Reducing costs through better care collaboration

For the past several decades, the U.S. healthcare system has rewarded the provision of high-volume, specialized patient care—and, as a result, we have seen costs skyrocket and our collective health suffer.

By contrast, the patient-centered medical home (PCMH) healthcare delivery model is a collaborative, team-based approach with the primary care physician (PCP) at its nexus. With financial and clinical risk shared among providers and health plans, it has the potential to not only improve care, but also to contain costs.

If there is one thing the healthcare industry has learned, it is that chronic illness drives high costs. Chronic illness often is rooted in poor preventive health habits and is responsible for a large portion of patient encounters in the current delivery system. In fact, some 70 percent of deaths in the United States are the result of preventable conditions, generally caused by diet, lack of exercise, smoking, and obesity.

Take, for example, the many diabetic patients who suffer from multiple co-morbid conditions. Under the current highly fragmented healthcare delivery system, they often receive care from several different physicians. With no collaboration among providers, these patients are subject to gaps in care, redundant testing, and greater exposure to medical error.

By contrast, the PCMH model offers financial incentives for PCPs, specialists and healthcare plans to share their data—thereby avoiding redundancies and identifying gaps in care before they result in hospitalization and emergency room visits. A 2009 study of a PCMH pilot in Seattle showed that after one year, patient ER visits declined by 29 percent and hospitalizations dropped by 11 percent versus a non-PCMH control group.

One of the most powerful elements in PCMH is the fact that patient health is the first priority for providers and health plans. Even some employers are getting involved, offering and sometimes mandating proactive programs—exercise, incentive rebates, or free prescriptions for chronic disease—because they have come to realize that it is to their benefit. The bottom line is that healthier employees make for a more productive workforce and lower insurance costs.

Wellness programs aren’t new, but new accountable care models like PCMH have the power to make them more effective, with more patient stakeholders invested in their positive change. Ultimately, lower costs will come when financial and clinical incentives spur providers and payers to hold patients accountable for the kinds of behavioral changes that lead to better health.

So how do we get there?

Using technology as a bridge

Collaborative healthcare can only work if interoperable technology supports bi-directional real-time patient data exchange. With a great deal of patient information at their disposal, health plans are in a unique position to bring the industry into the Information Age by:
 
•    Making the initial investment in technology—such as electronic health records (EHRs), e-prescribing, and electronic patient registries—to help providers have the solutions in place needed to participate in collaborative care;
•    Monitoring and measuring financial and clinical results; and
•    Recognizing that PCMH is a proactive approach that may take a little time to pay off—both clinically and in dollars and cents.

The data is here now. Our challenge is to find ways to share it among insurers, primary care providers, specialists, and patients. Integration among health plan data and multiple EHRs, as well as other data sources using common technology standards to support bi-directional data exchange, will allow providers to proactively:
 
•    Assess care needs for their members;
•    Monitor medications, tests, and treatments; and
•    Report back to health plans regarding patient health status. 

The next hurdle we must overcome is patient engagement, especially among underserved populations such as Medicaid patients. At the heart of the PCMH concept is the idea of individual responsibility. Patients must take responsibility for their own health, but in collaboration with providers who offer education and monitor compliance.

Again, technology may offer some solutions. Imagine the possibilities of a smart phone application that could remind diabetic patients to test for blood sugar and then relay the test results directly to the patient’s PCP. With more than 90 percent of Americans using mobile phones, it has great potential as an intervention tool.

PCMH models also must align financial incentives between providers and healthcare plans to make them accountable for patient health. When it is in everyone’s best interest to do the right thing—safeguard individual health—the system will be clinically and financially successful.

Aligning cost and quality of care

For many years, personal physicians have been on the periphery of a specialized, fragmented, and confusing healthcare system. In the PCMH model, PCPs resume their position at the forefront of the healthcare team, making referrals to specialists, closing gaps in care, and reporting back to health plans about results to PCMH goals, population health statistics, and other metrics that support collaborative care.

Leading edge, data-driven technologies now make it possible to monitor outcomes and reveal which physicians are providing responsible, comprehensive care—and to reward them financially for doing so.

Technology is the key to enabling communication among providers, aligning incentives among providers and health plans, and engaging patients in their own care. By harnessing these capabilities, the PCMH model shows tremendous promise. If we give it time to deliver on that promise, we will be well on the way to achieving higher-quality patient care at lower costs.

Meghan Oates-Zalesky is Senior Director, Solutions Marketing at NaviNet.