As he begins to shape an agenda for the next four years, President-elect Donald Trump has vowed to replace President Barack Obama’s signature Affordable Care Act, which has become prohibitively expensive for many.
That, of course, begs the obvious question with what?
While the answer is still on the drawing board, Trump has already indicated that his administration’s goal is to “create a patient-centered health care system that promotes choice, quality and affordability.”
While that hardly constitutes a definitive plan, the mention of patient-centered health care offers a glimpse into something physicians, hospitals and insurance companies have already been working on and refining for several years.
Last month, Blue Cross and Blue Shield of Georgia reported encouraging results from primary care doctors in Savannah who have been participating in the company’s value-based, patient-centered program for the last three years.
BCBS of Georgia’s Enhanced Personal Health Care launched in July 2013 and currently covers more than 200,000 patients in coordination with more than 1,200 physicians.
How it works
Participating practices most of them primary care offices receive up-front care-coordination payments each month from the insurance company to offset the cost of the additional work required to adopt a patient-centered care model and effectively manage care. They also receive information and insights gleaned from insurance company data that help them better manage patient health.
Those practices that succeed in maintaining or improving quality of care and hit their cost-of-care targets earn bonuses in the form of a share in the savings they deliver at the end of a 12-month measurement period.
But the plan benefits more than just practices and insurance companies.
Resources designed to ensure better patient care include data that enables providers to target members with chronic conditions or gaps in care – such as prescriptions that have not been filled or missed medical testing, as well as a system to flag members at risk for readmission to the hospital.
Already, the program is delivering results.
Statewide in 2014, participating primary care physicians delivered a 2 percent higher rate of care for diabetic patients, including screening for kidney disease and monitoring blood sugar levels, helping to prevent amputation and other complications of living with diabetes; a 3.5-percent better rate of cervical and breast cancer screenings; and a 4.5-percent increase in patients taking their cholesterol, blood pressure and diabetes medications as prescribed.
Locally, participating practices including SouthCoast Health, Memorial Health, University Physicians, St. Joseph’s/Candler Medical Group, Pediatric Associates of Savannah and Family Health Care Center in Statesboro have shown promising changes in patterns of care that have helped trim spending without compromising and often enhancing quality.
What it does
Angela Kaylor manages three physician practices for Memorial Health.
“Health care is evolving,” she said. “Everyone’s looking at quality data, quality measures. And we’re becoming more focused on keeping people healthy, becoming more of a proactive, rather than reactive practice.
Kaylor said Memorial is working with a number of insurance companies, although Blue Cross, Blue Shield was the first to introduce a patient-centered care program.
“The goal is to reduce costs while improving quality, patient outcomes and patient satisfaction.
“And it’s working,” she said. “We’re very proud of this program.”
Engaging patients in their own health care is a critical component of the program, Kaylor said.
“Take diabetes, which is as huge problem in this area,” she said. “We teach patients about their diabetes, why we do blood tests, why they need to get their feet and eyes checked and pay attention to their diet. But this program allows us to take it one step further by letting us know who hasn’t had their annual eye exam, for example, so we can call them and get them in and close that gap.”
The healthier people are, the less their health care is going to cost, she said
“That makes it a win for everyone.”
Savannah pediatrician Dr. Ben Spitalnick agreed.
“The healthier a patient is, the fewer medical services they need. If you can take a child and help them control their asthma, they’re going to be healthier as adults,” he said. “If you can help a child control his or her weight, they will be less likely to develop diabetes later on. If you can make sure a child gets all their immunizations, they’re less likely to catch diseases later on.
“So, what insurance companies have learned is if they get into the business of helping patients manage their health, not just their manage their insurance, they are going to have patients who are healthier as adults.”
Spitalnick said the program reaches out to his office when they have members who have specific health conditions but aren’t getting the services they need for that condition.
“The insurance company knows, for example, that an average asthmatic patient has to fill their prevention prescriptions every few months,” he said. “This is usually a compliance issue, because patients with chronic conditions don’t always think about taking their meds when they feel good.
“The same goes for diabetic patients and testing. So, if we are able to catch those things before a problem arises, it’s a big help.”
Improving communication
Dr. Thad Riley owns Family Health Care Center in Statesboro.
“We asked to be involved early on,” he said. “What’s great is they have the software that identifies what we call ‘hot spotters,’ to see who’s going to the emergency room when maybe we could have kept them out of the ER. Or, if they go into the hospital, it lets us know when they are released to we can set a follow-up visit and to possibly keep them from having to go back.
“It keeps us informed so we can be more proactive.”
Riley’s practice also has adopted another program that is focusing in on key indicators of chronic disease management, combining teamwork and information technology to improve care, avoid duplication of services and reduce costs, he said.
The office, which includes three doctors and three nurse practitioners, was one of the first in south Georgia to be designated a certified Level 3 patient-centered medical home.
A “medical home,” according to the National Committee for Quality Assurance, is a medical office or clinic where a team of health professionals work together to provide a new, expanded type of care to patients. Having a medical home feels like having an old style family doctor, but with a team of professionals, using modern knowledge and technology, to provide the best possible care in their office.
St. Joseph’s/Candler on board
It’s an idea that St. Josephs/Candler Medical Group has embraced, with its Eisenhower practice receiving NCQA Patient-Centered Medical Home recognition for using “evidence-based, patient-centered processes that focus on highly coordinated care and long-term, participative relationships.”
Each patient’s care is overseen by clinician-led care teams that coordinate treatment across the health care system. This team might include a physician, nurse, medical assistant and a care coordinator, as well as other health care professionals, like a pharmacist or physical therapist. The primary care physician keeps up with each case to make sure the whole team is communicating on the plan.
Research shows that medical homes can lead to higher quality and lower costs, and can improve patient and provider reported experiences of care, said Katie Gingrich, quality manager for St. Joseph’s/Candler Medical Group.
“The medical home program is helping us improve overall quality of care as well as continuity of care across the continuum,” she said.
“We use electronic medical records to help coordinate your care, so that you don’t have to repeat the same information with each health care provider. The goal is to make sure that everyone is on the same page when it comes to your care,” Gingrich said, adding that the various team members are like having “health coaches who help you get healthy, stay healthy and get the care and services that are right for you.”
St. Joseph’s/Candler also participates in the BCBS Enhanced Personal Health Care program.
“Blue Cross Blue Shield was one of the first commercial payers to move toward quality-based care tailored to the patient’s own medical needs,” she said. “Other commercial insurance companies are going in that direction, but BCBS remains by far the most in-depth program.”
Staying independent
While many doctors feel the uncertainty of the future makes it a scary time to be practicing medicine, Riley said it’s also an exciting time, with so much happening in the realm of data collection and other tools.
But, he said, independent physicians need the resources the insurance companies offer.
“There is no way an independent physician group can keep up with all of this on their own,” he said. “Programs like Blue Cross’s are critical in helping independent physicians stay independent.
“That’s an aspect of health care we do not want to lose.”
Date: November 21, 2016