Filed under: Accountable Care Organizations, Medical Homes
In The Quiet Health-Care Revolution, an article by Adrian Slywotzky and Tom Main in the November issue of The Atlantic, the authors tell the story of CareMore, a for-profit company serving more than 50,000 elderly patients through 26 care centers located in Arizona, California, and Nevada. Founded by Sheldon Zinberg, a gastroenterologist, CareMore was originally a group physician practice but it has since become a Medicare Advantage managed care plan. As such, it is paid a capitated, risk-adjusted rate for each patient it serves, giving it a financial incentive to hold down costs. Slywotzky and Main report that, through an emphasis on care coordination and creative “upstream” interventions, CareMore has improved outcomes, held down costs, and stayed in the black.
Each CareMore patient has a personal physician, called an “extensivist,” who ensures, with the help of an electronic medical record, that all of the members of the patient’s care team are communicating and coordinating with one another. The extensivist is also charged with ensuring that the patient understands and is able to comply with his or her treatment plan. One of Dr. Zinberg’s early decisions was that “noncompliance is our problem, not the patient’s.” As a result, among other things, CareMore provides its patients with free-to-them transportation to medical appointments.
Going hand-in-hand with CareMore’s emphasis on coordination is a focus on “upstream” interventions. For a patient with congestive heart failure, a wireless scale transmits the results of her daily weigh-in to a clinic allowing fluid build-up to be caught early. For a frail patient, “light muscle-training sessions and periodic toenail clipping” reduce the risk of falls. And for a diabetic patient, aggressive treatment of a cut foot reduces the risk of infection and amputation.
How does all of this impact quality and cost? Slywotzky and Main report that:
“CareMore, through its unique approach to caring for the elderly, is routinely achieving patient outcomes that other providers can only dream about: a hospitalization rate 24 percent below average; hospital stays 38 percent shorter; an amputation rate among diabetics 60 percent lower than average. Perhaps most remarkable of all, these improved outcomes have come without increased total cost. … CareMore’s overall member costs are actually 18 percent below the industry average.”
As with other, better known providers like the Mayo Clinic, whether the CareMore model is scalable is a question, one that may be answered in coming years because the company is growing and is likely to grow more after its purchase in August by WellPoint.
In a recently-released study conducted for AHIP–the industry group representing health plans–Kenneth Thorpe makes the financial case for enrolling more individuals, in particular those who are eligible for both Medicare and Medicaid, into health plans like CareMore that employ a coordinated, team-based approach to care. As Thorpe explains, so-called “dual eligibles” are among the most chronically ill and therefore expensive of all patients, accounting, despite their relatively small numbers, for “36 percent of total Medicare spending and 39 percent of Medicaid spending.” In 2011, Thorpe writes, “the federal government–through Medicare and Medicaid–will spend over $230 billion on dual eligibles.” Currently, “[f]ewer than 2 percent of dual eligibles are enrolled in a coordinated care program that managed all Medicare and Medicaid covered benefits.” Thorpe projects that if all dual eligibles were required to enroll in such a program, the federal government would save up to $125 billion and the states up to $34 billion over the next ten years.
Achieving better alignment of Medicare and Medicaid for the benefit of dual eligibles is not without its complications, of course. Yesterday, AHIP issued a proposal reviewing key differences between the programs-including the nature and scope of covered services, eligibility and enrollment rules and procedures, provider networks and access requirements, and beneficiaries’ right to information and to appeal-and recommending ways to eliminate or work around them. Among AHIP’s recommendations is that “States be given opportunities to share with the Federal government and with health plans, as appropriate, in savings generated through increased integration.” As it stands, “it may be difficult for States to justify State investment in efforts to generate such savings, for example through programs intended to decrease acute hospitalizations or increase reliance on Medicaid-covered [i.e. partially State-funded] services.”
Filed under: Chronic Health Conditions, Medical Homes
Health reform’s primary beneficiaries will be the uninsured, but it should also benefit those with “good” insurance. We all know horror stories of well-insured relatives and friends driven from pillar to post in attempts to get good treatment for serious chronic conditions. It too often seems that no one is in control: doctors aren’t paid to talk to patients, but rather to do things to them, and the roles of other professionals (e.g., advanced practice nurses) are sometimes minimized. As I’ve described earlier, there is some good news regarding medical practice reform in the bills, particularly for people with Medicare or Medicaid.
