What I Learned at the ATP Reunion Conference February 2014

I. Capitation is coming

Although Brent was careful to stress that despite this being gospel among those who “have drunk the kool-aid” it is not universally accepted. Still, the alternative narrative is just more of the same – more efficient fee for service – or aspirations for competing as one of a handful of fee-for-service places that will have billionaires flying in from all over the world and pay sticker price.

As a consumer – whether tax-payer, patient, employer or insurer, capitation is appealing.  A monthly fee is paid regardless of the care needed, used, or delivered.  The mystery has been whether hospitals and doctors can survive in that environment.  Watching Intermountain executives get up and say they want capitation yesterday, because this transition period is worse and they’re ready.  But we know Intermountain.  They’re practicality there – they said 70-90% of their business now is capitated.  But they’re not alone.  Virginia Mason, a large group practice in Washington State affiliated with University of Washington who gets 70-90% of their business in fee for service said they’re ready for capitation now too!  Even if most places don’t think they can make it in that environment, the few getting up to say they can will likely pick up the “business” and have a flood of others coming in to learn how it can be done.

II. Transition to Population Management

The transition model seems robust and many of you may recognize where in this framework you’re being pushed/pulled along to.

1. Quality/Cost metric reporting only

If you can’t measure it, you can’t improve it, you can’t fix it.

2.  Value-based purchasing/Pay for performance

Some of hospital/physician pay is contingent on meeting some quality metrics.

3. Upside-only shared savings

Encourage improved efficiency and any money saved by improving processes is           shared by the hospital and the insurance company.  (Currently in pay for service, many improvement projects result in reduced costs and increased profit for the insurance companies while reducing hospital volumes/procedures and revenue.)

4. Upside plus downside shared savings/Bundled payments

Save money and share profit if you are efficient and low-cost, but also lose money if you don’t meet efficiency standards.  For single procedure or single patient with chronic disease.

5. Disease capitation

Payment for a defined population adjusted for disease burden.

6. Full capitation

Capitation without disease adjustment.  Full population management.

This is where advocating for activity, nutrition, tobacco cessation and public health measures in general becomes part of the healthcare model.  Rethinking hospitals as being in the health business and not in the disease-treating business.  Efforts to prevent gun violence rather than improve trauma care? Improve nutrition and activity in kindergarten rather than diabetes treatment in adolescents?

III.  Doctors as -ists

This model of doctoring has been a long time coming.  First with hospitalists when the medical care was too complex and rapid for a primary care doctor to simply round on patients before and after clinic.  We have intensivists, laborists (OB/GYN’s in the hospital for deliveries in shifts) and SNF-ists – doctors on-site for Skilled Nursing Facilities in shifts.  It seems inevitable, to me, that as we’ve been listening to the airline industry for how to improve safety and efficiency in medicine, doctors are more and more becoming shift workers as part of a large team to be coordinated.  Although airline pilots are less happy than they were in the glory days, and the status of doctors may well decrease from what the prior generation of physicians remember as the “good old days,” there is no going back.  Regardless of the number of editorials lamenting the uncommitted new generation of physicians.  And yet, the personal relationship at the center of what doctors actually do will keep physicians thinking and solving problems for their patients, even as the swirl of process improvement goes on.  We don’t have to manage the warfarin dosing, or the insulin dosing or the blood pressure medication dosing, but there are plenty of evidence-free problems to help the patient manage, and the elusive diagnosis is still, well, so elusive!

IV.  The money is always in the details

One of the presenters said that their nurses went from spending 30% of their time at the bedside to spending 90% at the bedside.  A question from the audience about whether that was real, or possible, resulted in more details.  Nurse charting and sign out is done at the bedside.

V. Less is more? A NICU story

One of the more provocative presentations was from the St. George NICU.  The intervention was to change the culture and basically limit any kind of intervention.  Rounds were done with the parents and whole team at the bedside.  If you want a lab or an X-ray, you have to make a case for it.  No one said you can’t get daily X-rays or qam labs or weekly nutrition labs, but you had to justify to the parents and the team what you’d learn.  “If the baby is gaining weight, you don’t need nutrition labs just because it’s Monday,” he said.  And his outcomes, which showed that babies admitted to his NICU didn’t even necessarily have an admit full CBC and chemistry panel, and when they did, they had fewer tests, lost less blood to phlebotomy, etc. was compelling.  Now that he has the data, he can argue that this would be reasonable.  But a priori, it is hard to say.  Because, as another neonatologist noted, one seizure from hyponatremia resulting in long-term neurologic complications would wipe out all the “savings” and “harm reduction” for a thousand babies who didn’t get routine labs.

I don’t know what the answer is.  But certainly it seems we do too much.  Perhaps rather than focusing our resources on answering questions about whether the newest intervention would make outcomes better, we can focus our questions on which interventions we can remove.  In the adult ICU, it took decades to figure out that a Swan-Ganz catheter is useless in management and increases potential risk of complications, regardless of how comforting we found it to trend the numbers.  Do routine X-rays to follow the pneumothorax help you catch it before the kid crashes and needs CPR, when you can put in a chest tube calmly with fewer complications, or do they just relieve the provider anxiety and ultimately expose the kid to more radiation without affecting outcomes? I don’t know, but it seems that these might be the worthwhile questions to ask.

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