Optimal Medical Therapy is a Product: This Site Exists to Define, Update, Spread, and Support It.
You have learned here of the dramatic benefits of optimal medical therapy (OMT) compared with usual care and both are defined in the slide above. Beginning your OMT initiative is a quality improvement activity. Quality is a systems property and the highest performing OMT is highly systematic. In order to produce the highest quality product, the key steps must be done whether you are building a car, cooking a hamburger, or producing OMT. To the extent possible, the key interventions must be done with every patient every time and that will produce great results in 80-90% of your patients. We are not dealing with cars or hamburgers, so exceptions and complications will arise, and that is where your extensive training comes in.
I have done this as an individual, but I would not recommend that approach. It is much harder than it has to be. The best way to do this is with an advanced medical home team focused on a set of related chronic condions and the low hanging fruit is in cardiometabolic disease. I did this work in Appalachia with a team of PharmDs who were on the University of Tennessee faculty. They had all had had ambulatory care residencies and were certified diabetic educators. They trained an ambulatory care resident annually. They knew the medications better than anyone and they saw patients independently under a collaborative practice agreement. The team enrolled over 100 patients in the landmark ACCORD trial for type 2 diabetes. The pharmacists provided all the management for those patients. They were authorized in our practice to change treatment in real time without consulting a physician and they were magnificent. The team really moved the numbers. If the hemoglobin A1c was 8% or higher, we reduced it by 2.2% on average. With an advanced medical home team like this, there are many benefits. Systems and protocols get everyone on the same page and that truly enables all team members to contribute as much as their license allows. It dramatically reduced confusing messages to patients.
After that, I was a senior clinical advisor for BCBS of Louisiana where we worked to do the same thing and ultimately enrolled 700 primary care physicians in the Quality Blue Primary Care program. That initiative moved the numbers and saved money, mostly by reducing hospitalizations and length of stay in the hospital. I also worked as one of the regional medical directors for the Tranforming Clinical Practice Initiative sponsored by the Medicare Innovation Center. During all that experience, I learned as much from others as I taught, and I learned as much about what not to do as what you should do. This work is highly iterative and we will always be improving.
Here are the key elements of the systems to produce OMT
Develop trusting longitudinal relationships. Just because the approach is highly systematic does not mean that it is impersonal. In fact, it depends on longitudinal trusting relationships entirely. Someone on the team must spend enough time with the patient to develop that relationship and it need not be a doctor. These team members must be capable of empathy and a fee-for-service payment model is barrier to progress because of time constraints.
Focus on patients with high-risk, high cost conditions first to achieve the greatest, most rapid movement of clinical and financial outcomes
Identify those patients from claims data or practice information systems
Use evidence-based protocols consistent with best practices to manage congestive heart failure, heart artery disease, diabetes, chronic kidney disease, heart attack, stroke, amputation, atherosclerosis, and hypertension.
Use information technology to support the provision of care and the measurement of care processes and outcomes.
Use clinical and financial analytics at baseline and quarterly to document progress and identify areas for additional improvement. If you are not measuring it, you can’t improve it.
Use a population health tool. It is essential for this work. It creates triggers for your team to close gaps in care. If you are working for a self-insured employer for example, you must be able to identify employees who have not been seen, have not had a visit or test within the protocol specified interval, are not on an appropriate medication, or have not achieved a risk factor goal. This process can be automated and it is critical. In usual care, only 10% of patients with chronic kidney disease even know they have it.
Because it is highly systematic, you can easily explain how you achieved your excellent results and you can spread it throughout your organization. It can be standardized, scaled, and industrialized.
Here is an example of how OMT makes a difference compared with usual care. Statins are an essential part of OMT for patients with cardiovascular or related conditions. Patients with a known diagnosis of heart artery disease have the highest risk of heart attack and sudden death. Only about one third of them achieve their LDL or bad cholesterol goal of less than 70. Fewer than half are getting appropriate statin treatment. An optimal medical therapy team that dramatically reduces mortality and cost has 91% of their patients on a statin. They are focused on these issues. It helps.
If you are away from home or you move, you never know what your new healthcare provider will be like. Most people don’t know enough about medicine to really judge the quality of care they are receiving. They can judge the friendliness of the staff and the service, but they don’t know enough about science or have enough information about treatments to judge medical quality. As quality goes up, variation goes down. As quality goes up, costs go down. I would estimate that less than one percent of the American people have advanced medicals homes providing excellent OMT available to them. There is more variation in American medicine and medical quality than in any other business enterprise. You know when you stay at your preferred hotel brand exactly what to expect and you can count on the service and quality. You should be able to count on receiving optimal medical therapy for your chronic cardiovascular condition whether you are in Sarasota or Seattle. You don’t need to reinvent the wheel. Let us help you provide excellent OMT for your patients more quickly. wbestermann@congruityhealth.com