Two noteworthy articles caught my attention this week. One was an article by Wall Street Journal columnist Laura Landro called, How Doctors Rate Patients. The other was a March 27th piece by Rob Garver in the Fiscal Times titled, Hospitals Plot the End of Insurance Companies. While these two articles are not in any way directly related to each other, taken together they provide what I think is a brilliant treatise on the path toward accountable care.
In Hospitals Plot the End of Insurance Companies, Dr. Ezekiel Emanuel, who was one of the architects of the Affordable Care Act, is quoted as saying that we are beginning to see what he called the “Kaiserification” of our healthcare systems. By that he was referring to a model of health organization, like Kaiser Permanente, that is both insurance company and provider of care in one organization. For many years, I have been pointing to such organizations (staff-model health maintenance organizations or HMOs) as being among other things, the e-Health leaders in America. You see, organizations such as Kaiser that are both payer and provider are ideally positioned to use exactly the most appropriate care at exactly the most appropriate time and place. This includes being able to use technology to provide information and medical services to the populations under their care. Long before we were talking about “accountable care”, the staff model HMOs were delivering on the promise of a value-based, rather than volume-based system, precisely because they didn’t have to worry about the perverse incentives associated with traditional fee-for-service models of care. In Hospitals Plot the End of Insurance Companies Mr. Garver reviews why many hospital systems across America are now beginning to find ways to bring insurance premium payments directly into the hospital. He also points out that, alternatively, many insurance companies are now investigating ways that will allow them to become care providers too. So fully played out, everything starts to look a whole lot more like Kaiser.
During my own career, I’ve practiced in both kinds of organizations–traditional fee-for-service and managed care. The downside of fee-for-service is perverse incentives that may cause physicians to provide too much care, or sometimes even unnecessary care. Too much care drives up costs and worse yet, unnecessary care may actually harm patients. But there is also a downside to managed care where incentives may exist to do less than is needed, and that can also cause harm. The socially-conscious, population based care touted by health maintenance organizations while good for the “population” can sometimes be bad for the individual. I’ve always said that you can get what you need from a health maintenance organization, but sometimes you have to be a bit more demanding in order to get it. That’s where the article on How Doctors Rate Patients comes into play.
Ms. Landro reviews how some hospitals, health plans and employers are now scoring patients on how engaged or “activated” they are in their care. It turns out that highly activated patients generally have much better health outcomes. The Patient Activation Measure or PAM scoring system was developed at the University of Oregon’s Health Policy Research Group. It provides a way categorize patients into one of four so-called activation levels. It does this by asking patients to rate between 1 and 100 how strongly they feel about certain statements related to their health and their healthcare providers. The four levels of patient activation look something like this (Source Insignia Health).
So, to my own way of thinking (and perhaps too simplistically) if all provider organizations also become insurance companies, and all insurance companies also become provider organizations, then we have a clear path to a healthcare system that can actually deliver on the value-based care envisioned by the Accountable Care Act. However, in order to control for possible reverse and equally perverse incentives to provide too little care in such organizations, we must also measure “patient activation” and find ways to move the majority of patients to PAM scores in Level 3 or Level 4. That it seems would deliver the balance of power needed to keep what’s best for the population vs. what’s best for individuals in check.
Prior to the Internet age, personal computers, smartphones, social networking, ubiquitous information access, and analytics the above might not have been possible. But patients now have what they need to be smarter, more engaged and activated consumers of healthcare if only we can teach more of them how to use the tools they now have at their disposal. What do you think?
Bill Crounse, MD Senior Director, Worldwide Health Microsoft