learn essential elements of patient safety and quality, teamwork in the health care environment, health maintenance, and continuity of care, without sacrificing fundamental knowledge. Education must become learner centered with shared responsibility and decision making as a primary model for patient-centered care.
With the emerging technology of high-density, high-speed, mobile content on-demand, information delivery must revolutionize clinical pedagogy to achieve an anytime, anywhere, just-in-time delivery of medical and patient information. Mobile libraries and electronic medical records can accompany the resident and student to the bedside. Education must focus on how to navigate and manage these mobile resources. This mode of delivery should enrich and empower a renewal of the apprentice approach to the clinical care aspects of primary care and specialty physician training.
Taking the Lead
In conclusion, our health care education and delivery systems must and will change. We must conceive of an appropriate response to these changes that addresses the shortfalls of the health care system and begins to develop role models, mentors, and training approaches that, in fact, train the kind of physician that we need for the future. If we do not take action now, even if we are able to correct the workforce availability issues that we are sure to face, the workforce we do have will not be prepared to deliver high-quality and efficient care. Academic medical centers have been crucial in providing an adequate workforce to our health care system and should be the center for developing innovative models for health care delivery, integration, and educating future health care providers. The time is now, and academic medical centers must take the lead.