Episode Details

This interview with Lisa Trumble is mostly about clinically integrated networks (CINs)—what they are, how they work, how data get shared. Furthermore, we talk about hybrid CINs, meaning, for example, a virtual front door that might lead to in-person care. After that, we talk about the potential impact of direct contracting, which Lisa says could significantly change the healthcare marketplace. The hybrid talk, by the way, is toward the middle of the show; and we talk about direct contracting—that's near the end if you're short on time and you want to skip around.

But before we go there, let's just level set a little bit, shall we, on the topics of accountability and integration as general constructs. Specifically, what's the impact, or lack thereof at times, when the provider is not accountable for patient results? I'm talking here about fee for service, in general, where the provider is not accountable for patient results.

Like, if we're talking about a fee-for-service world and what it incents, it goes like this: Transaction happens. Somebody sends a bill. The end.

I mean, in a fee-for-service world, the patient encounter may be the highest- or the lowest-value patient-doctor transaction in the history of humankind; but either way, the payment is the same. So, the incentive is to figure out how to encounter lots of patients and/or upcode wildly, I guess. The incentive is not to coordinate care or teach a patient how to take advantage of a telehealth offering to mitigate some social determinant of health or spend 10 minutes doing some education or shared decision making or establishing rapport and being culturally sensitive. Any docs who are doing that stuff are doing it on their own time in an FFS world.

Here's the good news and the bad news—and I don't often hear it spelled out this bluntly, so I'll do the honors: If anyone wants to get paid to create patient health, they have to be accountable for the outcomes created—upside and downside. Frankly, when an organization is super worried about the downside, that could be—not in all cases, but it certainly could be—a clue that maybe their approach is a little bit more transactional and/or inefficient than perhaps they would like to admit.

There's been much talk over the years about the importance of giving patients so-called "skin in the game," but what might work out better is to mandate that providers have so-called skin in the game. Providers have to be accountable so good providers can reap rewards and bad ones don't. The episode with Sunita Desai (EP334) is all about how providers have proven to actually be better "consumers" than "consumers," so there could be a constellation of rationales here.

Now, if you're accountable for care, you must actually create outcomes, as just discussed. And to actually create outcomes, there must be integration. Integration is necessary. Care coordination is necessary both with internal and external other providers and entities. There are very, very few cases where a chronic condition can be appreciably improved by a random assortment of 7- to 15-minute patient encounters. Managing chronic conditions requires a longitudinal journey that weaves together most often more than one doctor, also nurses and a PA and a speech pathologist and a nutritionist and a Certified Diabetes Educator and maybe a physical therapist or two. Considering that 85% of healthcare spend in this country has to do with chronic conditions also ... yeah, integration is really required. And, yeah, how many decades later, we're still talking about interoperability.

Here's a tidbit I found kinda apropos: Female doctors make $2 million less, apparently, over a 40-year career than their male counterparts. That's per research in Health Affairs,

Listen Now