Medicine must take the leap into health
The U.S. health care business is going through one of the biggest transformations since parents gave doctors chickens for delivering babies.
For most of our country’s history, doctors have been smallbusiness people, collecting fees for services ranging from setting a bone to treating an infection. The more services a doctor can perform a day, the more he or she gets paid.
Anounce of prevention, though, really is worth a pound of cure. Chronic illnesses like diabetes, obesity and heart disease account for 86 percent of U.S. health care spending, according to the Centers for Disease Control. The best way to reduce health care costs is to prevent disease, not treat it.
That means overhauling the fee-for-service system that most insurance companies and doctors rely upon. The Affordable Care Act took a big step in 2012 when it began paying doctors to keep patients healthy by joining accountable care organizations, or ACOs.
The nation’s most successful ACO is operated by Houston’s Memorial Hermann Health System, which has signed up doctors of all specialities to create a coordinated team that uses its facilities. The ACO then negotiated with Medicare or a private insurance company to treat a certain group of patients.
The two sides used insurance claims data to predict how much it would normally cost to treat that group of patients for a year, and they agreed to split whatever savings the ACO can generate by reducing waste, increasing efficiency and preventing illness. If the ACO spends
“We’ve started to predict who is at risk of developing diabetes and have started to target our programs around them.” Dr. Ni sh ant An and, Memorial Her mann
more than expected, it eats the losses.
Memorial Hermann’s ACOsaved more than $89 million in 2015 while caring for 50,055 elderly patients and earning a quality score of 96 percent, according to the federal Centers for Medicare and Medicaid Services. Memorial Hermann has been the top-rated ACOsince it started operating three years ago, saving Medicare close to $200 million. Medicaid pays ACOs 50 percent of the money saved, as long as 33 measures of quality remain high. Last year, 392 ACOs nationwide saved Medicaid $466 million.
And ACO’s success begins with analyzing each patient’s health records and insurance claims data and then establishing protocols that prioritize the patient and use evidence-based treatment plans, said Dr. Nishant Anand, physicianin-chief for Memorial Hermann’s Physician Network.
“It’s about providers and physicians, who know what the right thing is to do, coming together and coordinating care and trying to transform health care,” he said. “Thirty percent of what’s spent on health care is considered waste — well, we can fix a lot of that, because 10 to 15 percent of that is the duplication of tests.”
Talk to patients about cutting costs, though, and they immediately assume doctors are rationing care. But Anand says the longer it takes patients to get better, the more services they will use and the more it will cost. The best treatment is the cheapest, he said.
“We’ve started to predict who is at risk of developing diabetes and have started to target our programs around them,” Anand said. “If I can reverse the effects of diabetes, each year that I can improve their well-being is going to have a lot of savings 10 or 15 years down the road.”
ACOs try to wrap each patient with all of the services he or she needs, whether it’s a doctor, hospital, testing center, social worker, nurse or a specialist who simply reminds patients to take their medicine or keep their appointments.
Carol Robicheaux, 70, enrolled in Memorial Hermann’s Medicare ACO after she was hospitalized for pneumonia and congestive heart failure. Her doctors set her up at home with a device that was remotely monitored at Memorial Hermann.
“Myblood pressure would go up, but then a nurse would call me. Sometimes my cardiologist would call me,” she said. “They arranged for me to go to a wellness program ... to exercise where everything was monitored, and there would be a feed through to mydoctor.”
Robicheaux found that her doctors ordered fewer tests, scheduled fewer appointments and she didn’t need to explain to each doctor or nurse what the others had told her.
Making sure patients like Robicheaux don’t require readmission is a key quality metric, but also allows the ACOto accept more patients. Increased volume makes up for lower revenues from the cost cutting, explained Chris Lloyd, CEOof Memorial Hermann’s ACO.
The biggest challenge is creating the infrastructure that makes it possible for 200 employed doctors and 1,800 independent physicians to coordinate care for 50,000 patients.
“Our IT systems are a very expensive proposition, but it becomes directional for us, it directs our physicians,” he said.
Doctors regularly complain about computers intruding into the exam room, or the challenges of learning a new system. Patients always worry about getting shortchanged. But with costs and insurance premiums rising faster than incomes, we need a better system.
Scaling up the ACO model will be hard, both in terms of upfront costs and creating a new culture. They can only succeed by earning their patients’ trust. But modern medicine has moved beyond simply responding to injury and illness to focusing on preventing them, and that’s how health care providers must be rewarded in the future.