It is an exciting and fatiguing time to work in healthcare. We continue to operate the most expensive healthcare system per capita in the world. Even hospital employees have growing deductible amounts for their own healthcare, making it difficult to avoid financial hardships when someone in your family goes to the emergency room. It is even more expensive to be admitted to the hospital.
During my time working as a healthcare executive for more than a decade, I am impressed with the improvements in safety and quality of care. I am confident that most hospitals have reduced the risk of getting the wrong medication, getting a blood clot, having a pressure sore, having wrong side surgery, or falling while in the hospital. All these improvements have occurred at the business enterprise level, i.e. within the four walls of the hospital. Community-level innovation can augment these improvements by preventing dangerous complications from chronic diseases and improving your post-operative recovery when you leave the hospital.
Unfortunately, our fee for service payment does not currently incentivize collaboration across care settings or at the community level. This is how the majority of providers and hospitals are paid today in the US. Trust me that healthcare executives and providers want to see improved care coordination and communication. We see the value but have considerable challenges funding activities that are not aligned with the dominant fee for service payment.
There are bright spots of innovation around the country like Community Care of Lower Cape Fear in North Carolina.
Paramedics can provide more hands-on clinical support that prevent hospitalizations and emergency room visits as well as educate patients about their treatment plans,” said Lydia Newman, NHRMC’s executive director of clinical integration. “Community Care of Lower Cape Fear care managers also engage patients in strategies for self-managing their illness to prevent complications.
Today, healthcare systems (hospitals) usually assess their healthcare communities using a number of reports. Non-profit health care providers are required to submit a 990 IRS report which reflects their investments in a variety of programs and quantifies the cost of uncompensated care they provided. In addition to financial analysis, they also produce a narrative assessment which highlights the underserved problems in their communities. This can include things like the number of patients with undertreated diabetes, hypertension, and other diseases. It also provides an opportunity to highlight collaboration with other organizations to address needs which are not covered by fee for service patients and for patients who are uninsured.
If one were to look at these community assessments on paper, it sounds like the executives and providers employed by a hospital are accountable to meet these needs. However, if one defines accountability as “how do I get paid to do my job” they are not accountable. In fact, too much work at the community level could be interpreted as a distraction from work within the four walls of the hospital.
Healthcare systems commonly promote their economic impact as a community benefit.
This is an effective way to show how new construction, adding healthcare jobs and adding new services benefits the community. However, these investments may also increase the cost of care and do not necessarily improve access to care for uninsured or under-insured patients.
I helped to establish a community-based health information exchange (HIE), www.healthlinc,.org, in 2005 when there were very few financial incentives to coordinate care. During that time, we carefully developed business models with our community that aligned with 3 services: efficient results delivery, effective care management, and beginning medication management. We also utilized grants to subsidize the startup of all of the services. These services remain vital to reduce redundant and expensive care. Unfortunately, despite the growth in advanced value-based payment models (ACO, CIN, CPC+, IAH, and others) the majority of payment in this medical community incentivizes more care and more testing.
During a recent visit to Bloomington, Indiana I had the privilege of attending 2 community activities that are likely to have enduring results. Both have minimal to no support from their local healthcare systems. Both are driven by caring mothers involved in healthcare delivery. Both are addressing the social determinants of health in actionable ways. This medical community is focused on screening using a validated measure called the Adverse Childhood Events (ACE) scoring. Dr. Nadine Harris’s TEDMED talk eloquently describes her work as a movement.
Dr. Robert Block former President of the American Academy of Pediatrics “ACEs are the single greatest unaddressed public health threat facing our nation today.”
Despite the slow rollout of advanced payment, I see many positive examples of community collaboration which make me hopeful that healthcare executives will all be accountable for the cost and quality of care in their communities.