Dr. Mark Nunlist: Want to improve health care? Ask the patient.

This commentary is by Mark M. Nunlist, M.D.,of Lebanon, New Hampshire, who was a partner in White River Family Practice from 1983 to 2013, serving patients from both Vermont and New Hampshire.

I write in response to the article Dec. 19 regarding the performance of OneCare Vermont and the sense among some at the Green Mountain Care Board that the board’s investments in OneCare may not be justified. 

I am a family physician retired from a 30-year career at White River Family Practice in White River Junction, Vermont.

For decades, medical practitioners have been compensated for their work based on the number of patient transactions and the complexity of those interactions, perversely incentivizing some to see more patients and perform more services without regard to whether those services were wanted or needed by patients. 

In the past decade, leaders have sought to change payment mechanisms to improve the care quality of individuals, and the health of populations. OneCare, as an accountable care organization under Vermont’s “all-payer” model, accepted the responsibility of coordinating payments to health care providers based on spending targets, care quality, and outcomes, to realize that lofty goal of improving quality with reduced cost. 

However, as with most health care payers, OneCare Vermont is relentlessly increasing administrative staff and mandates from the “top down” while crushing those on primary care’s front line with ever more complex “quality measures” based on retrospective analyses while ignoring patient input. 

This approach, tried by payers nationwide without measurable success for decades, continues to fail for several reasons. 

First, data based on patient diagnoses, past hospital events, and test results are always delayed, and are frequently woefully out of date by the time the information reaches primary care practitioners responsible for patient care. 

Second, this approach neglects assessing risk for health deterioration and potentially avoidable costly care among most patients who have yet to come to the attention of the database.

Fortunately, there is a simple, cost-free way to address both concerns: Ask the patient what matters to him or her and what is needed. 

Specifically, one can query patients as to how confident they feel that they understand and can manage their health care issues and risk. Excellent data from across the country demonstrates that patients with low “health confidence” are at high risk for subsequent emergency room use or hospitalization and possibly avoidable high-cost care. 

This approach to risk assessment from direct, real-time patient-reported measures is cost-free, does not involve a multimillion-dollar organization to collect and analyze data, and allows immediate action to assist patients in need at the front lines of care.

Three years ago, White River Family Practice applied to OneCare Vermont for grant funding to test the application of a short list of patient-reported measures to our patient population. This list, called the What Matters Index or WMI, is freely accessible to anyone at howsyourhealth.org. It relies on five single-item measures, each of which guides specific actions, and their composite sum identifies the risk for subsequent hospital and emergency use. 

The five items for adults are self-reported: insufficient health confidence, bothersome pain, bothersome emotional problems, polypharmacy, and a suspicion that medications may be causing illness.

Our implementation was intended to confirm that patients reporting two or more adverse responses were indeed at higher risk for subsequent potentially avoidable high-cost care, and that prompt intervention to address patient concerns would improve their confidence in self-management, their sense of well-being, and save health care costs. 

Regrettably, our proposal — which would have consumed less than one-half of 1 percent of OneCare’s budget — was rejected. At OneCare’s invitation, the practice reapplied with a reduced budget, but our proposal was again rejected.

Notably, Blue Cross Blue Shield of Vermont is willing to partner with interested primary care practices to test the What Matters Index and other innovations at the front line of primary care, providing modest financial incentives in support of innovation from the “bottom up.” Such testing of small, front-line innovations at minimal cost could lead to big improvements in the quality of health care delivery and major savings in avoidable high-cost care.

This practitioner is not surprised to read of the Green Mountain Care Board’s frustration with OneCare Vermont when Vermont’s sole accountable care organization persists in applying measurement and data analysis techniques that over decades have not led to improved quality or lower cost. 

It is not surprising that Blue Cross Blue Shield of Vermont is similarly frustrated with OneCare Vermont.

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Tags: Dr. Mark Nunlist, family physician, OneCare Vermont, What Matters Index, White River Family Practice


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