The Affordable Care Act is the primary manifesto of health care reform. While its primary focus is to facilitate increased access to the underserved, it is also designed to reduce the cost of health care and improve delivery.

To this end, it directs Medicare to contract with accountable-care organizations, or ACOs, which
comprise primary care physicians, specialists and hospitals to offer incentives based on improved clinical outcomes for a designated patient population.

Up to this point, the latest sea change in health care has been the transition to the patient-centered medical home, or PCMH, which incentivizes individual medical clinics to employ a patient-centered, whole-person approach that addresses prevention, psychosocial issues and lifestyle education. It’s all empowered by electronic health records. This is the basis of integrative medicine and how we have always practiced at Manakai o Malama.

In contrast, the ACO model includes clinics that have converted to PCMH together with specialists and hospitals to lower costs by reducing inappropriate emergency department visits and hospital readmissions.

At every level, the health care industry in Hawaii is in high gear. It is widely anticipated that Hawaii Pacific Health and Queen’s will soon roll out competing programs.

The recent legislative session saw attempts by Banner Health, a Phoenix-based nonprofit operating 23 owned and leased hospitals in seven states, to enter the Hawaii market. At the same time, independent physician associations are vying for position and considering their own offerings.

Many physicians believe that this may be the last and best opportunity for medical doctors to influence health care and ensure that the soul of medicine is not eroded by large health care organizations.

Physicians are also concerned that the economic benefit of improved clinical outcomes and cost savings will not trickle down to providers in an equitable fashion. Discussions are afoot not only with government payers but also with private insurers throughout the state.

Meanwhile, Kaiser Permanente is in a highly favorable position. In many ways, Kaiser has always functioned as an ACO. Janet A. Liang, president of Kaiser Permanente, Hawaii region; and Dr. Anthea Wang, an internist at Kaiser, both say that population management is a key to Kaiser’s success.

“It’s not enough just to have an electronic health record,” Liang told me in a recent interview. “Instead of waiting for patients to say something is wrong, we have taken the responsibility to reach out.”

Kaiser carefully organizes queries, analyzes utilization and pharmacy data and looks for gaps in care.

It then automatically alerts primary care providers on the screen during each visit as to what actions should be considered, including preventive screening and chronic disease management. Kaiser providers are also easily able to review all of their diabetic patients on one report to ensure each patient is getting needed care.

In addition, Kaiser has fully integrated a diverse range of health care providers into care teams. Clinical pharmacists fine-tune medications under physician supervision, and nurse educators and case managers help to ensure optimal care. The care team approach has worked to create a robust and seamless role for services such as home health, palliative or comfort care and hospice.

Communication, according to Liang and Wang, is the third pillar to Kaiser’s success. There is not only close collaboration among the care team, but patients have the ability to set and cancel appointments, request medication refills and ask questions of their providers. A family member recently diagnosed with bladder cancer on the mainland called and asked me for advice. She gave me the password for her Kaiser patient account. I was immediately able to view her tests and answer her questions. Kudos to Kaiser Permanente.

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Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.