Making ambulatory services more efficient in a downside payment health system.

Taking a good look in the U.S ambulatory services of a big healthcare institute as an outsider who is coming from a system built on HMO's makes you see the pros and cons of each system while realizing that none of the systems are perfect. Healthcare in Israel is only 7.5% of the Gross national product (GNP) with average life expectancy of 82.6 years while in the OECD countries it is 80 years old [1]. In the united states healthcare is 17.9% of the GNP[2] and the average life expectancy is 78.6. Those numbers cannot lie putting the fact that reforms should be made to make health services more efficient and less financially driven like they are today. While the ACA (Obama care) was supposed to make healthcare more equal and affordable to everyone it feels like it didn't really change the real structure of the U.S healthcare system that is more of a "business" rather than a "health for all" system. That makes me think the biggest question of all – Does healthcare should be a business at all?

Being the decision maker of a large ambulatory academic center who came from a different system I will have to understand the benefits of coming from a different system in order to implement new changes while being modest enough to say that I need some help to understand the current system and to preserve the good things it brings to the table. 

Recognizing that the best medicine is still after all available in the U.S and if you have a very good insurance this is where you want to be to get the most high end top medicine in the world have to be balanced with the fact that if you don't have a good insurance you might end up with a Hugh debt just because you wanted to survive.

Bringing a real change to the ambulatory system while taking into consideration that money spent per each patient should go more toward value per patient and less "pay for service", knowing that it might make some physicians less wealthy but this is the right thing to do for the benefit of all.

So how do we make the change?

The diagnosis-related group (DRG) system

DRG payment is based on the care given and resources used by patient within a certain group and this is being used by giving the patient a code which represent their main diagnosis which might put them in the need for more resources. This system was implemented in different countries in the world [3]. Medicare and other insurance companies are already using the DRG system as a guideline for ambulatory services but mainly also for the "cost of hospitalization". As a downside risk arrangement system realizing what are the costs of each kind of patient and take into consideration the average number of outliers will be crucial in maintaining a good balance between patient's health and financing. Example for that will be a Diabetic patient that can be categorized mainly as a Diabetic patient but than has to be subcategorized as a one with a target organ involvement or balanced sugar (A1C) levels. Having said that for the patient who is part of the DRG for diabetes who doesn't have end organ damage more efforts should go for the prevention of getting to that point. That’s why we should also consider the option of not using the subcategories for charging more for each patient in the same DRG but rather use the same amount of money for each kind of patient deciding if it should go more for treatment or prevention.

Another interesting option was done in china where they shifted the fee for service care (FFS) to "DRG based case-mix" system that was found to be lowering the financial barriers of care and improve efficiency. In this case we will have to implement quality control measures to make sure that patient quality of care is not being jeopardized.  [4]  

"One patient , one care coordinator"

One of the good things that HMO's brings with them is that each patient has his main care provider for a long time, this kind of relationship creates more trust and knowledge of the patient and his real needs which will eventually safe costs due to less duplicated services and unnecessary tests. The phenomenon of "Healthcare shopping" is very common in a system where you can choose to jump from one provider to the other sometimes without them knowing about each other. This can easily create too frequent tests, having same examinations over and over and eventually this will not just won't be for the benefit of the system but also can harm the patient. In my new ambulatory service Every patient will have one(!)  Provider which will be his navigator for the other services he needs. If the patient will need to see later on a specific physician (e.g cardiologist) he will be referred only by the PCP and the cardiologist will have to update the PCP with the findings. Each patient will have a limited number per year of second opinions he can ask for.

Asking more "Why" rather than "What"?

One of the major issues in ambulatory services are the unneeded referrals to unnecessary tests which may be done due to misjudgment of the providers or a pressure of the patients on the physician to send them to those tests. In my ambulatory services the providers  will have to be more of a "thinking" physician and to write carefully what is the Differential diagnosis for the patient symptoms that made him send the patient to this test. The providers  will be monitored for that performance on that basis and will get his bonuses not just by patient satisfaction but also by criteria of "good medicine results" asking the right questions to get the right answers. A good example for that would be sending a patient with headache to  MRI – the physician will have to write why this patient needs MRI for this kind of headache and what are his main concerns in contrast to another typical patient with headache (Neurological deficits, vision problems etc'). This problem will address the overuse and almost abuse of unneeded expensive tests which might result  further tests (EMG etc') that eventually won't lead to diagnosis.

Sometimes "Less is more" also in patient care!

