News
Quality: The Medical Home as Community Effort
Janice Simmons, for HealthLeaders Magazine, April 8, 2010
A collaborative ACO model is yielding clinical and financial results.
One of the first sites in the country to test the relationship involving a patient-centered medical home, value-based insurance design, and a community collaborative that includes healthcare providers, local employers, consumer groups, and payers initially got a kickstart with a rejection.
Today, this Michigan collaborative, called "Pathways to Health," has been garnering national attention because it has the outlines of the new delivery model—an accountable care organization (ACO)—that has received close attention during the healthcare reform debate. Plus, new data show that patient health is improved and money saved when it comes to using this patient-centered model to care for patients with chronic conditions.
Several years ago, Integrated Health Partners, a physician hospital organization that joins the Battle Creek (MI) Health System and the Calhoun County Physicians Organization, had been participating in a BlueCross BlueShield of Michigan's (BCBSM) Physician Group Incentive Program that financially rewarded physicians in a PPO network by addressing issues such as chronic disease management and generic drug use.
It studied the improving chronic care model developed by Ed Wagner, MD, and his colleagues at Seattle's McColl Institute, and became intrigued. "After we looked at it, we said this just makes sense. It's pretty intuitive that this is how medicine should be practiced and how patients should be engaged," says Ruth Clark, IHP's executive director.
"We started thinking about this and planning about how we might get this to happen," Clark says. Three years ago, they came across the notice of a Robert Wood Johnson program grant for assistance in improving healthcare quality. They decided to apply.
"As a PHO, we have relationships with folks at health plans. We have physician relationships. But when it came to employers, for the most part, they didn't even know that we existed," Clark says.
IHP engaged the help of Pat Garrett, the then-CEO of Battle Creek Health System, a multicare system formed 20 years ago from the merger of two local hospitals. Garrett, who often heard the refrain from local employers about what could be done to lower healthcare costs, was able to convene a panel of about a dozen employers, including the Kellogg Company and the city of Battle Creek.
They were joined at the table by consumer advocates, consumers, and health plans; a leadership team with the stakeholders was formed. Eventually, Pathways to Health was under way. But then came the bad news: It did not receive the grant it was anticipating.
"I think that was really an important moment—not getting the grant. They queried the stakeholder group about folding it up or moving ahead with their plans. At that point, they thought [the collaborative] was a good idea—we were making progress," Clark says. "They decided to move forward and see where we could go."
"Did we want to be in the front of the steamroller or under the steamroller?" says Mary Ellen Benzik, MD, IHP's medical director. "Clearly we decided to drive it."
"I think we've always understood that to transform care and make it cheaper, it's really good for the economics of our community," Benzik says. "I think we've always had in the back of our heads that this is important—the accountability to Battle Creek. We didn't want the city to die like other cities in Michigan."
"What's really cool was hearing employers vocalize the same thing," Benzik says. "What they're saying is if you don't change how much . . . we pay for healthcare in our community, we can't be sustained as employers. They saw this pathway . . . as the route to economic recovery."
To get started, the advisory council—made up of insurers and large and small businesses in the city—began meeting. So far, three employers are looking at the use of value-based insurance design: The Kellogg Co., the city of Battle Creek, and the Battle Creek Health System with its own employees.
"The collaborative model basically took the idea of networking and best practices sharing and added a third element to the planning," says Bill Greer, a compensation consultant for Kellogg. This is the use of value-based insurance design, which focuses on lower deductible rates and coinsurance on services that make a difference in improving employees' health.
Pathways to Health also has meant moving in other directions that "have just made sense to us," says Benzik. It has, for instance, emphasized a patient-centered medical home among its many small practices.
"You create the system. You create the kind of work environment that you want to be in—and the kind of relationship you want with your patient and your team while putting a whole community of support around you," Benzik says. "It's just fun watching reenergization of providers. It's fun watching physicians return to the joy of practicing primary care."
No major changes—such as reducing patient panels—were made in setting up the medical home concept. Emphasis, though, is placed on keeping accurate patient data and putting the PDSA (Plan-Do-Study-Act) process into action to see what is working and what is not. "It's just been organic—how healthcare can be and should be—but someone keeps putting a name on it," she quips.
Assisting in the move toward medical homes is a payment structure that rewards improved care. "We created a model that basically defrayed many of their costs of participation," says Thomas Simmer, MD, a BCBSM senior vice president and chief medical officer.
These physicians are compensated for lost revenue—for instance, the times they go to meetings or receive instruction. They also are "rewarded for their patient improvement and performance along the way," Simmer says. They could receive up to a 10% increase in their office visit fees—if they achieve the patient-centered medical home designation.
And while the information is preliminary, BCBSM has found that for the three years the patient medical concept was in effect, the hospitalizations "for those conditions that better ambulatory care can prevent" dropped by 40%. "It's an example of the costs that you want to take out of the system. It's not rationing care—but simply never getting sick enough to need the care that costs so much," Simmer says.
The next stage is building "around the primary care foundation" of an ACO that allows the entire system to work effectively between "fragmented parts of the delivery system," Simmer says. "I suspect that as more definitions develop nationally about what it means to be an ACO, we're going to be applying those principles in Calhoun County."
