America's top hospitals say that one of the best ways to make care more efficient is to force doctors to work together rather than as a network of specialized independent contractors. But while these hospitals agree on the ends, their means differ, making it difficult for lawmakers to point to just one model on which to base health care reform legislation.
Instead, the health care bills currently circulating simply allow for more study of what are called "accountable care organizations," loosely defined as an ad hoc group of doctors who agree to work and get paid as a team. The House tri-committee bill creates pilot programs to test ACOs, while the Senate Finance Committee mark would allow ACOs to participate in Medicare if they agree to report quality data and meet benchmarks for cost and clinical outcomes set by the Department of Health and Human Services.
At the Mayo Clinic, doctors use a "coordinated care model," where a patient's well-being is arranged through one primary doctor. Dr. Doug Wood, chairman of the health care policy and research division, recalls that for one patient he arranged a stress test, a gastric consultation and an appointment with a diabetes specialist and started a discussion with a cardiac surgeon about a bypass operation -- all in one appointment. "The expectation is that one of us will have the responsibility to make sure the patient is taken care of," Wood said.
By centralizing oversight of a patient's care, the system functions similarly to medical homes. Wood said the system reduces costs while keeping quality high by ensuring that tests aren't repeated unnecessarily and that patients aren't being treated multiple times for the same problem.
The Cleveland Clinic, meanwhile, prides itself on being one of the largest integrated care systems but doesn't rely on Mayo's primary-physician model. Instead, CEO and President Delos "Toby" Cosgrove said that the clinic's bold restructuring two years ago, which grouped doctors by related fields, has made care more patient-centric.
"For example, we set up a neurological institute and put in psychiatrists, neurologists and neurosurgeons. Let's say you have a headache -- all of the people that would treat you are in the same place," Cosgrove said. "The money all goes to the same place," he added, "so the decisions are based on what the patient needs, not who financially benefits."
Cosgrove said that system wasn't designed to reduce costs but has anyway. Concentrating relevant specialists in the same place and directing them toward the same goal means fewer repeated tests and more options for patients.
At Geisinger Health System in Pennsylvania, administrators noticed that some patients with chronic conditions, especially the elderly, were taking up the most time and resources. So as a cost-cutting measure, they decided to get their doctors into an ACO-like system. Dr. Howard Grant, the executive vice president and chief medical officer, said Geisinger groups patients with chronic conditions together under a dedicated team of doctors, rather than distributing them among physicians who also see younger and healthier patients.
At Intermountain Healthcare in Utah, there is no defined integrated system and doctors are not kept on salary. However, they do offer their chronic patients a care coordinator, someone who ensures that they're taking their medicine and who helps arrange appointments when necessary.
Wood said he was encouraged by the integrated care proposals in reform legislation, but that the best way to truly bend the cost curve would be to more actively encourage hospitals to move to an integrated medical home system. "You have to implement an incentive for shared decisionmaking," Wood said. "We would recognize and make a payment for physicians who use that shared decisionmaking. Right now, there's no direct payment for doing that."
Cosgrove said this would also help doctors learn new strategies and information. After all, how can you expect one doctor to know everything to do with every patient?
"When I was a kid, the doctor came to my house with a black bag and all the diagnoses were made by looking at you," Cosgrove said. "Now you go to the hospital and your blood is drawn and analyzed and studied by different people. Doctors try to be individuals, and the incentives are there for doctors to be individuals, but that's not reality. The body of knowledge has gotten so big that you're going to have to have colleagues in order to take care of people."
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