Beginning in January of 2014, the largest insurance coverage expansion since 1965’s passage of Medicare and Medicaid was implemented. The result is that millions of people who previously lacked access to healthcare insurance are now seeking care. However, with this influx of new patients physician practices are also confronted with new payer parameters that need to be documented to gain full reimbursement for services rendered. According to Visante’s Dr. John Trowbridge, Senior Vice President for Clinical Effectiveness, Pay-for-Performance and related reimbursement incentives will require developing cross professional team-based care and sophisticated IT systems to coordinate, track, and document improved health parameters in patient populations.

The following is from an interview with John Trowbridge (MD, CPE) as he reflects on some of the pressures on today’s physicians and care systems from the perspective of his experience of more than 35 years as an internist, hospitalist, and physician executive, as well as a Clinical Professor of Medicine at the UCSF School of Medicine.

What keeps physicians awake at night?

(Dr. Trowbridge) The uncertainty about practice sustainability in an era of exponentially increasing demands for documentable practice care performance requiring sophisticated IT systems and staffing while resources are dwindling has resulted in unprecedented “physician burnout”, especially among primary care providers.

Compounding these external forces is a tradition of “professional thinking” wherein we, as physicians, attempt to involve ourselves in — and control — each micro care process and decision. This habitual micromanagement blocks the transformational change needed to effectively manage any complex practice or business, and to transition from solo practice/”Mom and Pop business” thinking to developing effective care systems.

In the era of traditional medicine the focus was on acute care services, whereas now 75% of the total care costs center around chronic conditions, and the emphasis for primary care physicians is to manage conditions such as hypertension, hyperlipidemia and diabetes effectively to minimize heart attacks, strokes and renal failure. The other major component is to provide preventive services to all patients, which involves tracking multiple data points and having systems such that services occur reliably and results can be documented.

What needs to happen next?

(Dr. Trowbridge) According to the Office of the National Coordinator for Health Information Technology (ONC), primary care physicians have outpaced other specialties in adopting EHRs. (http://www.aafp.org/news/practice- professional-issues/20141210oncbrief.html). This is a start; but developing trans-professional care with the team of pharmacists, nurses and program assistants is also a critical component, which is difficult for physicians, who traditionally don’t do teams.

What kinds of opportunities do you see for pharmacists?

(Dr. Trowbridge) I anticipate that pharmacists will become the backbone for medication management of chronic diseases. Physicians cannot spend the time to deal with the important details of monitoring and managing titration, drug interactions and side effects while attending to other patient concerns. One estimate, from a study in 1995 by the American Academy of Family Practice, indicated that it would take 14 hours a day for a physician to effectively manage the top 10 chronic diseases in his or her practice. By leveraging current IT and communication technology, physicians can alleviate some of the mechanics of chart review and telephone calls, however, pharmacists have the detailed knowledge base and a history of developing complex, but reliable clinical systems, which can further free physicians to see patients.

What is needed from physicians as a group is a decision of exactly how to utilize and sequence medication for managing problems such as diabetes hypertension or hyperlipidemia. In my experience, physicians have trouble perceiving that by managing medication slightly differently from other physicians in their practice, they greatly reduce the possibility of clinical team support for medication management of chronic diseases. The opportunity here is to develop a team in which pharmacists can operate under protocol, managing the medications and monitoring patients with chronic diseases for multiple physicians. It turns out that patients are less sensitive about who is working with them provided that each professional is fully focused and has the time to dedicate to helping them.

What do you think will be the impact of team-based care for patients and care efficiency?

(Dr. Trowbridge) I had the opportunity to be a director of chronic conditions management for a facility in Kaiser Permanente Northern California for several years. Working with IT specialists, pharmacists, nurses and program assistants, we were able to decrease the incidence of transmural myocardial infarction (aka the “widow makers”) by 62% over a period of several years. The basis of this effort did not involve the latest and most expensive medications, but rather collaborative practice development through establishing guidelines, protocols, trans-professional communication processes, and the generation of respect and trust among all providers.

The health and happiness benefits for patients experiencing these results are obvious. But only slightly less obvious is the astounding cost avoidance of invasive cardiac procedures and cardiac surgery. Add to this the longer term cost avoidance realized by reducing the incidence of future heart failure with all of the procedural and organizational costs, as well as avoidable deaths.
In addition to developing systematic care for chronic outpatient conditions such as diabetes or hypertension, a collaborative care management system can be applied to a number of acute-care scenarios.

For example, responding to the growing threat of antibiotic resistance though antimicrobial stewardship involves a similar approach of having all professionals contribute what they do best to a coordinated program. This necessarily must include guidelines for active pharmacy support in the selection, dosing and administration of antibiotics that will be most effective for each patient, while limiting resistance development.

When one looks across the landscape of medical care, we are in the midst of a sea change from just providing medical services to improving health and documenting effective clinical results. Realizing the opportunities provided by current medical technology is a task that is too complex for the traditional ”vertical” organizational paradigm where physicians write all orders and attend to all details. In fact, we are the last major industry to evolve toward integrated logistics across professional lines to reliably achieve excellent results for complex tasks. I believe that team-based care, supported by sophisticated information and communication technology, is the next frontier for fulfilling our intent to do the best we can to support people in living healthy lives.

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