The lessons from COVID-19 outline a path forward toward sustainable, high-quality healthcare. Physician leaders should lead this evolution.
The COVID-19 pandemic up-ended healthcare in America; however, looking beyond the Herculean efforts of caregivers during this battle, we know there are lessons on how we should deliver healthcare.
Recently, the physician leaders of the 31 multispecialty medical groups and integrated health systems that form the Council of Accountable Physician Practices (CAPP) weighed in on what our experiences during COVID-19 have taught us, how we should share them, and how we can chart a course for the future of healthcare.
WHO IS FARING BEST DURING COVID AND WHY
There is no argument that this pandemic is a devastating crisis in terms of its impact on society and its impact on our healthcare system. While all medical providers suffer from the weight of this public health crisis, some are faring better than others. Those medical groups and health systems that have strong foundations to provide integrated care are demonstrating the ability to:
- Rapidly adapt to pandemic conditions by implementing new ways to safely deliver care through telehealth, drive-through testing sites, and alternative venues such as hospital-at-home.
- Quickly identify vulnerable patients using population health management and predictive analytic tools so these patients can be safely monitored and treated.
- Implement system changes rapidly, including innovations that generally would have taken months or years, due to long-established cultures of leadership and teamwork.
In contrast, practices that were not part of these kinds of systems face much more serious challenges. Many lack the technology or the data to respond adequately to a crisis. When in-person visits and elective surgeries are paused, the practices’ revenue streams dry up, precipitating serious financial harm.
Going forward, does this mean the demise of private practice — a concern within our profession for decades? No, it means an evolution. Medicine is now a team sport with the physician as the quarterback. All doctors should have the operational support and tools — analytics, connectivity, telehealth, care coordination — they need to succeed.
THE PANDEMIC IS BREAKING BARRIERS IN THINKING AND PRACTICING
By forcing change, the pandemic is breaking up old patterns of thought and practice. Doctors who previously said they would never do a video visit are now required to do so for the safety of their patients, staff, and themselves. To their surprise, many find they like the convenience and are discovering that they can care for their patients just as well via telehealth as in-person visits.
Working remotely is another new experience for many, one that is also surprisingly appealing in convenience and safety. Relationships between primary care and specialists are now digital. Vulnerable patients can stay home and be monitored with digital devices. Necessity, again, is becoming the mother of invention.
Pay-for-value or capitated contracts provide many medical groups with more stable revenue, prompting other groups to rethink the viability of fee-for-service medicine. Groups that have experience with these types of payment arrangements see another benefit: Their staff and physicians get creative when thinking about how to restructure care.
One physician leader noted that the years spent working with physicians and staff to analyze care pathways and create more efficient, connected, coordinated care teams is paying off in crisis management. When COVID-19 hit, these providers already had experience practicing team medicine. The communication hurdle of getting physicians on board with working collaboratively with care teams was already behind them. The organization could hit the ground running and focus on the emergency at hand.
Another physician leader noted that because specialty care had to shift to accommodate COVID-19 patients, discussions are now taking place about reorganizing the traditional way of delivering cardiovascular care. These kinds of innovations would never have occurred if the pandemic had not up-ended the established way of doing things.
The learnings from COVID-19 outline a path forward toward sustainable, high-quality healthcare. We, as physician leaders, should lead this transformation.
RECOMMENDATIONS FOR TRANSFORMATION
The CAPP physician leaders agreed that the following six recommendations are necessary to transform American healthcare delivery to achieve our vision of accountable care.
1. Fasttrack the movement from feeforservice to valuebased payment.
Through the years, accountable, progressive physicians have repeatedly called out problems with the traditional fee-for-service method of payment. Under this system, there are no incentives for collaboration or innovation to produce better outcomes, just perverse incentives to overtreat or, at best, maintain the ineffective status quo. Fee-for-service promotes waste, duplication, fraud, and fragmented, cumbersome care for patients.
We know from experience that when optimal patient care is rewarded, physicians and care teams develop approaches to care that are in the best interest of the patient.
A message that we must take to our skeptical colleagues is that pay-for-value allows us to practice medicine the way we want to, providing our patients with the proper care at the right time and reducing what is often called “administrative hassles.”
As practitioners of accountable value-based care, we see clearly that these payment arrangements can not only promote better, more efficient healthcare, but also they provide us with more financial stability to ride out emergencies like this pandemic.
2. Embrace and expand telehealth.
Had the American healthcare system created incentives to innovation over the years, telehealth would have long ago been accepted as an alternative to in-person care. Forced to adopt this model of care during this crisis, patients and physicians alike have become used to this treatment method, and they like it. Patient satisfaction for telehealth visits among CAPP groups frequently tops the already high satisfaction rates for in-person visits.
Telehealth now has a value proposition that exceeds convenience. It is safe and, in many ways, more efficient than in-person sessions. A physician can now connect virtually with specialists while the patient is on the line or video, obtain a consultation, and immediately determine the next step in the patient’s care without the customary wait for referrals and more visits.
Patients and physicians are using patient portals, texting, and emails to manage care during this pandemic. We have quickly crossed a great digital divide, and this connectivity will remain a permanent part of how we practice. From now on, telehealth should be embraced, expanded, and paid for at the same level as in-person care.
