Accountable Care Demands Accountable Communication

Among the many debated aspects of health reform legislation, none is creating any greater interest and discussion within the provider community than the concept of "accountable care." Whether your organization sees accountable payment as a promising opportunity or threatening risk - or both - the sobering reality is that the cost of care in the U.S. must be reduced to forestall a doubling in Medicare spending over the next seven years. Even more daunting, the government estimates that given our current trajectory, health care spending will comprise 30% of GDP in just 20 years if practices don't change dramatically very soon.

For health care providers, the imperative represents a brave new world. For perspective, since 1970 there has been only one year (1998) when Medicare spending held steady year-over-year. And while the early days of managed care impressively cut the rate of increase of non-Medicare spending, the savings were short-lived and unsustainable. This time, savings must be real. And they must be long-term.

Appropriately, health care systems are already moving to adopt and implement structural changes that will be necessary to increase accountability for both the outcomes and cost of providing care:

• More comprehensive access and use of electronic clinical data systems;
• Tighter integration with physicians;
• Greater focus on prevention and the "front-end" of care to manage chronic care in lower cost settings;
• Less frequent and lower cost acute care episodes, with increased emphasis on productivity, controlling supply expense and utilization in the hospital; and
• Seamless integration with the later stages of chronic and end-of-life care.

While Accountable Care Organizations may be touted as a new approach to delivering care, their goal of reducing cost by more aggressively managing episodes of care looks and feels an awfully lot like the original vision for yesterday's HMOs. Perhaps American's vehement reaction to any suggestion of reforming the health care system traces at least in part to their memory of losing choice - and perceived quality - during the managed care revolution of the 1990s.

To avoid another consumer backlash like the one that doomed HMOs, providers must include patients and families in dialogue and decision-making in a more meaningful way than ever before. Whether we like it or not, the days of patients' willing compliance simply because "my doctor said so" are waning. Following are suggestions for appropriate places to start.

While the exceptional, dramatic denials of coverage made headlines, it was patients' loss of choice and control that contributed more to the demise of most HMO plans. While physicians and hospitals could blame care decisions on insurance company "bureaucrats" before, in Accountable Care Organizations they too will be at risk.

Open communication starts with interviews by physicians and other care givers that allow patients to take the lead. In his book "The Patient's Story," Robert Smith advocates starting with patient-centered, open-ended questions that allow patients to share symptoms, concerns and background on their terms. Doctor-centered questions can follow to isolate specific details that are necessary for an accurate diagnosis.

Patients also have the right to fully understand why a specific treatment option is recommended for their condition. Care professionals can insure this understanding by asking key open-ended questions that encourage patients to open up: What concerns you most right now? What aspects of the treatment plan we've chosen do you still have questions or concerns about? How are you feeling about your care? This approach strengthens the connection between patient and physician and builds trust.

For most patients, the days when they could expect their primary care physician to manage all aspects of care regardless of the setting are over. With the emergence of hospitalist and intensivist programs, primary care physicians hand-off care frequently. Even in the office, some aspects of care are more often handled by nurse practitioners or physician's assistants. In many cases, physicians have done little to prepare patients for these handoffs and new, unfamiliar roles.

Especially during hospital stays, communication among all physicians - primary care, hospitalists and consulting specialists - is critical to ensure care is managed most efficiently and patients are comfortable that everyone is "on the same page." The attending hospitalist must see his/her role as quarterback of the care team during a hospital stay, regardless of how many specialists may be involved. And handoffs among the hospitalist group shift-to-shift should be explained and expected by patients, not an unanticipated disconnect in care. Finally, a well-crafted discharge summary is important, but that document alone is often not sufficient to provide the kind of coordination patients expect and deserve when they transition back to their primary care physician after hospitalization.

How well did staff work together as a team? On patient surveys, research shows that this question is among the most highly correlated with overall patient satisfaction and willingness to recommend the institution. For patients, staff working together as a team means that physicians, nurses, case managers and other care providers communicate throughout the stay and don't rely solely on the electronic medical record to exchange information. In the hospital setting, multidisciplinary rounds, daily conversations between the attending physician and primary nurse, and a culture that encourages all members of the care team to speak up with significant questions or concerns can contribute to patients feeling well informed.

Given patients' emotional reaction to even the mention of health care reform, many are poised to resist any efforts perceived as an attempt to limit their choices or control, including the introduction of Accountable Care Organizations. Only through consistent, open communication across the care team and with patients do these new efforts have a better chance of succeeding than yesterday's managed care.

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