Most of us have heard about the enactment of the Affordable Care Act (ACA).  This will pave the way for the biggest change to our health care delivery system since the enactment of Medicare and Medicaid.  The hope is that it will transform our current fragmented, fee-for-service health care delivery system into a higher-quality, higher-productivity system with more efficient, coordinated care.  The ultimate goal is to improve the quality of care and reduce costs. 

Roughly 10% of patients currently account for about 64% of all U.S. health care costs... much of this due to potentially avoidable complications and unnecessary hospitalizations.  These measures occur partially due to the fee-for-service incentives for services, and failure for appropriately rewarding the coordinated efforts for care to PREVENT illness in the first place.

In order to bring about these changes, there are measures that will cause a so-called “creative destruction” of our current health care system to bring about the better, more efficient management of chronic conditions.  Ultimately, better tertiary prevention and reductions in expensive specialty referrals, tests, and complications should improve patients’ health and cause fewer exacerbations of chronic illnesses.

So to bring about these changes, there is now a call for groups to coordinate these measures into larger, integrated delivery organizations—preferably Accountable Care Organizations (ACOs)--that use primary care practices as the patient centered medical homes (PCMHs) to serve as these management teams for patients.  Hospitals or physician groups may end up serving as ACOs (or other groups), but that will remain to be seen as time goes on.

My practice is independently-owned.  We are affiliated but not owned by the local hospitals.  However, we were invited recently to be a part of a collaborative group that will work to serve as individual PCMHs within the larger hospital group, which will be seeking ACO status by 2012.  Currently, there are many medical practices—Internal Medicine, Family Medicine, and Pediatrics—in Pennsylvania which are part of the collaborative PCMH.  Most of the other groups in our collaborative ARE hospital-owned, so we are going out in uncharted territory.

There is a new language to learn in this world... goals to set, data mining to do via our EMR system.  We must design a “Visual Wall” to be displayed in full view of patients.  This will show what our current projects are, e.g. are all of our patients with diabetes on statins and an ACE-I or ARB (or why they are not), and statistics of how we improved from point A to point B.  Or, how up-to-date are the patients with their routine vaccinations and/or preventative measures (mammograms, PAPs, etc.) Or how have we improved in the management aspects, e.g. staff relations or communications.  The possibilities are endless.

The point of this is not to “finger-point” or show our mistakes, but rather to point out where improvements have been made...and need to be made.  Sort of a continuous quality improvement flow-chart, if you will. 

What it has done, even initially, is made me and my collaborative physician much more aware of the preventative needs of patients.  Oh, we were always great about giving out flu shots, and even the Pneumovax during flu season.  However, we have gone through boxes of Tdap this year as well, due to the newer recommendations about Pertussis vaccinations.  We also update the patient’s charts as their preventative test results come in; a mammogram result is scanned into their chart, but as we review it, we update their “preventative medicine” section of the chart with the date and result of the test.  This will allow for easier “data mining” later.

Ultimately, hopefully it will help a patient prevent a case of pneumonia... or find a case of breast cancer earlier.  Or help us track our patients with diabetes so that we can make sure they are coming in routinely for visits and lab work... instead of showing up yearly when their medications run out.  Or help office relations run more smoothly.

I’ll keep you updated as we trek through the process.  It will definitely be a challenge... and hopefully will pay off for our patients... and for us as providers.

Reference:  http://healthpolicyandreferm.nejm.org/?p+13020&query=TOC

Kim Spering is a family nurse practitioner who currently works at Brndjar Medical Associates, P.C., a family practice in Emmaus, PA.  Her past experience includes the fields of medical/surgical ICU, open heart/trauma ICU, labor and delivery, nursing education, nursing supervision, and as a nurse practitioner in both family practice and OB/GYN settings.  She currently serves as a NP preceptor for her graduate school alma mater, DeSales University, as well as for local baccalaureate programs.  She is passionate about patient education and helping patients understand that they are ultimately responsible for their own health.  She also firmly believes that the public needs to be educated on the value of NPs and PAs in meeting the health care needs of the next decade and beyond. In her free time, Kim enjoys family vacations with her optometrist husband, Mark, and her two sons, Matthew and Connor.

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