How do we get people into medical settings where their chronic conditions can be well-managed? Interesting work is being done in many quarters on this issue. In a recent Health Affairs paper, Steven D. Pizer and coauthors reported that people with chronic conditions in regions of the country with thin Medicaid programs are likely to be uninsured, notwithstanding Medicaid’s strong orientation toward disability and chronic care. In a companion article, Andrew P. Wilper and coauthors reported on high levels of uncontrolled — often undiagnosed — chronic conditions (hypertension, diabetes, and elevated cholesterol) among people without insurance. Public insurance expansions in pending reform bills would assist these low-income people with chronic illness get coverage, and the chronic care provisions have the capacity to provide appropriate medical management of their most pressing conditions.
Structure is emerging on best practices for the delivery of sound coordinated care. The NCQA has worked with physician groups to create tools to evaluate practice settings according to their ability to serve as therapeutic homes for all, but in particular for those with chronic conditions. The Physician Practice Connections – Patient-Centered Medical Home program provides tools for public and private payers to evaluate a physician practice before designating it a “medical home” – and compensating it accordingly. The tools evaluate prospective medical homes on factors such as their active support of patient self-management; use of non-physician staff for patient management; employment of procedures to maintain high levels of patient communication; and adoption and use of evidence-based care management protocols for chronic illness.
So how much does it cost to do this right? A recent study from Commonwealth Fund sheds some light on this complex issue. In the study, Stephen Zuckerman and coauthors take on the difficult task of examining the marginal cost of converting a 20th Century practice to a 21st Century medical home. It makes interesting reading, and tentatively suggests that the cost could be modest. Zuckerman et al. are attempting to compute cost. They recognize that cost is only a component in a more important calculation: what is the value of creating medical homes? They cite to a 2008 Deloitte report that gathers research tending to show that the cost is probably worth it, even in purely economic terms. That is, it appears that the savings achieved in avoided hospitalizations and other expensive interventions is significant, washing out the cost of supporting sound chronic care management. It is not, of course, only about efficiency; ending the chronic care horror stories is the true goal.
Expanding insurance is only the first step in delivering the care people need. For people with chronic illness, the finance and delivery system needs to work with the whole person, family, and community, and not slice the patient into 8 minute blocks and procedure codes. A consensus statement of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association describes a commendable principle of care coordination that has particular application for people with disabilities and chronic illness:
Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
Practice follows payment. Payment reform must facilitate the adoption of practices that serves chronic needs.
Director, Center for Health Law Studies
Chester A. Myers Professor of Law
Saint Louis University School of Law
Senator Baucus’ March 3 press conference sponsored by the Kaiser Family Foundation Health Care Reform Newsmaker Series: Sen. Max Baucus (D-MT) offered a few insights into the early state of the debate on health reform legislation.
Two points stood out. First, he observed that “delivery reform” was for him a central element in designing reform legislation. Pressed to define what he meant, Baucus mentioned value based purchasing and the medical home concept. Second, he stated that the tax exclusion for employer health insurance payments was on the table, noting two characteristics that make it an appealing target: regressivity and potential source of considerable “revenue.” On these and other issues, Baucus stressed the critical role OMB scoring will play in shaping the ultimate design of the legislation.
The known unknown here, however, is how some of the relatively novel delivery reforms like medical homes will be defined and implemented — and hence ultimately scored by OMB for their impact on system costs. One problem is that the “medical home” may encompass a wide range of delivery/financing arrangements. In general the medical home has been broadly defined as a physician-directed practice that provides care that is “accessible, continuous, comprehensive and coordinated and delivered in the context of family and community.” But as Bob Berenson and colleagues pointed out in Health Affairs last September, few primary care medical practices are close to having the size, management capabilities and infrastructure (electronic and otherwise) to function as medical homes. Transitioning to such practices (even on a virtual office basis) will surely take time, money, and a sea change in culture and practice style. Estimating the pace and effectiveness of such change may prove as daunting as projecting next months Dow Jones average.
