The current revolution in how higher value health care is practiced and paid for could bring “tremendous” gains in value for patients and payers alike.
Dr. Fred Bloom, president of the Guthrie Medical Group and a family medicine physician, shared the potential “tremendous” gains from a “Practical Approach to Coordinating Care” perspective at The Alliance Annual Seminar on Aiming for Impact on May 12,2016 at Monona Terrace.
Bloom joined Guthrie Medical Group in Ithaca, NY, in 2014 after working in increasing roles of physician leadership over a 28-year tenure at Pennsylvania’s Geisinger Health System, which is known for being at the forefront of adopting new ways to deliver care.
Demand for Quality
Bloom said the health care revolution is focused on improving the quality of care for patients. The Medicare Access and CHIP Reauthorization Act (MACRA) changes the way doctors will be paid for the next 10 years. Bloom said MACRA requires physicians to improve quality by 2019 or lose significant payments.
Since Medicare provides a significant share of revenue for doctors, hospitals and health systems, health care providers are paying attention.
“We’re really looking towards alternate payment models because of the government pressure,” Bloom said.
There’s a positive side to this pressure; doctors and other health care providers “are finally getting resources and funding to take care of patients the way they always wanted to.”
Creating Sustainable Models in Higher Value Health Care
A better system for health care means creating a sustainable model that addresses all three elements of the triple aim: improved health, better care and smarter spending. At the same time, a better health care system would increase the satisfaction of doctors, since national surveys show just 30 percent of doctors are happy with their jobs.
Bloom said a primary care doctor can realistically provide care for 983 patients. Yet the average primary care doctor is asked to serve 2500 patients. Meeting all the recommended standards for their routine care would take 18 hours a day, plus another 4.6 hours a day spent to meet the needs of acute patients. In other words, there’s not enough time in the day for primary care doctors to do it all.
Instead, Bloom advocated using a team model that is directed by the primary care doctor, who focuses on managing acute care episodes and directs team members as they care for patients with chronic conditions and non-acute problems.
“It’s about the physician as team leader,” Bloom said. Team members include nurses; physician assistants; care managers; pharmacists; social workers; allied health workers such as dieticians, therapists and medical technologists; nutritionists; behavioral health practitioners; and health coaches. Telemedicine can also play a role in managing less complex issues.
Still, the sickest patients will need the help of a care manager to navigate the health care system. For terminal patients, Bloom advises “opening up the discussion” so that end of life discussions start at the beginning of treatment.
Creating patient touchpoints at critical points in the system can make a big difference in outcomes. Bloom shared the results of Geisinger studies that showed that patients fare significantly better when a care manager monitors their care.
Managing these transitions can make a difference even with low-risk patients. For example, a study of congestive heart failure patients relied on an interactive voice response telephone system at a cost of $28 per patient per month. For 30 days after leaving the hospital, low-risk patients called a telephone number and responded to automated questions by pushing specific buttons on their phone to indicate whether they had problems or questions. If needed, a care manager integrated into the doctor’s office then followed up with them.
The practice reduced readmissions by 44 percent, which Bloom said shows that even patients who appear to be doing very well sometimes need help.
Finding Higher Value Health Care
Some integrated health systems are working to help find value in health care. Bloom said these efforts must focus on quality first and then add the cost component.
In the rural area where Bloom practiced at Geisinger, for example, he could send patients to four different MRI sites. There was a three-fold difference in the cost of MRIs, yet quality of care was the same.
“It turned out I always used the highest-cost MRI in town,” which was owned by Geisinger, Bloom said. As awareness of price differences increased, Geisinger cut the cost of MRIs to remain competitive.
Bloom said doctors often need help to know who the high-value providers are. He praised The Alliance’s QualityPath program as a “tremendous idea” because it addresses both quality and cost.
Geisinger helped physician specialists learn about cost variation by showing them their data. Some doctors had cost variations that were justified by sicker patients, but others lacked a reason for higher costs.
After two years, Geisinger shared the data with primary care doctors. When primary care doctors made referrals, it became Geisinger’s practice to fill the schedules of high-value specialists first.
Health care must help “activated patients” who are engaged in their care and make it easy for them to get the right care at the right time, Bloom said. When that happens, patients and payers alike will benefit.
By using care coordination to guide patients, Geisinger pilots showed it was possible to reduce admissions by 18 percent and reduce the total cost of care by 7 percent. Bloom said a summary of Geisinger’s work published in 2012 showed that for every $1 invested in case management and similar approaches, there was 100 percent or more return on investment.
“There’s a tremendous savings and opportunity from going this route.”