World Class Health Care at Walter Reed

Last fall I was asked by Maryland Senator Benjamin Cardin to join a group evaluating whether the new Walter Reed National Military Medical Center [WRNMMC], when completed in a few years, would be “world class.” The group, a subcommittee of the Defense Health Board, met multiple times to learn about the plans and develop a report for Congress. The report is now available at http://www.health.mil/dhb/meetings/NCR%20BRAC%20HSAS%20Report%20-%20Final.pdf . Here is a brief summary. The Base Realignment and Closure Commission [BRAC] determined five years ago that the current Walter Reed should be closed and the functions moved to two facilities. One would be a community hospital and outpatient facility at Fort Belvoir, VA just south of Mount Vernon. It would give primary and secondary care to active and retired military that live in the southern half of the national capital area. The other would be on the grounds of the current National Naval Medical Center in Bethesda, MD just northwest of Washington. This conjoined facility would be renamed the WRNMMC and would have multiple functions. Primary and secondary care for those military personnel who live in the northern half or the capital area; tertiary care to those from throughout the region and total care for the wounded warrior.
We found that the Fort Belvoir facility was well designed but that the new WRNMMC had some definite deficiencies. Here is a summary. There was never a master facility plan for the campus which currently houses multiple functions and has many older buildings that over time should be replaced in an orderly manner. There was not a “demand analysis” completed to determine what the needs would be in to the future. For example, with the wars in Iraq and Afghanistan, would there be need for more, less or different OR configurations? With a growing retired military population in the area, what would be the new needs? Instead, a static approach was used, shifting the current functions at Walter Reed to the two future facilities. We also found that there would be no in-house simulation laboratories for learning OR procedures, cardiac cath or GI endoscopy techniques. In a modern hospital these are critical and must be immediately adjacent. The campus has externally mandated constraints on parking, logical from a local roadway perspective but not recognizing that staff from one shift cannot leave until the staff from the next shift has arrived – this means more spaces, not fewer. There is a METRO stop at the corner but in the winter it is a long walk to the hospital – some type of tunnel or people mover is needed to encourage ridership.
The report just went to Congress and to date the following has occurred:
House -- FY10 Defense Appropriations
“Medical care in the National Capital Region - The Committee continues to be concerned over the impact of care in this area with the consolidation of WRAMC and Bethesda Naval. Congress’ independent evaluation of DoD’s comprehensive plan was positive, for the most part. They await DoD’s 30-day assessment of that review’s findings and recommendations.”
Senate -- FY10 Defense Appropriations - Amendment by Senator McCain “Requirement for a master plan to provide world class military medical facilities in the National Capital Region” - agreed to by unanimous consent.
It is encouraging that Congress is taking the report seriously.

Maximizing Rights with Responsibilities to Enhance Access and Reduce Total Costs

Healthcare reform was supposed to be about both access to care and reducing the cost of care. So far it is only about the former and the new costs look to be huge with only a portion of the uninsured actually benefiting. As to cost reductions, the only suggestions have been mostly just about reducing payments to providers with the assumption that they can figure out how to provide good care with less funding. That is not a strategy but just a tactic – and it will backfire.
There does need to be a way to reduce costs and the way to do so is a combination of rights and responsibilities related to the development and the care chronic illnesses. It is possible to reduce health care expenditures without rationing and without draconian across the board cuts to providers. Much of the rapid rise in costs is due to the increase in chronic illnesses that last a lifetime and are expensive to treat – heart failure, diabetes with complications, cancer, etc. Over 70% of healthcare costs go to treat these individuals who are only about 15% of the population. And these illnesses are increasing in prevalence as the population ages and as we persist with adverse behaviors such as smoking, over eating, lack of exercise and stress.
Chronic illness should be addressed from two perspectives – coordinating the care of those who are already ill and preventing new illness from occurring. Both will reduce costs and improve the quality of life.
What has become very clear is that chronic illness needs intensive care coordination to prevent unnecessary specialist visits, procedures, tests and even hospitalizations – the source of excess expenditures. Primary care physicians [PCPs] are in the best position to coordinate care but do not do so because they are not reimbursed for the effort. They receive about 5% of the healthcare expenditures but can have a major impact on the other 95%. Changing the reimbursements to PCPs with the proviso that they coordinate care would have an immediate impact.
Workplace wellness programs that offer reductions in health insurance payments in return for healthy behaviors reduce over-all costs and improve the health of the workforce. Safeway, General Mills and others have convincing data on the value of wellness programs. It’s an incentive toward healthier living.
Similarly, insurance policies should have variable rates for behaviors and preventive medicine – not smoking, weight control and obtaining simple screening tests like blood pressure and cholesterol would mean lower premiums.
Combining rights [access to insurance at lesser cost] with responsibilities [live a healthy life style] for patients and rights [increased pay] with responsibilities [coordinate care] for PCPs will have a major impact on the total costs of care and do so quickly.

