Reform at the Office Level
Submitted by Administrator on Sun, 2009-06-14 08:24
Francis J. Crosson, MD is the Founding Executive Director,
The Permanente Federation and Chair of the Council of Accountable Physician Practices (CAPP). He writes about health care reform, seeking "a rationale designed to influence the physician microenvironment so as to support physicians in developing patterns of clinical decision making that result in better health outcomes and lower costs."
In "Change the Microenvironment: Delivery System Reform Essential to Controlling Costs" (April 27, 2009), he states: "U.S. health care costs are excessive, both by international benchmarks and, by inference, from observation of the degree of cost variation within the U.S., as demonstrated in the Dartmouth Atlas of Health Care." Also, expanding coverage will be costly and "not supportable for private insurance or public programs."
Causes:
· Aging population, living longer with more disease or conditions
· Adverse lifestyle choices (e.g., "smoking and poor diet that lead to cardiovascular disease, cancer and diabetes")
· Acquisitions as driven by the technological Imperative—e.g., new drugs and medical procedures
· Appropriate or Inappropriate--a reimbursement system that "often rewards" either, indiscriminately
The microenvironment of which he speaks is the practitioner's office where experience, guidelines, policies and fear of malpractice apply. It is also the place where the financial pressures of running a practice cannot be ignored.
He separates delivery system reform proposals into 3 categories:
- Structural—medical home, physician-hospital integration, and accountable-care organizations;
- Payment—for care coordination, in and outpatient bundled case rates, pay-for-performance, and "other 'shared savings' proposals, and various forms of prospective payment or capitation";
- "Tools" that facilitate and monitor either or both of the above such as medical information systems (e.g., EHR, acuity-adjustment, episodes of care and comparative-effectiveness data). He adds: "Comparative-effectiveness information is more likely to be accepted by society as a tool for appropriate clinical decision making rather than as a mechanism for coverage determinations."
Although he pushes for group practice to effect these reforms, these goals and objective belong to the provider community, regardless of structural differences.
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