3. Migrate care to the home.
To avoid exposure to the coronavirus, many patients are unable or unwilling to leave home for medical attention. Digital monitoring, video visits, and connected healthcare teams make it possible to treat these patients in a home setting, keeping them safe, meeting their medical needs, and ensuring that they have the physical and emotional support they need. Medications can be delivered to the home, vital signs can be monitored, and two- and even three-way communication with the patient and care team is possible.
This migration to more home care will continue. Programs offering hospital care at home will continue to be developed and expanded. Often safer and more convenient than in-patient care, home care is certainly less expensive. Patients with chronic conditions can receive the devices they need to be monitored outside the physician’s office. A generation ago, we saw the development of the hospitalist profession to attend to the special needs of hospitalized patients; soon, we may see the advent of physicians who specialize in hospital-at-home.
4. Empower primary care with the tools to keep America healthy.
While some may wax nostalgic for the days of Marcus Welby and the family practitioner who visited patients in their off-hours, the fact is that the wealth of medical knowledge required today for the complex world in which we live far exceeds the ability of a single physician to master.
All doctors, whatever their practice setting, need access to technology that provides them with up-to-date information, connects them with patients and other healthcare providers, and supports them by tracking and alerting them to problems with their patients. This kind of system support for physicians can yield the type of coordinated care experience that all patients want.
Yet, many primary care practices in this country still struggle to provide care in the current fragmented fee-for-service world. Some larger, integrated groups collaborate with smaller practices to share resources and technology so these practices can enjoy the integration needed for patient care and practice management today.
Together, they form broader networks for patients, particularly those in rural areas and those who are not located near major medical centers. These collaborations mean better preventive care, improved coordination of care when there is an illness, and access to specialists and centers of excellence when needed.
Rather than being an outpost in the community where patients go for minor ailments, the modern primary care physician must be positioned at the center of an integrated delivery system, surrounded by the specialists, ancillary services, team members, and information required to deliver a superb patient experience and the highest level of coordinated care.
Instead of the black bag and stethoscope that epitomized the primary care doc in days gone by, today’s physicians have smartphones, laptops, data systems, and home monitoring devices that help them deliver 24/7 primary care.
5. Organize and collaborate to remedy social disparities.
Underserved populations are suffering greatly during this pandemic, with higher rates of infection and mortality. Many are essential workers, which increases their likelihood of exposure. Taking public transportation to jobs, not being financially able to call in sick, and living in crowded home conditions due to a lack of affordable housing creates more opportunities for the virus to spread.
“Community health” can be achieved only when everyone has an equal opportunity to be healthy. People need equal access to providers, living conditions that are safe, and food that is nourishing. Until everyone has access to affordable quality care and the economic security to self-isolate and take care of themselves, we are all in danger.
COVID-19 laid bare the critical need to address these long-standing social inequities at the federal, state, and local levels. Healthcare systems and physicians can collaborate with their communities to create ways to identify health threats, improve access to care, and address social determinants that lead to poor health.
6. Involve physicians in designing the next iteration of the healthcare delivery system.
Physicians and other providers must be the engineers of the healthcare system. Think about that statement for a moment. What would healthcare look like if accountable physicians and providers designed it? Certainly, nothing like what we have today.
For physicians, healthcare is all about the patient, not about maximizing profits for health plans or filling hospital beds. As physicians, we do not want to only take care of the sick; we want to optimize the health of our patients and our communities.
Many of today’s physician leaders have the clinical skills and the business and management training to build efficient systems and improve the patient experience. We are developing new care delivery approaches. We are building the culture and teams necessary to foster patient-centered innovation. At the local and national levels, we must negotiate seats at the table when policymakers and regulators address healthcare issues. We must be an active voice that educates patients and the public at large about the benefits of high-performing health systems and work to replicate and improve on our models of care across the country.
We believe that when physician-led mission-driven systems are universal, the American healthcare system will be stronger and more patient-centric, better able to deal with public health crises as well as provide higher quality healthcare than Americans receive today.
THE FUNDAMENTALS OF HEALTH SYSTEM REFORM
CAPP physician leaders believe that these priorities — expanding telehealth and care at home, investing in primary care and prevention, addressing health disparities, and more rapid movement away from fee-for-service payment — are fundamental to health system reform. By capturing the lessons from this crisis and moving forward collaboratively, providers, policymakers, and purchasers of healthcare have an opportunity to create the care delivery system we all want for America.
Stephen Parodi, MD, is the chairman of the Council of Accountable Physician Practices (CAPP), the executive vice president of external affairs, communications, and brand at The Permanente Federation, and an associate director for The Permanente Medical Group.
Norman H. Chenven, MD, is the vice chairman of the Council of Accountable Physician Practices (CAPP) and founding CEO of Austin Regional Clinic in Austin, Texas.
The Council of Accountable Physician Practices is a coalition of more than 30 integrated medical groups and health systems, supporting coordinated, connected, and evidence-based medicine and involving more than 80,000 physicians. www.accountablecaredoctors.org.
This article appeared in the July/August 2021 issue of Physician Leadership Journal.