Care Coordination in a Retirement Community – Better Care at Lower Costs

Older individuals tend to have more complex chronic illnesses and they need lots of preventive care. The Erickson Retirement Communities determined to learn if attentive primary care would lead to better quality care, better quality of life and yet lower costs overall. By way of background, their basic goal was to improve the quality of life for their residents – good marketing. So they built in nutrition, exercise and other programs for the residents who live in a campus-like setting. Yet they found that their biggest failure from the retirees’ perspective was medical management. The Community hired a physician who initially spent about thirty minutes with each patient’s visit. The word got around and more and more residents signed up for his care. Once that happened he had to cut back until he was seeing each patient for about ten to twelve minutes per visit. And so the residents were again not satisfied. So the Community hired additional full time primary care physicians and paid them enough in salary over what Medicare paid so that they could afford to take the needed time with each patient. It quickly became apparent that the residents liked this approach but it meant only about 400 or so patients per physician rather than the national average of about 1500+ for a primary care doctor. It was more expensive up front but Erickson found that the number of hospitalizations for this group declined by about 50% suggesting that good coordination of care was effective in not only increasing satisfaction and quality but also in reducing costs. Of course, the reduction benefited Medicare but Erickson still had the extra expense of the added physicians to make the program work. Erickson then went to Medicare and petitioned for a demonstration project. To date over four thousand retirees in multiple retirement communities joined this Medicare Advantage program. The results again confirmed the value of good care coordination, the value of a computerized medical record and orchestration of chronic care by a primary care physician who could spend adequate time with each patient. At one retirement center, inpatient hospital days dropped from a national average of 2096 per 1000 Medicare enrollees per year to less than 500. And since these retirement communities generally have older residents, age adjusting the data meant that it was equivalent to only about 200 hospital days per enrolled resident. Another key metric is an unplanned return to the hospital shortly after discharge. The national rate for Medicare recipients is near 25% but the Erickson plan has kept these to less than 10%.They found that one key to success was having the primary care physician be the “orchestrator” among all of the patient’s specialists, being sure that the patient’s medications were appropriate, not mutually adverse, and in the correct dosage for a geriatric person. The primary care physician attends the resident when hospitalized, bringing the patient’s electronic medical record to the hospital on the doctor’s laptop. [They found that if the patients were cared for only by the hospital-based hospitalist, the tendency was for the acute problem to be well managed but for other issues to get out of control leading to longer lengths of stay and various complications.] As a result, they can assure that the individual continues to get appropriate care for all of their needs, not just the one problem that sent them to the hospital this time. Care coordinators are used as well but in tandem with the primary care physician who has the needed time with each patient. They conduct regularly scheduled programs of health management. There are behavior modification courses as in employer-based wellness programs but also specific programs for monitoring, coaching and prevention for specific high risk diseases. To reiterate, the program provides what a typical primary care physician either does not or cannot provide today [although most would like to provide.] It includes the behavior modification programs, plus the monitoring and coaching for patients with cardiac, chronic lung, diabetes and other diseases found in wellness programs sponsored by employers. To this is added aggressive management of these complex chronic diseases with close care coordination from their very beginning rather than when they become problematic later on. There is extensive use of non-physician providers which helps to keep the costs down but the contact level high. In short it is a wellness program, a care management program and a disease management program all rolled into one.

Disease Prevention For All And Care Coordination For Those With Catastrophic Illness

The care coordination described in the previous post is a major part of the new CareFirst Blue Cross Blue Shield plan. But there are three other important components.

First, the PCP will receive increased compensation for all of his or her CF-insured patients, not just those with complex chronic illness. Hopefully, this will be enough to assure that every patient gets the time and attention needed for the best possible care. It also means, hopefully, that the PCP will be less inclined to quickly refer to a specialist rather than taking the time needed to sort out the patient’s problem [This happens a lot today and drives ever more specialist visits.] By the same logic, it is anticipated that the physician will do a more complete history and physical exam, negating the need for more tests and procedures. The result is better care for the patient, a more satisfied patient since the doctor will not be in a “rush” and a more satisfied physician. Better care at lower total cost.

Second, CareFirst recognizes that over 90% of their clients remain with them year after year so it is financially logical to try to assure good preventive care. This will cost more today but should pay off in the years to come with lower costs because the patient will remain healthy. So in this new practice arrangement, CareFirst will pay for any preventive/ screening program/ test that is well defined by evidence. This might include cholesterol measurements, mammography and colonoscopy and it might include dietary consultation, or a smoking cessation program. As an added incentive to get this type of preventive care done, CF will waive any co-pays or deductibles that the patient might have to otherwise pay.

Finally, it is recognized that some small percentage of patients will develop a truly catastrophic condition such that the PCP can no longer easily coordinate the care. These are the 5% of patients that consume a very large portion of the healthcare dollar. This is the patient that must be referred to a specialty center or an academic medical center, have major surgery or perhaps receive an organ transplant. My own observations over the years demonstrate that these are the types of patients who get less than the best possible care because the hand offs and referrals among providers are less than satisfactory. This is where quality breaks down, where safety issues arise, and where all too often excess tests and procedures get done. And since no one is orchestrating the entire care program, the patient is left with well intentioned caregivers but less than the best care.
In this situation, CareFirst will develop an incentive-based relationship with the specialty provider – probably a hospital system – to assure care coordination. The hospital system will assign a “navigator” to each such patient. The navigator will have the responsibility to be sure that the care of the patient within the system is well coordinated, just as the PCP does in the community setting. This navigator will work the interface among the myriad specialists, departments, even hospitals and centers that the patient must utilize for his or her care. The result could be much better care quality yet at a substantially reduced total cost.

The whole concept here is to coordinate the care that the patient receives with the expectation that the patient will be better served, the providers will be more satisfied and the total costs will be reduced. It will mean a real change in how the primary care physician functions – a change from being an intervener to be an orchestrator. And a major change for the hospital system in that it will need to become an orchestrator as well, not just a place for specialty care. And it is a change for the insurer, one that accepts that care coordination and disease prevention costs money but recognizes that the end result is better care at a lower cost. This plan uses various incentives to align needs – we could say that it gives rights but with corresponding responsibility.