Introduction

A New Approach to Improving Heath Care Delivery Systems

The current landscape

On March 23, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act (PPACA). The PPACA will expand access to insurance coverage, expand Medicaid coverage for low-income Americans, create new competitive health insurance markets and prohibit restrictions on who can obtain insurance coverage. While the heart of the PPACA promises to dramatically expand access to insurance and care for millions of Americans, its ultimate success will rest on the abilities of states, communities, providers, insurers and payers to create care systems that patients want and that can meet patient needs while achieving long-needed improvements in quality, access and affordability. The goals of reform will fall short if our fragile care systems aren’t addressed at the same time. In fact, there is a strong likelihood that many of our care systems will be overwhelmed by health reform if the effort does not address such issues as our deteriorating primary care systems.

Fortunately, the PPACA does include a number of provisions designed to encourage state innovation in improving population health. These include: funding opportunities for states to create care models that improve chronic disease care; improve prevention; promote expansion of the health care workforce; enhance the quality of care; test innovative payment and service delivery models that can reduce expenditures; and improve the coordination and efficiency of health care services furnished to Medicare and Medicaid beneficiaries. The Center for Innovation that is established under the PPACA is not only another vehicle for fostering state innovation, it is also intended to be a vehicle for rapidly diffusing innovation and translating successful innovations into program policy and regulation within the Centers for Medicare & Medicaid Services. Under reform, states and communities are being challenged to establish sustainable care systems that meet residents’ needs.

The first step is determining the type of care system residents want and ensuring that this system both corrects current weaknesses and has the capacity to meet the demands that will accompany comprehensive federal reform. The Commonwealth Fund Survey of Public Views of the U.S. Health Care System (2008) captures the public’s dissatisfaction with the existing system and the problems with access, information and coordination. In fact, half of respondents called for fundamental reform, and much of that dissatisfaction can be attributed to the growing inadequacy of our primary care system. Unfortunately, all signs indicate the problem is only worsening.

Trends and concerns

Over the past decade, the number of U.S. medical school graduates entering family medicine has plummeted 50 percent. In that same period, the number of internal medicine residents who pursue careers in adult primary care has also fallen by half. These trends – especially when considered in light of the nation’s aging population and dismal record of managing patients with chronic illnesses – are cause for grave concern, and their implications are already becoming apparent. In 2007, for instance, nearly one-third of Medicare beneficiaries reported difficulty in finding a primary care physician.

Consider the situation created when Massachusetts enacted legislation that provided health care coverage to nearly all residents. Shortly thereafter, the state’s health professionals were overwhelmed by hundreds of thousands of newly insured patients, many of whom were unable to find a medical home. As Dr. Kevin Grumbach noted in an essay for Health Affairs, “The lessons of the Massachusetts Health Care Reform Plan of 2006 make it clear that an expansion of insurance coverage quickly uncovers the debilitating problem of the crumbling infrastructure of primary care.” (Health Affairs, January 2009)

If a state like Massachusetts – which boasts abundant medical resources – has difficulty absorbing a sudden influx of patients, how will the many less-endowed regions of our country accommodate the throngs of newly insured that could be created by national health reform? Before any reform occurs, we must put in place the high-performing health systems that can accommodate large numbers of new patients while delivering the improvements in access, quality and cost that our systems desperately need.

What must change?

The Commonwealth Fund notes in “Organizing the U.S. Health Care Delivery System for High Performance” (2008) that health care delivery in the United States is a cottage industry characterized by fragmentation in the community, with the providers who care for community residents often working in their own silos with little contact among themselves. This fragmentation, combined with a fragile primary care system, places many residents – particularly those with chronic illnesses – at increasing risk for poor care and poor outcomes.

The Commonwealth Fund Commission on a High Performance Health System also found the following to be true about existing U.S. health care delivery systems:

Patients navigate unassisted across different providers and care settings.
Poor communication and lack of accountability for patient care among multiple providers lead to medical errors, waste and duplication.
Peer-accountability, quality improvement infrastructure and clinical information systems are often absent.
High-cost, intensive medical intervention is rewarded over high-value primary care, including preventive care and the management of chronic illnesses.

According to the Commission, a high-performing health care delivery system must possess six key attributes:

Clinically relevant patient information is available to all providers at the point of care.
Patient care is coordinated among multiple providers, and transitions across care settings are actively managed.
Providers (including nurses and other members of care teams) both within and across care settings are accountable to each other.
Patients have easy access to appropriate care and information, even after working hours.
Providers have clear accountability for the total care of patients.
Members of the system are continuously innovating and learning in order to improve the patient experience and the quality and value of health care delivery.

After examining 15 diverse health care delivery systems, the Commission concluded that ideal delivery systems are characterized by the following:

Providers are organized.
An organization exists to support the care improvement process.
The organization has leadership.
The organization provides accountability.

Building a better delivery system

The following modules describe one step-by-step approach to building such a system. Known as Community Care of North Carolina, this program serves the state’s most vulnerable and high-cost populations. Through access to a primary care medical home, vigilant care management and provider collaboration, Medicaid recipients and low-income uninsured residents enjoy access to more comprehensive, high-quality care that is less costly to administer.

Ours is a public/private partnership: a comprehensive care improvement plan and delivery system that includes community physicians, hospitals and health departments and other local organizations. While Community Care of North Carolina has been tailored to our state, there are many states and regions that share our characteristics: significant percentages of the population living in rural areas, a medical infrastructure dominated by small independent practices, and a low penetration of managed care. We’ve found that formal organized delivery systems may not emerge naturally in such areas; often, local or state government must help facilitate their creation.

Through Community Care, North Carolina has developed an infrastructure that improves care for Medicaid recipients and provides a vehicle for improving care for all patients. Community Care is a collaborative effort through which the State has partnered with community physicians, hospitals, health departments and other community organizations to build regional networks to improve the quality, efficiency and cost-effectiveness of care for Medicaid recipients. The program is built on the State’s primary care medical home model with each participating recipient selects and enrolls with a primary care practice that will serve as his or her medical home. Each medical home provides direct care to enrollees, arranges and coordinates other care that may be needed, and agrees to participate in the clinical and care improvement initiatives of its network. The network brings care management and other support to the medical home, helping physicians manage enrollees with complex medical and social conditions.

The Community Care networks use population management tools to achieve positive results in quality, cost and utilization, including the following: providing a medical home; implementing evidenced-based practice programs; providing targeted case and disease management; coordinating care delivery with an emphasis on improving transitions; improving patient self-management skills; helping practices improve management of chronic illness care; and providing a structure within which community providers can work to improve enrollee care and outcomes. There are currently 14 Community Care networks serving more than one million Medicaid and uninsured residents in North Carolina. Community Care is presently working with the Centers for Medicare & Medicaid Services on a five-year demonstration project (a Medicare Health Care Quality Demonstration) that is extending Community Care’s care management system to Medicare beneficiaries in North Carolina.

For health care delivery systems, greater organization is associated with better quality and, in general, greater efficiency. As the Commonwealth Fund Commission on a High Performance Health System noted in its report, however, there are multiple approaches to creating effective organizational structures. The Community Care model detailed in this toolkit is one example of a successful system; we hope the descriptions and lessons learned will be useful to other communities seeking to implement similar programs.