By Michael Magill, MD
At academic medical centers (AMCs) all over the country, health care delivery and payment reform are becoming reality. AMCs need to think in a new way about the markets they serve. Timing for AMCs transforming care delivery is critical. We need to find the perfect middle ground, or what I like to call the “Goldilocks Factor:” AMCs need to transform delivery, definitely not too slowly, but not too fast for their markets either… and finding “just fast enough” is not easy.
The services we provide are, now more than ever, about comprehensive care and population management to achieve the “Triple Aim” of improved quality, improved health, and controlled cost. Primary care is key to successful care of defined populations under payment models such as Patient-Centered Medical Homes, capitation, and shared savings. But some highly subspecialized services will likely remain fee-for-service, at least for a time and maybe indefinitely, while value-based payment covers increasing fractions of AMCs’ total care.
We have to learn how to balance managing population risk and health along with continuing to provide subspecialized care paid fee-for-service,. If we reduce utilization of subspecialized care by populations quickly without replacing this fee-for-service volume, we will reduce our revenues and get in financial trouble. If we are too slow and do not learn how to manage market risk, and then the market changes abruptly to heavily risk-based contracting, we won’t be ready for it and will get in financial trouble. We have to build comprehensive care for populations while reaching regional or even national markets to “backfill” subspecialized care that will decrease for defined local populations. This will require competing to provide these services on the basis of cost, quality and patient satisfaction. So, just like the porridge in “Goldilocks and the Three Bears,” we have to be just right.
At the University of Utah School of Medicine, we have been working to redesign primary care delivery to improve efficiency and quality and lead us to the care model that is just right for our patients. Our primary care system includes eight production-oriented clinics in various neighborhoods and communities of northern Utah plus two teaching sites for family medicine faculty and residents. The clinics together deliver about ¼ of all outpatient visits provided by University of Utah Health Care. One of our initiatives, the University of Utah Community Clinics’ patient centered medical home model, “Care by DesignTM,”has had substantial success in implementing a team-based model of care that increased the ratio of medical assistants (MAs) per provider to 4-5:2 with expanded MA roles, enhanced access, and prospective care management for chronic conditions and prevention.
We had to find a way to balance the two sides of the equation. The primary care and specialty sides must work together to provide quality care at a controlled cost. Investment in primary care builds institutional capability for population management. Investment in controlling utilization and cost of fee-for-service specialty care prepares the organization to compete in a transformed payment environment. AMCs should become “medical neighborhoods,” incorporating advanced medical homes and a continuum of coordinated services including highly subspecialized care.
For the future of academic medicine, we need to think about what services to provide defined local and regional populations, and what services to provide patients who may travel from surrounding states or beyond. Going forward, everyone is going to have to diversify their care delivery methods and explore new opportunities not just to stabilize revenue and reduce costs, but to improve patient experience and health of populations, while also supporting the full range of academic missions of the AHC. It will not come overnight, and it will take work, but we will eventually find our “just right” bowl of porridge.
—Michael K. Magill, MD, is Chairman of the Department of Family and Preventive Medicine at the University of Utah School of Medicine, and also serves as Director of Research for the University’s Community Clinics system. He can be reached at Michael.Magill@hsc.utah.edu