Quality Care: A Unique Perspective Part 2

How can the issues with the ACA be fixed?

I remember in the early days of Medicare Advantage when people were constantly calling it a failed program. And now over 30% of those on Medicare are enrolled in it—and it’s growing every year. As for the ACA, the problems are fixable, and I am hopeful that a bipartisan approach will do just that.

As for the sicker patients being a drag on the system, I think that will take care of itself over time. Often these people couldn’t buy insurance before because they had preexisting conditions.  So, they’re costlier to take care of now. The claims bulge is something that will settle down over time. And I think there is an opportunity to help speed that along by driving patients with high complications to medical homes where their care can be better managed and they can be kept out of the hospital.

What else in your view can make the ACA better? 

Many people who are newly covered have behavioral health diagnoses. We need to figure out how to make the system better for them. They need better access. I think a lot of psychiatrists have dropped out of private plans. In some markets, they’ve even dropped out of Medicare. Patients can’t get their medications. We’ve got a crisis on our hands.  Partly it’s catch up from the prior thinking on these patients with regards to institutionalization. We’ve been naïve about what needs to replace inpatient care for these patients.    

With all that said, I firmly believe we’re on the right path and these shortfalls will be addressed, if we can get together politically and solve our problems. 

What other significant challenges remain for improved quality of care? 

Well, getting back to EHRs, of course interoperability is an issue. This is especially true for the more extensively sick people in the system where care coordination really matters. For them, the system is highly unsatisfactory.  

Let’s assume that all the clinicians taking care of a chronically or seriously ill patient are doing their jobs well. That’s all well and good, but if they can’t look at the collective notes on the patient—all the drugs they’re taking, for instance—then bad things are going to happen.  

So, interoperability is crucial. I know they’re working very hard on it, but at the same time there seems to be a lot of finger-pointing about whether it’s the delivery systems or the vendors that are standing in the way. But something has got to give here. It’s got to change. 

In your view, what one or two game-changing steps can managed care organizations take over the next year to make sure they are in the best possible position to offer true quality care? 

My sense is that there are two very important steps that plans need to take.  One, figure out how to create better synergy with providers in their network, individual clinicians, medical groups, and other new forms of organizations at the delivery system level.  

The way that we started with managed care, many functions resided at the plan level that are now being done more effectively because there’s a better relationship with the doctor at the medical home level, and at the ACO level.  

Secondly, figure out how to have a more positively-oriented relationship with patients. When you look at customer relationship ratings, health plans often wind up toward the bottom of these lists. 

Why do you think health plans have struggled to develop positive customer relationships?

Because often patients only hear from their plan when they’re trying to get a service that’s being denied or when they’re trying to make an appointment with a doctor who now turns out not to be in their network. There needs to be a mindset change, and also practical things that plans can do to make the patient experience more positive.

I see a need to change the mindset from being thought of as a barrier to being an enabler of good use of care. 

What else can managed care plans do now to move the needle?  

Let clinicians know where there are gaps in care. Some plans already do this, letting their clinicians know when certain patients need a mammogram, or to have their hemoglobin A1c checked. It’s pretty easy to do, and I think it’s a lot better than giving clinicians their HEDIS scores. That makes some of them angry because they think that you’re judging them. It should be about working together to make sure patients are getting the care they need.

So, it’s less of a report card and more of a dialogue?

Yes, and it’s an action plan that can help the clinician. The practice doesn’t see claims data, whereas the plan has the tremendous advantage of seeing it. But the action is best implemented at the practice level.  So, putting the information there in a useful way for the clinicians is very important.

There is also going to be tremendous change in the way clinicians are paid by CMS under the Merit-based Incentive Payment System.  It’s going to be top of mind for clinicians over the next few years. So, it’s a great opportunity for plans to help clinicians in their network meet the new payment requirements. 

We have heard it said that the art of practicing medicine is getting lost in the attempt to improve quality. Do you agree with this sentiment? 

Change is hard. Many clinicians were trained in a different mindset—a different philosophy of care. The attitude has been, “If I do my job well then the patient will have a good outcome.” But the thinking really needs to be, “If we don’t all do our jobs well and relate to each other, the patient won’t have a good outcome.” 

I don’t think the art of medicine has to get lost in that changing mindset. A chance to listen to patients and hear what’s going on in their lives. To find out why they aren’t they taking their medications.  The opportunity to be empathetic, understanding. This is especially true with the elderly. Here is a great example of practicing the art of medicine. Rather than always driving toward a quality number, if they’re having a bad experience with a certain drug, clinicians have an opportunity to change that. 

And you think that managed care plans need to convey this message more clearly to clinicians? 

Yes! Quality measurement is more than a simple number, it is about changing behavior and responding to feedback from clinicians about, say, blood pressure goals and hemoglobin A1c targets that might be unrealistically low in the elderly.

We don’t want cookbook medicine—it’s too static. We want evidence-based medicine that’s more customizable to the patient. We’re not there yet. At least not in all places. 

I think we all feel impatient for the future that we know is not too far away. So, I reject the idea that the art of medicine is dead. We’re in an awkward period for sure, but I think we’re on the right path.