How the Affordable Care Act Will Change the Provider Mindset

ReinventingAmericanHealthcareLargeI recently read the book “Reinventing American Healthcare” by Ezekiel Emanuel. It quickly became my new favorite book as Emanuel provides an amazing history of American health care dating back to the 1700’s. For someone working in the health tech industry, this history was not only informative, but provided a fascinating background that has helped us to better understand the behaviors of the clinicians and health systems we work with at Glooko.

The book provides a history as to how we ended up in the pre-Affordable Care Act (ACA) world. A world that as described in Emanuel’s book title, is a “Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone (Health) System.” A world that incented providers to focus on administering “billable” in-office services and procedures and to be reactive to emergencies versus taking proactive measures that prevent emergencies or complications.

A physician who had been operating in this pre-Affordable Care Act world was conditioned to focus on activities they could bill for, including clinical incidents (hospital visit, an injury, an escalated illness) or prescribed interactions like an annual primary care visit. This paradigm left proactive care delivery and activities, like reducing infection rates in hospitals, adopting electronic medical records and implementing preventative services like nurse check-ins, mental health screenings and immunizations, mostly ignored.

The pre-ACA world also drove certain behaviors inside medical practices that have proven to be difficult and slow to change. Since practices were only incented to engage in billable services, a lot of proactive care delivery went by the wayside. And the processes to support proactive measurements like physicians calling to check on chronically ill patients, health coaching and tracking patient health remotely, known as remote monitoring, were not only not supported, they were rejected because they didn’t generate income for a practice and in-fact were costly. Subsequently, medical practices and health systems alike built no processes or tools to empower or manage proactive care.

The negative consequences of this are being felt as we transition into a new ACA world. As proactive services, or outcomes-based care, are being incented by the ACA, these services are only being slowly adopted because medical practices don’t have the processes, tools or mindset to properly implement them.

As Emmanuel states in the book, “There will be more frequent monitoring so that people in the health system will call you to provide suggestions and services related to prevention and health promotion…” He continues, “Physicians are apprehensive about the ACA: the act is big, they are not trained to and do not regularly read legislation, and they know it includes both cost control, electronic health record requirements and reporting. Uncertainty (and change) brings fear and anxiety.”

Recently, when the new CPT code, 99490 for “chronic care management – CCM” came out we heard more fear and push-back by physicians than acceptance. The CCM code incents physicians to engage with patients more proactively, paying them for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions. Basically, if a provider spends 20 minutes each month proactively reviewing a patient’s care plan, engaging with them to ensure success of the treatment, answering their questions and tracking their case, the provider will be paid between $40-$60 per month per patient.

When talking to practices about using this code, we’ve heard everything from:

“We don’t have the process in place to deliver proactive services” to “I don’t believe that we could actually get paid for calling patients, in fact, we are banned (by an unnamed health system) from making any calls out directly to patients, we can only answer calls.”

As courageous practices, Accountable Care Organizations (ACOs) and Integrated Delivery Networks (IDNs) take on more and more “at-risk” contracts where they are given a cap of fees they are paid for each patient, they are more likely to take on these proactive services because ultimately it will not only make them money, it will save them the cost of more expensive critical care which these types of services prevent. In fact, as we have started working with pioneering ACOs and IDNs around the US, like Atrius Health and the Diabetes Glandular Disease Clinic (DGD), we’ve seen that they are not only conducting remote monitoring, they are going beyond, making it their mission to proactively serve their patients, even if at first they aren’t “paid for it.” It is just the right thing to do in the long run.

Is your practice or organization changing with the times and adopting process, technology and mindset to meet the needs of patients in the age of the Affordable Healthcare Act?

Robin Beadle