Primary care Vs. the different disciplines physicians

The big challenge in a health system that wants to have the best physicians in the different disciplines (Dermatology, cardiology, gastroenterology etc') is to make them feel that they have a financial and academic benefit taking part in the system but in a downside risk system different procedures can not cost too much so the healthcare system would not end up losing money.  In that case the physician should have an extra benefits from procedures and those benefits needs to be a mixture of financial and academic benefits. Part of a good practice which should be encouraged by bonuses is the coordination with the patient's PCP which eventually can save some money overall and is not being done enough.

Having said that a system where the procedures being done by physicians might be prone to unnecessary procedures for a financial benefit which might be a problem if the healthcare is a downside one and the "money" you get for each patient is limited. Like said before we will need to create education system where also the professional physicians will need to give the exact reason for each one of the procedures. We will also check annually the number of procedures done by the different physicians and the overall benefits and results of the tests (If one physician did 1000 procedures with 10 positive results while the other did 100 procedures with 10 positive results it might tell us something too).

 How to keep your physicians and Providers happy? It's not only about the money!

Keeping your physicians and providers  satisfied is not all about money but also about giving them the best environment to grow and develop their career.

The syndrome of burnout encompasses a spectrum of emotions, including feelings of ineffectiveness, emotional exhaustion, loss of meaning at work, depersonalization,  loss of motivation, self-doubt, helplessness, and reduced personal accomplishment. Recent reports suggest that major causes of physician burnout include electronic medical records and comprehensive records documentation, excessive clerical burden, excessive workload, too many hours at work, loss of autonomy and control, loss of support from colleagues, loss of work–life balance, and loss of self-accomplishment [5]

How can we solve it?

1.      Create a team that will brain storm the idea of "how to decrease administrative burden"

2.      Let providers have some time for research and academic work if they want to.

3.      Train your stuff with a annually structured program which will be part of their work.

4.      Create a "team work" environment with multidisciplinary team meetings.

5.      Create a structured system where the physicians claims and problems not just being heard but also taken into consideration.

6.      Give providers the best technology and top tear technology so they will feel that they have exactly what they need to be the best.

Eventually I think that keeping those rules might compensate a decrease in the Salary so that can be a balance between the money spent on providers (which is a big part of the system spendings) and the healthcare abilities to pay will be addressed.

Using other Provider types  to reduce costs and increase efficiency

As part of creating more efficient system we will have to use the uprising of a specific professions like PA's, NP's, care coordinators etc.' in order to reduce costs and let the physicians being the supervisors of the more strategic things and to create the frame for a better service. Using those modalities will reduce the cost of providers and will also make the physicians more satisfied by reducing administrative burden.

An interesting study was done regarding that issue and concluded that case-mix-adjusted total care costs were 6-7 percent lower for NP and PA patients than for physician patients, driven by more use of emergency and inpatient services by the latter. They  found that use of NPs and PAs as primary care providers for complex patients with diabetes was associated with less use of acute care services and lower total costs. [6]

Using more care coordinators will also be a great way to implement prevention strategies. That should be one of the most important things in ambulatory services. 

Summarizing,

In a downside risk arrangement system where your resources are limited and you want to give the best ambulatory service we have to balance between best practices and financial limitations. This includes patient focused and providers focused measures. To make it work providers have to feel engaged and loyal to the system and not driven only by financial benefits but other benefits too (educational, developmental etc.) While bonuses and extra fees are given based on showing thinking practices that asking more "why" rather than "what" using the resources we have as a providers in a more intelligent way and not simply because "We can". Patient wise we need to build a system built on DRG codes but understanding that we should use almost equal resources for each patient either for treatment or prevention measures (E.G – treating diabetic complications in severe patients but using same resources on patients who are going to be in that situation by implementing well-structured prevention programs).

Bibliography

1.          ministry, I.H., the national spending in Israel totals just 7.5% of the GNP. . https://www.health.gov.il/English/News_and_Events/Spokespersons_Messages/Pages/07112019_1.aspx.

2.          CDC, https://www.cdc.gov/nchs/fastats/health-expenditures.htm.

3.          Mihailovic, N., S. Kocic, and M. Jakovljevic, Review of Diagnosis-Related Group-Based Financing of Hospital Care. Health Serv Res Manag Epidemiol, 2016. 3: p. 2333392816647892.

4.          Zhao, C., et al., Diagnosis-related group (DRG)-based case-mix funding system, a promising alternative for fee for service payment in China. Biosci Trends, 2018. 12(2): p. 109-115.

5.          Grimes, P.E., Physician burnout or joy: Rediscovering the rewards of a life in medicine(). Int J Womens Dermatol, 2020. 6(1): p. 34-36.

6.          Morgan, P.A., et al., Impact Of Physicians, Nurse Practitioners, And Physician Assistants On Utilization And Costs For Complex Patients. Health Aff (Millwood), 2019. 38(6): p. 1028-1036.