 Robert Berenson et al., A House is Not a Home: Keeping Patients at the Center of Practice Design, 27 Health Affairs 1219 (Sept/Oct 2008)
The NY Times reports that according to Dr. Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and an associate professor at the Harvard School of Public Health, “there’s a drastic decline in the number of geriatricians – and just 300 new ones are being trained each year – yet the number of people over 65 will double in the next 20 years. Those who work in geriatric care are among the worst paid in the health care system.”
That last statement, as shown in a recent post regarding physician compensation, is backed up by numbers. According to the American Group Medical Association (AMGA) the median compensation for a geriatrician is $179,344. The median compensation for a podiatrist is $180,080. These AMGA numbers have been approved by the Center for Medicare and Medicaid Services (CMS) for use in CMS related calculations.
Dr. Gawande “and others see a pressing need for new approaches to keep aging patients as healthy as possible and living independently as long as possible.” The Times reports that “Dr. Chad Boult, a geriatrician at Johns Hopkins School of Public Health in Baltimore, says the goal should be care that is well coordinated, and patients and families who are involved in and educated about the care plan.”
To that end, Dr. Boult is participating in the testing of a “team approach” which is somewhat reminiscent of the subject of a recent post, Alaska’s Southcentral Foundation’s “medical home” approach. Southcentral’s “comprehensive” health care strategy has shown some promising results. The Times reports that
Dr. Boult is involved in testing a team approach, in which nurses trained in geriatrics are helping physicians in the Baltimore-Washington area provide coordinated care for 50 or 60 of their highest-risk older patients. The nurses go to patients’ homes, develop comprehensive care plans, help the patients in self-monitoring, help them overcome obstacles to self-care and connect patients and their families to community agencies.
According to geriatrics experts, social workers trained in the problems of the elderly can also participate by performing home assessments, for example, to prevent falls and costly, disabling fractures. They can help overcome barriers to good nutrition, and they can help make the community connections for assistance with the activities of daily living, like shopping.
Dr. Boult said that “The Baltimore team project has already demonstrated an improvement in the quality of care that ailing elderly patients receive, and by keeping patients out of the hospital, he expects it will save money for insurers like Medicare.
The NYTimes also reports, however, that the current fee for services compensation scheme has not yet been structured so as to provide monetary incentives for such prophylactic care. The Times states: “While current insurance systems pay many thousands of dollars for hospital-based care, they cover only a fraction of the far less expensive care delivered by doctors and nurses that can keep patients out of the hospital,” and that experts say “a new model of care is needed.”
Read full article here.
A recent piece in the Anchorage Daily News highlights some health care successes worth noting. Southcentral Foundation serves the medical and other needs of Alaska Natives. Its network includes a primary care clinic and some specialty services and it jointly runs the Alaska Native Medical Center with the Alaska Native Tribal Health Consortium.
Southcentral’s approach is one version of the “medical home” model that is said to have piqued the interest of members of the Obama administration. It is a “comprehensive” approach to health care which distinguishes acute and traumatic maladies from chronic conditions. The Southcentral system is premised on the belief that the “mechanical-repair model” (it’s broke, let’s fix it with a procedure and/or medication) “is great if you are in an accident and need trauma care….But the vast majority of health care deals with chronic conditions and the fallout from behavioral choices people make.”
For these chronic issues, Southcentral offers a team which “includes a doctor, nurse, and case manager, as well as access to a nutritionist, traditional healers and a behavioral counselor,” and “follow-up services – pharmacy for drugs, labs for testing – are right on the same campus, making access easy.” Southcentral’s Karen McIntire has stated that “70 percent of primary care does not require a doctor,” and that “In our system, who you see depends on what you need.” The Anchorage Daily News reports that “With this comprehensive approach, Southcentral reports major changes for the better. Writing in the January 2008 issue of Family Practice Management, CEO Gottlieb reported that emergency room and urgent care visits have dropped by more than 40 percent, while use of specialists fell 50 percent and the number of hospital days shrank by 30 percent.” Read full story here.