“Who is your doctor?” This question is often asked by friends or acquaintances when the subject of health arises or perhaps when someone moves to a new city and is seeking a new physician for annual exams and checkups. In today’s healthcare climate, the more appropriate question may be, “What is your healthcare system?” or “Who is your healthcare provider?”
Increasingly, the doctor-patient relationship has been replaced by a provider-patient relationship or a health system-patient relationship. The impetus for much of this change has been the tide of legislative, payment and regulatory reform that has swept the country. The argument, from a patient care standpoint, has been overall improvement of care through better coordination, in order to achieve the so-called “Triple Aim” of improving a patient’s experience of health care, improving population health and reducing health-care costs. Although many changes are with these laudable goals in mind, one key question remains unanswered: “Who is in charge of the patient and has his or her best interests in mind?”
According to a recent report by Accenture, by the end of 2016, it is estimated that only 33 percent of physicians in the U.S. will be practicing in an independent or so-called ‘private’ practice setting. The growth of employment models for physicians follows the acceleration of consolidation in health care in general. Physicians are often driven to this decision for a variety of reasons, in particular, declining reimbursements coupled with increasing overhead due to regulatory burdens.
Better Care is Not Guaranteed
Although some might think that physicians employed by a health system would provide more cost effective and coordinated care, the evidence thus far has not supported this. Moreover, from a patient safety standpoint, while physicians are flocking to large health systems for financial security and improved quality of life, there is little evidence that these institutions provide better patient experiences or outcomes. In fact, some of the most prestigious health care institutions in the country have come under recent scrutiny for lapses in patient safety. Furthermore, there is some evidence that employed physicians provide more costly care in some scenarios. Other studies show that private physician-owned clinics and organizations demonstrate lower readmission rates and lower cost of care.
There are some reasons to believe that the larger infrastructure of an integrated health care system can provide the necessary ingredients to improve patient care and safety. It is critical that a culture focused on the patient is at the core of all clinical systems and decision making. Moreover, health care systems should place physicians who can provide clinical context and understanding of patient care issues in key leadership roles when making decisions that impact the health care system. Unfortunately, there are too many negative examples of decisions made for business reasons that ignore or even compromise patient safety.
In spite of this turbulent change, there are signs that as healthcare reorganizes into a larger, integrated schema with one or more hospitals serving as hubs, the quality of patient care and safety can be maintained. Two positive examples of health systems that have placed physicians in key leadership roles are Kaiser Permanente and Geisinger. A unique feature of both of these systems is that they provide health insurance in addition to being health-care providers. In both systems, the insurance plans and the clinical services have significant physician leadership in management and oversight.
Leading by Example
Steven A. Toms, MD, MPH, FAANS, is the director of the Division of Neurosurgery and associate chief medical officer at Geisinger Health Systems in Danville, Penn. Although much of Geisinger’s focus in recent years has been on re-engineering care with a view to population health management, they have never let that focus detract from individual patient care. Much of Geisinger’s approach to improvement of care delivery and patient experience is data driven, with careful analysis of a robust data set culled from Geisinger’s system-wide clinical IT systems.
Although many of the neuroscience programs target reduction of redundant and duplicative care in order to reduce costs, the ultimate goal of these measures is to improve clinical outcomes and the patients’ experience of care. As examples of some of the initiatives in the neuroscience department, they have targeted developing non-interventional assessments of patients with acute low back pain in order to reduce unnecessary imaging and early referrals to interventional pain specialists and spine surgeons.
Another early success has been the ProvenCare™ Lumbar Spine program. This has been a multi-disciplinary effort to introduce multiple evidence-based practices into the care of patients undergoing routine lumbar fusion surgery. One of the key components of the program is a unique peri-operative pain management protocol that focuses on multi-modal therapeutic interventions for pain management. The result has been increased mobility and decreased length of stay after lumbar fusion surgeries as well as decreased narcotic use post-op. Dr. Toms acknowledges that a great deal of the work in their division focuses on educating physicians regarding the economic impact of their day-to-day decisions in patient care: whether to order additional surveillance imaging in patients with brain tumors, what hemostatic agent or dural replacement they use in the operating room, the clinical utility of lab tests and whether it will impact patient care. “Physicians need to be involved in the process of redesigning care; we cannot abdicate our leadership and responsibility in this matter,” said Dr. Toms.
Harsimran Brara, MD, FAANS, is the regional coordinating chief of neurosurgery for the Southern California Permanente Medical group: the medical group that partners with the Kaiser Foundation Health Plan. He serves as assistant medical director of the Neuromuscular Service Line for the Los Angeles Medical Center. The Kaiser system is also bringing high-level data analytics to bear on neurosurgery care, with spine care a particular focus. A recent effort to develop a high quality, electronic medical record (EMR)-based registry of spine surgery patients resulted in identifying risk factors for 30-day readmissions. The findings have led to changes in the care design system-wide, with a particular focus on post-operative outpatient visits.
The Kaiser system has developed virtual appointments between patients and their surgeons, including video-integrated virtual visits so that patients and surgeons can discuss issues face-to-face. During these virtual visits, surgeons are able to assess patient’s incisions and their functional status. Dr. Brara believes that care like this makes a difference not only because it cuts down on a targeted quality measure like post-op readmissions but because it also reduces variation and handoffs. Rather than a patient talking by phone with on-call staff who may not be familiar with his or her issues, the virtual appointments provide continuity of care between patient and surgeon.
The Kaiser system is also working to streamline the management of new referrals for acute low back pain by developing a virtual clinic that can triage patients in a standardized manner and identify patients, based on imaging, symptoms and potential clinical red flags, who would benefit from early surgical referral versus non-interventional specialists, such as physical medicine or pain management. The overall goal of all the new care redesign in the Kaiser system is to deliver the right care, at the right time, to the right patient. Dr. Brara believes it is key for physicians to be vocal advocates for their patients, actively working within their health care system in a collaborative manner to ensure that changes have patients’ best interests in mind.
For neurosurgeons, the interpersonal relationships with our patients, their families and our intimate knowledge of a patient’s condition are central to our work. Although our work is increasingly coordinated with other allied health professionals and must meet the cumulative administrative demands of our health care systems, it is still based on the traditional surgeon-patient relationship. We must learn to adapt to the rapid evolution of the payment and regulatory environment which dictates how we care for patients and how we are remunerated for this work. But ultimately, our goal is to provide the best possible clinical outcome for our patients. To maintain the highest standard of safety for patients requires a champion, a quarterback, who is at the center of a patient’s complex journey through the healthcare system. The examples of Kaiser Permanente and Geisinger hopefully provide positive evidence that the surgeon-patient relationship can be maintained and even enhanced in the current health care climate.
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