John R. Brumsted, M.D. is the President and Chief Executive Officer of Fletcher Allen Health Care and Fletcher Allen Partners.
Change is afoot in health care and is assured now that the Supreme Court has upheld the Affordable Care Act. A critical component will be modifications in the way we are reimbursed for services, with the obituary of fee-for-service payments now written and published. Change is always challenging and frequently involves risks, so the question is how to realize change in the face of unknowns.
For much of my career as an academic physician, I was involved in developing, evaluating and implementing changes in surgical practice. At its core, we were replacing procedures requiring a large abdominal incision and extended recovery time with minimally invasive techniques done through endoscopes for outpatients. Surgery is inherently risky and testing new procedures doubly so. These risks were mitigated in several ways. First, and most importantly, we tested procedures in a no-risk environment using a variety of models. Only when techniques were perfected and safe were initial trials undertaken with well-informed patients. Second, we practiced as a team, including physicians, nurses and technicians. Everyone understood their role and what was expected before we graduated from the practice environment. Third, we all knew the ultimate goal – to accomplish the same surgical task, but with the reduced pain, recovery time and expense associated with a minimally invasive approach. The result of this work, here and nationally, has been to replace standard invasive procedures with endoscopic techniques that have dramatically reduced morbidity.
The transition to “accountable care” also entails some risks. Accountable care ties reimbursement of a medical team to clinical outcomes and the total cost of care. In this model, the delivery system has a budget to provide care for a defined patient population; a portion of the funds are withheld and returned only if certain quality outcomes are achieved. The principal risk to the delivery system is being unable to provide the necessary care with the allotted funds and having to absorb the excess expense with no additional revenue to cover the loss. Can we mitigate this risk? I believe so.
The Centers for Medicare and Medicaid Services (CMS) is encouraging teams of providers to form Accountable Care Organizations (ACOs) and apply for a three-year shared savings program for Medicare beneficiaries. At the beginning, the ACO will be given a budget target for the population of Medicare beneficiaries for whom the ACO is “accountable,” based on the prior year’s expenditures. If the annual rate of growth in cost for this population is less than the national average, savings are generated and ACO providers will share in these savings. Notably, if the target is not met, providers will receive the usual Medicare reimbursement for services—i.e., they are not taking a financial risk on the population.
This type of ACO allows the delivery system to practice being accountable for a population in a no-risk environment. To do well will require a focus on quality, keeping folks healthy, and developing an integrated system of care. We are applying to participate in the CMS shared savings program and have made the offer to other providers around Vermont to join us, so we can take the opportunity to practice as a team in developing the clinical and business relationships that will make us successful when we are held accountable for the care we deliver.
The ultimate goal is clear. We must provide access to high-quality care that is affordable, while remaining clinically and financially strong as an organization. I am confident we will achieve this goal, as we have time to practice as a team of providers all dedicated to serving our community. When we arrive in the operating room of accountable care, we will be ready.
John R. Brumsted, M.D. is the President and Chief Executive Officer of Fletcher Allen Health Care and Fletcher Allen Partners.
ACO’s may be conceptionally a good idea, but not enough planning is done to make these ideas operational and properly reported in a planned and efficient manner. ie electronic health records. Are all these different plans able to share information with plans from different hospitals? Can these EHR even be applied to all departments within the same hospital in an efficient and timely manner? I hope that ACO plans are not pushed on providers without proper operational and practical proceedures.
What is Fletcher Allen doing to involve patients in the process? As a person who has been seen in numerous departments at FA, I can testify to the fact that some areas of the hospital and some staff members are exceptional, while others are quite under par. Some doctors order completely unnecessary and expensive tests because they lack diagnostic skills. Others fail to order simple blood tests because they do not follow diagnostic best practices identified by other hospitals.
How is the patient’s experience being integrated into the quality measures and ongoing assessments? I would love nothing more than to contribute to the quality improvement process. Apart from filing a complaint, or filling out a rather meaningless survey, I know of no other mechanism.
Dr. Brumsted, how can I make my experience available to those at FA who are interested in cutting costs and improving the quality of care? Patients — current and former — have much data to share.
Thank you for your thoughtful response, Dr. Gonzalez. In several areas of the hospital, we have patient or family advisory councils who help guide our decisions on quality improvement and the patient experience. Is there a particular area you are interested in working with? If so, I can check to see what avenues might be available to you to share your experiences. Also, patient surveys are a critical part of our feedback process – we do review all patient comments and any potential solutions to concerns and issues are taken into consideration.
Note that the first topic of discussion is doctor reimbursement, not patient care.