Chewing on a big fat wad of gum

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By Janet Hurley, MD

Changes in health care have been fast and furious in the last several years. The advent of MACRA created the need to prepare for MIPS and APMs, and more robustly report on quality and cost. There is an ongoing desire for interoperability and EMR modifications requiring more “clicks” than we would like. Many physicians have added new types of team members to their practices, such as social workers, nurse navigators, or care coordinators to reach out to patients in new creative ways.

Some of this has been good for patients, and some of it possibly not. Some days it feels like physicians are chewing a big fat wad of gum, and feeling choked.

Early in 2017, I took a new position in my health system as medical director of population health. One goal of this department is to use care team members in new, creative ways to meet the educational and social needs of our patients. While it might be ideal for the physician to spend 45 minutes with each patient, addressing medical needs and providing counseling about mammograms, colonoscopies, smoking cessation, diabetes, congestive heart failure, and many other things is not a practical reality for most practices.

Trying to fit all of that into a 15 minute visit will snuff out the most important reasons the patient came to the clinic in the first place. It is hard to move from a former “lone ranger” type of practice style to a team style, where some of these duties are delegated. Hiring these team members costs money, and payers have not been quick to offer per-member per-month support. Being accountable for these processes without financial support to change is choking the joy out of primary care practices across the country.

My population health department was chin-deep in care coordination, nurse navigation, behavioral health integration, ACO quality monitoring, cost monitoring, transition-of-care processes, value-based payer contracting, and other things when I took the position. Yet due to recent acquisitions made possible by a strategic partnership with a larger health system, our provider numbers doubled and our geographic footprint in our region tripled.

We are now challenged to transition our population health processes to many other clinics, some of which have limited — if any — care coordination or nurse navigation processes, and have never measured quality nor been held accountable for quality or cost metrics. For me, that task is daunting.

Our team has followed several strategies to improve this process.

  1. Educate. Educate. Educate. Provider education about the “why” of population health is essential for buy-in, and to reducing the risk that they will feel threatened.
  2. Start small and celebrate wins. This is particularly true when our population health nurses help a patient with a social determinant of health. Often physicians feel frustrated when they are held accountable for poor quality outcomes on a non-compliant patient. We all win if our nurses help to identify the social problem and meet the need, so the patient can enjoy better health.
  3. Leverage IT solutions whenever possible. Our organization has embedded clinical decision support tools into our EMR to make it easier for providers to do the right thing. This same EMR enables us to have high-quality, robust reporting tools to provide accurate and timely feedback to physicians.

How can a small practice achieve these same goals without the financial benefits of a health system? One way is to start small and code smart. I heard a solo family physician tell a story about adding a social worker to her practice. The social worker covered her own salary by doing Medicare annual wellness visits and chronic care management billing. The social worker not only assisted with the social needs of these patients, but also could call patients with routine health reminders, or provide valuable counseling services for patients who simply needed a listening ear. The overall net financial cost was low, the patients were healthier, and the doctor was happier. This is one strategy to improve quality and reduce cost. Perhaps other practices could benefit from this small step toward helping their patients.

Either way, health care in America is changing. As we transform our practices, patients will see the benefits. Doctors may even achieve and maintain high levels of joy in their practice. The task is daunting, yet we do not have to do it all at once. As with any large monstrous process, we must “chew” a small bit of it at a time.

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