A New Jersey healthcare landscape with fewer hospitals and less direct interaction between doctors and patients – but one in which more patients receive high quality healthcare – was sketched out by one of the state’s most prominent healthcare leaders at an NJ Spotlight conference late last week.
Keynote speaker Dr. Jeffrey Brenner led the charge into this new world by describing some of the fundamental flaws in the state’s healthcare delivery system, which he believes can be alleviated by adopting a model called accountable care organizations, which emphasize coordination by healthcare providers and pays them more if they actually improve the health outcomes of patients, rather than just paying them for each service they deliver.
Brenner leads the Camden Coalition of Healthcare Providers, which could soon apply to be an ACO for the state’s Medicaid program.
Brenner’s “hot-spotting” work with the organization, which uses patient data to better target healthcare resources – has earned him national recognition. Last year, he was awarded a MacArthur Foundation fellowship, also known as the “genius grant,” for his work.
Brenner laid out the history of ACOs, which grew from research indicating that increasing the amount of healthcare doesn’t necessarily lead to improved health for patients. He noted that New Jersey ranks highest in the country in the amount of care provided– including the number of patients who visit at least 10 specialists – in the last six months and the last two years of life.
“We’re better than anyone else in the country at bouncing our older and sicker and dying patients from doctor to doctor, specialist to specialist, and they get lost in the delivery system,” Brenner told the audience of about 180 gathered for the February 28 event at the RWJ Fitness & Wellness Center in Hamilton Township, Mercer County.
After Brenner spoke, a panel of healthcare experts – including hospital and ACO leaders – sketched out some of the challenges in improving healthcare delivery.
Assemblyman Herb Conaway Jr. (D-Burlington), a doctor, said that access to patient data will be crucial in improving the coordination of care. He expressed disappointment that Gov. Chris Christie didn’t pursue a federal grant to build a database that would include all insurance claims for healthcare services in the state.
Jeffrey Brown, executive director of an ACO trade group — Affiliated Accountable Care Organizations, an initiative of the New Jersey Health Care Quality Institute — said ACOs could help correct some of the problems in the U.S. health system.
Brown cited an estimate that the U.S. healthcare spending is larger than the entire Chinese economy, while average health outcomes are similar to those of Cuba.
Dr. Morey Menacker, CEO of the Hackensack Alliance ACO, noted that patients with the financial means come from around the world to avail themselves of American healthcare.
“The system may not be the best system, but the care is the best care available,” Menacker said.
The Hackensack Alliance ACO illustrates some of the promise of the ACO model. It is participating in a Medicare program in which it receives additional payments when it reduces healthcare expenses while also improving patient outcomes. It saved an estimated $10 million in its first year.
Brenner said that one reason for wasteful healthcare spending is the state’s relative wealth, which allows many New Jerseyans to avoid making tough decisions that would help make healthcare delivery more efficient, said Brenner, who is also the medical director for Cooper Health System’s Urban Health Institute.
He noted that two new hospitals that will require additional financial outlay by both taxpayers and patients were recently built in Mercer County — the University Medical Center of Princeton at Plainsboro and Capital Health Medical Center in Hopewell — without any public vote on the issue.
ACOs and other new models can make the delivery of healthcare more sensible, Brenner argued, illustrating that point by not how poorer states have managed to make strides in improving health outcomes.
“Many have large, integrated delivery models where hospitals own doctors’ (practices) or you have very large doctors groups that have joined together into large integrated delivery systems — they deliver more effective care, higher quality care and lower cost care,” Brenner said.
“In New Jersey we’re so far away from that,” he added, because the state has more small practices and more doctors who are specialists.
Brenner compared the coming changes in healthcare to those made by carmakers in the early part of the 20th century.
Car designers and engineers could do more high-level work when cars were no longer made in small shops but were built in factories, while front-line factory workers began to have more input due to the production system developed by Toyota.
In healthcare using the ACO model, primary-care doctors can delegate 95 percent of the routine work that they currently do, allowing other healthcare workers to engage in tasks like reading normal results from routine lab tests.
“An ACO really is about industrializing the healthcare system, standardizing , protocolizing, innovating, delivering more services at a lower cost and making sure that those services are available at a high quality for everyone every day,” Brenner said, adding that it will be a long and difficult transition for providers who are unwilling to apply new approaches.
Brenner said the success of these efforts depends on being able to use data effectively, redesigning each healthcare worker’s role, and engaging more with patients, the community and the various healthcare stakeholders.
Patient data – particularly records for the small percentage of patients who account for a large share of inpatient hospital admissions – should be used by nurses to coordinate targeted visits, much like marketers who mail advertising based on consumer data, Brenner said.
In the absence of this coordinated care, there are cases like one patient Brenner encountered who had received 73 CT scans of her head. This potentially dangerous exposure to radiation may have occurred because the patient wasn’t receiving coordinated care, despite having made a series of trips to hospitals in the same system.
Brenner said the patient’s problems were rooted in anxiety, and that care coordination provided by the Camden Coalition of Healthcare Providers led to more effective treatment that reduced the patient’s pattern of frequent hospital use.
Brenner said several programs are taking a similar approach – providing coordinated care to a specific “market segment” of patients.
He’s aiming to draw attention to the work of those groups through a new organization, the Good Care Collaborative.
Dr. Kevin Mange, vice president and chief medical officer for Barnabas Health Medical Group, said the data used to improve healthcare delivery must extend beyond the insurance claims for healthcare services to include other information gathered by providers both inside and outside of hospitals.
Mange said the delivery system should no longer be conceived as being based on a one patient-to-one doctor ratio, but instead on a patient having a team of healthcare professionals, including a doctor, a nurse, a nurse practitioner, a behavioral health specialist, a pharmacist, a social worker and community organizations.
Dr. Douglas Ratner, chairman of Jersey City Medical Center’s Department of Medicine, said there are many ways that providers can innovate in how they provide patient care. He cited hospital programs that reduce the number of in-person visits with doctors, as well as improving the use of palliative care, which concentrates on treating patients’ symptoms rather than curing advanced diseases.
Wardell Sanders, president and CEO of the New Jersey Association of Health Plans, said insurers also are working on innovative approaches using data to provide more efficient care.
“We’re going to see successes, we’re going to see failures – we shouldn’t be afraid to fail” in order to achieve lasting success, Sanders said.
Conaway added that healthcare providers are in a challenging position when negotiating contracts with insurers. He said that hospitals like Bayonne Medical Center – which charged Medicare the most of any hospital in the country – were in a difficult position. If insurers offer to reimburse hospitals like Bayonne at a level that is so low that they consider closing, these hospitals may sell to for-profit operators that then cancel insurance contracts, Conaway said.
Conaway cautioned that despite the promise of ACOs, there is also a risk of introducing additional bureaucracy.
“We probably ought to be wary of increasing administration in the provision of care,” he said.
Brenner took some controversial stands, saying in response to one question about safety-net hospital funding that the state “cannot let safety-net hospitals and clinics fall apart,” but then adding that a city like Newark only needs “one great hospital” rather than the three that it currently has.