Thursday, July 4, 2013

IN-DEPTH: Boosting care, managing costs are health care challenges

Written by
Lisa Bernard-Kuhn

Region tests models ushered in by federal law, some of which are already saving money and raising quality

While debate lingers about the Patient Protection and Affordable Care Act, some key pieces of the federal health care law are already saving hundreds of thousands of dollars and improving patient care locally.
At Mercy Health, a year-old accountable care organization is teaming nurses with patients before they are discharged from the hospital and at home to help manage their health and prescription regimes.
In Over-the-Rhine, patients at Crossroads Heath Center are getting help organizing their medicines, reminders for appointments, and phone calls from nurses to make sure they have a way to get to the doctor.
Within TriHealth, at least 19 physician practices receive monthly payments from large employers, health insurers and Medicare for each patient that receives enhanced coordinated care at one of its new patient-centered medical homes.
And more than 14 physician practices that are part of St. Elizabeth Healthcare receive monthly payments from large employers, health insurers and Medicare for each patient that receives enhanced coordinated care at one of its new patient centered medical homes.
Ushered in by Obamacare, the models mark the region as one of the few in the country where so many new approaches for delivering health care and paying for it are being tested. Each model has a different name and a slightly different approach. But at their core, all try to curb costs and improve patient care by focusing on primary care and managing the health of the sickest among us.
“We’re moving away from fee-for-service payments into a world where providers are recognized for taking better care of their patients and keeping them healthy,” said Craig Brammer, vice president of the Greater Cincinnati Health Council, the Health Collaborative and HealthBridge.
In the short run, several of the programs are yielding promising results by producing fewer costly trips to the emergency rooms for Medicare patients and improving the health of diabetic patients and others with chronic conditions.
But longer term, the jury is still out as to which models will have staying power. “This is the starting point, not the end point,” said Brammer.
Boosting outcomes, payments via 'accountable care'
Locally, Mercy Health is the region’s first and only health system to take the path of becoming an accountable care organization, in which it shares the financial risk of keeping patients healthy.
Roughly 1,200 health-care providers across the country have signed on to the program, aimed at managing the health of some of the most vulnerable and costly patients: elderly and disabled patients on Medicare.
Nationally, savings from the new model are expected to be as much as $1.9 billion by 2015, according to the federal government.
Mercy says it’s seen impressive results since launching its accountable care group, Mercy Health Select, a year ago. Though the data are not final, the improvements are on pace to show a nearly 50 percent reduction in hospital admissions for the more than 25,000 patients served by the program. It’s also expecting a 35 percent reduction in re-admissions for patients and roughly the same decline in emergency room visits overall.
“In the past, we were used to taking care of the patients who came to our door, or patients who showed up in our emergency room, but that is such reactive medicine,” said Dr. Amy Frankowski, medical director of Mercy Health Select.
Mercy’s system includes 35 patient-centered medical homes, which includes a team-based care approach with larger roles for physician assistants, nurse practitioners and other staff who help coordinate more comprehensive care for patients.
Across those practices, Mercy’s 18 nurse care coordinators employed by the accountable care organization focus their time first on the top 5 percent of the most chronically ill patients. These roughly 1,200 patients have conditions that are most severe, complicated and, if left unmanaged, become the most costly to treat.
The nurse care coordinators work one-on-one with each patient, helping manage their diets and tackling any barriers – such as transportation – that might keep them from follow up appointments.
Among the patients is 76-year-old Kathy Calhoun of Reading. Twice a week she gets a call or visit from her nurse care coordinator, who also helps manage the health of Calhoun’s 78-year-old husband, Paul.
The coordinator is “on top of everything,” said Kathy Calhoun. “She’s great about making sure I’m taking my medication correctly and she talks to me about my diet. Until her, I never had a nurse call me.”
In all, the health system says it has seen a “5 to 1” return on its investment, saving more than $500,000 in the first year the model was tested, with just 310 patients. Should savings stay continue to track as they have, they could total in the millions.
Accountable care programs offer hospitals two options for incentives.
Hospitals can take on risk immediately, in which case they get 60 percent of any savings, and potentially face losses.
The other option, which Mercy Health has taken, allows health systems to receive a payment worth half of the money it saved Medicare during the three year trial. Mercy will decide in 2015 if it wants to continue.
“These are important learnings, and if they’re successful we can expand them,” said Frankowski.
Creating 'medical homes' at St. E., TriHealth, Christ
Other large health systems in the region including St. Elizabeth, TriHealth and Christ Hospital have taken the path of transitioning their physician practices to patient-centered medical homes.
Roughly 75 area practices, including 19 offices at TriHealth, are participating in a national pilot known as the Comprehensive Primary Care Initiative.
Collectively, the practices are getting up to $60 million more from Medicare through 2016 to improve primary care. The Greater Cincinnati and Dayton region was one of seven nationally last spring to receive grants from the Center for Medicare and Medicaid Innovation to help doctors afford more comprehensive medical care, including follow ups.
“The theory is, if we can invest more on the front end with primary care, and really engage and coordinate care, then we’ll all save money down stream,” said Dr. Will Groneman, executive vice president of system development at TriHealth.
The practices receive monthly fees that average about $20 per Medicare patient. Those incentives are matched with similar programs from large employer-sponsored plans and insurers including Humana, Anthem Blue Cross & Blue Shield or United Healthcare.
In 2015 and 2016, the monthly incentives will decrease, but doctors can share in any savings to Medicare from the experiment.
The test is entering is its second year locally, and analysts are reviewing data to determine how successful it’s been, Groneman said. “We’ve heard from large employers that it has been successful in saving costs,” he added.
Using U.S. buying power to bring broader change
Some of this has been tried before. But many of the programs were headed by health insurance companies, and even some employers.
But the fundamental difference this time around is making it pay to give better care.
Because Medicare is the single largest purchaser of U.S. health care services, the way the program chooses to pay out its benefits is followed by the private insurer market.

“To change payment policy, it literally took an act of Congress,” Brammer said. “With federal health reform, it provides opportunities to test new payment models and to scale that up in a way that will work.”

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