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Jan. 24--Health insurer Highmark says it's proving that paying doctors more for good work leads to savings for everyone.
As a result, Highmark plans to expand its effort to turn family medical practices into "patient-centered medical homes." This involves a team approach to caring for patients, including coordinating their overall care, educating them about their illnesses and calling them to make sure they take good care of themselves.
It also involves a new level of risk for doctors -- only those who attain the desired results will receive "enhanced" payments from Highmark. However, Highmark officials say they've received virtually no negative feedback from doctors.
"What we are doing is re-empowering physicians, handing power back to them," said Dr. Paul Kaplan, Highmark's senior vice president for provider strategy and integration. "We will have happier patients. We will have happier doctors."
Highmark also says it has already proven the concept saves money. Highmark rolled out the concept last year in a pilot involving 12 medical practices which encompassed 160 doctors and 45,000 patients.
Medical costs of patients involved in the pilot dropped by about two percent, while costs increased for the rest of Highmark's members. The savings resulted from things such as nine percent fewer patients needing to be hospitalized, and a larger drop in patients having to go back into the hospital because of medical problems. The costs of patients with coronary artery disease dropped by five percent, and the cost of patients with diabetes dropped by 3.5 percent, Highmark said.
Now Highmark is expanding the effort to include more than 1,000 primary care doctors in about 100 practices involving about 171,000 Highmark members, including some in the Harrisburg region. Highmark also has stated a goal of having 75 percent of members in a patient-centered medical home setting by 2015.
Highmark, whose local operations are centered in East Pennsboro Twp., has roughly 900,000 members in the region extending from State College through the Harrisburg area and into the Lehigh Valley, plus million more in western Pennsylvania, where Highmark is based.
The medical home concept isn't entirely new. In the Harrisburg area, for example, Susquehanna Twp.-based Capital BlueCross and PinnacleHealth System began collaborating to create medical homes at Pinnacle-owned medical practices in 2010.
"We believe there is a huge return on this," said Michael Fiaschetti, Highmark's president of health markets.
It does, however, result in some up front costs for medical practices, who might need to invest in things such as computer hardware and to expand or revamp their staffs.
One of the keys is a new level of electronic sharing of information between Highmark and doctors, with the goal of giving doctors more data to help them stay on top of their patients' conditions. Another involves creating a team of doctors, nurses and others, with some team members devoted to things such as educating patients and talking to them about their illnesses, or to coordinating their care.
Under this approach, the medical practice is expected to check up on whether chronically ill patients are following through on steps such as taking their medications and getting the required tests. It becomes routine for someone from the medical practice to call patients to check up on them. Kaplan noted insurers have used the approach of calling patients such as diabetics, but it works better when the call comes from the doctor's office.
For doctors, one of the appeals of the medical home approach comes from being freed up to focus on the most difficult medical situations among the day's patients, and relying on staff members to handle more routine patient needs, Kaplan said.
HIghmark says it has been helping medical practices establish the "infrastructure" needed to carry about the medical home concept. This has involved some software purchases, but mostly providing short-term staffers, often a nurse, to help the practice make the adjustment.
Highmark also provides substantial information needed to manage illnesses in the best and most cost-effective way. While practices might need to make an upfront investment, they can recoup their costs and more as as result of the enhanced payments available for attaining the desired patient outcomes.
Highmark says the medical home approach is part of the foundation for the "Accountable Care Organizations" called for in the nation's new health care law, called the Affordable Care Act. Accountable Care Organizations, which involve medial providers from hospitals to specialists to family doctors, are another effort to encourage better coordination of medical care and reward medical providers for quality rather than volume.
More than a generation ago, the health insurance concept called "managed care" gave doctors the opportunity to earn more by lowering overall costs. But it failed to produced the desired results on a national scale, with doctors complaining they were unable to make the best medical decisions, and patients complaining they were losing access to needed services.
In describing the medical home approach, Highmark officials insist it enables doctors to earn more while also giving an incentive to provide the best medical care. Fiaschetti said quality will always be a big part of the formula for rewarding doctors.
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