Trust and good relationships with patients are essential in providing high quality healthcare. A key factor in this equation is being available for patients when they have questions or concerns. This availability is especially important for patients dealing with chronic illnesses or other health issues. Opening an avenue for these patients to have access to care, even outside the clinic, can greatly enhance the trust they feel and the relationship they share with their provider.

Like many others, our clinic is in a state of evolution as we make the transition from a traditional fee-for-service model into a more comprehensive care setting for our patients. We decided last January to begin offering Chronic Care Management as a resource to reach some of our most at-risk patients. Right away it became obvious the success of the program was going to hinge on finding the right person as a liaison between patient and provider. It had to be someone the patients felt comfortable talking to and someone I could trust. It was a very difficult leap of faith, but I decided there was no better choice than Susan Williams, my nurse of 15 years. Susan already has good relationships with all of my patients, and they trust her. I promoted her to the position of Care Manager, and we began enrolling patients.

With Susan leading the way, our patients immediately embraced the program, and we have seen many of our most in-need patients begin to manage their health more effectively and efficiently. We have over 80 patients under management, and only two have discontinued the program.

We launched a new cell phone line so patients in the program could access Susan directly. She carries the phone during office hours so that patients no longer need to speak to the receptionist. They no longer worry about not getting a call back or if their message is lost in translation. If there is a problem, Susan comes to me directly, and we decide whether the patient needs to come to the office or if we can handle the problem remotely.

It became immediately evident, once these patients knew they could get an answer quickly, their tendency to run to the emergency room decreased. Susan began keeping a list of patients who were seen in the office on the same day they called and spoke to her. While this is a number that never shows up in the data, we have counted over 40 occasions since last June where the patient called asking if they should go to the emergency room, and instead they were seen in the office. Even if they actually do need hospitalization, I can admit them to our hospital directly from my office, avoiding the time, stress, and extra cost of a trip to the emergency room.

A specific example of the effectiveness of the program involves a patient who had an outpatient procedure to replace his pacemaker battery. The following day he spiked a high fever and called the number provided by the cardiologist. He was unsuccessful at reaching any of the clinical staff and was told he would get a call back, which never came. Instead of going to the local ER, he called Susan. She informed me of the problem, and I had her call the Cardiology practice. She was quickly able to get the physician on the phone and direct admission was arranged under the care of the patient’s cardiologist. With a simple call, an ER visit was avoided and care was provided quickly.

Aledade ACOs emphasize the special relationships small practices have with their patients, and their guidance helped us launch this beneficial care management program. Our patients value the personal relationship they have with Susan, and we have direct evidence the program has led to better health outcomes and lower hospital and ER utilization by our patients.

Preserving True Choice via Diversity of Organization and Universal Standards for Outcomes

Healthcare delivery is inherently local. Every community has its own history; its own needs; and its own resource base. This is especially true in Maryland, with unique communities among its beautiful coasts, soaring mountain ranges, and vibrant urban areas. Indeed, Maryland’s strength comes from this diversity, which is carefully maintained through the deliberate promotion of thoughtful policy, purposeful actions, and local solutions.
In a similar fashion, the Maryland Comprehensive Primary Care Proposal must deliberately promote strategies to strengthen and advance diversity among providers and Care Transformation Organizations (CTOs).
The proposal highlights a desire for competition among Care Transformation Organizations (CTOs); we wholeheartedly agree that competition is the best tool for improvement. However, competition can present tremendous challenges, especially in health care, and many organizations will seek to minimize the level of competition for their own benefit. Competition in health care must be deliberately supported through the selection process and model design so that various options present attractive options on their own, aside from the need to subsidize the CTO-practice relationship. Prior models have shown this to be the case; indeed, the recent trend towards consolidation is evidence enough.
The CTO selection process should not just value having two or more options for practices, but rather seek different types of CTO offerings. By example: choosing between two systems whose integration is based on common ownership is fundamentally different that choosing between a wholly-owned integrated system and a networked system whose integration is based on shared patients and shared data.
An effort to spur and maintain true competition among CTOs would enhance the strength of the state’s Proposal and greatly increase its chances of success.

Reinforcing the Primary Care Physician – Patient Relationship

Every Medicare beneficiary benefits from a strong primary care physician relationship. Primary care physicians “quarterback” their patients’ health care. Those who do so in their own practices maintain the independence that makes their practices unique and trusted.
There are certainly rare cases where the only health need a patient has in a year is a singular acute issue. There are also cases, usually towards the end of life, that a patient’s needs are so intensive they are removed from the community.
However, most health care needs—and most health care spending—are driven by patients with multiple chronic conditions or who suffer from preventable or otherwise avoidable illnesses and injuries. These patients remain in their community, and benefit most from the one-on-one relationship with their primary care physician.
Attribution should revolve around that relationship and the model CTO – practice contract should seek to preserve that relationship. Only in the rarest of cases where it is inescapably obvious that primary care is no long primary to the patient’s health care needs for a given year should specialist or facility attribution be employed.