As Payers Adopt Coordinated Care Model, Results Suggest Everyone Wins

Dr. Cliff Bleustein
Dr. Cliff Bleustein

Guest post by Cliff Bleustein, M.D., M.B.A., chief medical officer, Dell Services.

For decades, reimbursement for the time spent coordinating care and keeping people healthy has been mostly non-existent. But the tide is turning, as government and private payers see that coordinated care and the time spent keeping people healthy can lower the amount of money they spend treating illness.

Primary care physicians are even seeing higher reimbursements in some areas. For example, beginning in 2011, CareFirst BlueCross BlueShield, the largest insurer in the Washington, D.C., area, substantially raised reimbursement rates for general internists and family practitioners who adopted the medical home model, which emphasizes care coordination. They also rewarded them with significant bonuses if they met quality standards and reduced costs. They also provided the physicians with round-the-clock nursing assistance to help with their sickest and riskiest patients.

CareFirst CEO Chet Burrell said in news reports that the program is saving “hundreds of millions of dollars in accumulated, avoided costs.”

Government payers are also reaping benefits from coordinated care, including Medicaid, Medicare and the Veteran’s Administration.

That’s good news for everyone. Coordinated care requires an upfront-investment in people and technology that is often beyond the resources of a primary care practice, but it is far less expensive than the business-as-usual, uncoordinated care that has seen costs rise at double the rate of inflation for most of the past two decades. If public and private health plans make that upfront investment, paying for the time and the needed resources, they can reap the financial benefits while patients reap the benefit of better health.

So what is coordinated care? It’s a system of resources, technology and information that the primary physician uses to provide the most appropriate care for each patient. The way a patient wants to experience healthcare depends on individual needs that vary over time, so having multiple delivery methods is an important aspect of coordinated care. Beyond face-to-face visits with the primary physician, options should include nurse practitioners or physician assistants, health coaches and social services, retail and urgent care clinics, phone, email, text and video conference communication. This allows the coordinating physician to offer the most effective and cost efficient option for each patient.

To date, the strongest evidence of the efficacy of coordinated care is in the management of four major disease types: congestive heart failure, diabetes, stroke and depression and other mental illnesses. Most of the patients in these groups have complex needs, and they have a high rate of hospitalization if their care is ineffective. Care coordination helps avoid many of the complications that lead to hospital stays. Generally, coordinated care improves medication compliance and helps avoid the problem of multiple physicians prescribing multiple drugs without knowledge of what other medications the patient is taking. It also martials the necessary social and support services to help the patient stay healthy. By ensuring that the patient gets the appropriate services, care coordination reduces the major driver of cost for these groups – hospital inpatient days.

A large component of care coordination is access to all the necessary data. Fortunately, the technology now available gives physicians much better access to the data they need. While adopting electronic health records has been a big challenge for many physicians, EHRs reduce the effort needed to track patients’ care. For example, EHRs can be used to easily sort the data to find out which patients in a practice have had immunizations and preventive care and which need reminders. And new, cloud-based options are proving easier to manage and less expensive to operate, as well as facilitating data exchange.

As hospitals work to integrate physician and hospital EHR data, physicians are getting a more complete view of treatments, medications prescribed and other data that was difficult to obtain in the age of paper records.

Physicians and hospitals are also harvesting data from new sources, such as social media and wearable devices that can send biometric data over the Internet. For chronic care patients, remote biometric monitoring and telehealth visits are proving very good at preventing the development of crisis situations that result in emergency visits or hospitalization. They also are effective at engaging people in their own care and helping them better understand the connection between what they do and how their illness responds. That understanding leads to better compliance with recommended treatment and fewer days in the hospital.

Coordinated care is also effective at preventing hospital readmissions. A small study of post-hospital care for congestive heart failure patients provided biometric monitoring and telehealth visits to 12 patients and usual care to another 12. There were seven readmissions in the control group, while only one readmission in the study group.

As more public and private health plans see the value of coordinated care, we’ll all benefit through lower costs, better access and better health outcomes. It’s a realistic prescription for what ails the U.S. health system.

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