The state is halfway through the five-year pilot program authorized by the
The program is designed to benefit consumers -- and taxpayers -- by stemming soaring health care costs and improving their health, while stabilizing the financial future of the health care system.
To keep it going, state officials and hospitals must convince primary-care practices, nursing homes, specialists and other providers to do the same -- keep costs in check while improving the well-being of patients -- by better coordinating care from the emergency room to the follow-up at your family doctor.
One way of doing this is by improving communication among providers. The duplicate tests, incompatible prescriptions and repetitive hospital visits caused by a lack of shared medical records cost billions of dollars a year nationally.
For patients, the result should be a system with fewer tests, emergency room visits and return trips to the hospital, as all the providers who treat a patient coordinate their care. But patient advocates worry that the focus on cost control could overshadow patients' needs if hospitals neglect needed care to save a few bucks.
"We appreciate the fact that they have created -- on paper -- a patient-centered model," said
So far the pilot program has focused on hospital costs, but, to keep the deal beyond 2018,
"Certainly therein lies the real experiment, and I think it's going to be difficult," said
To make it work,
As a year-end deadline approaches for the state to submit a plan to the federal
The proposal will be a blueprint for how the state will get doctors, nursing homes and other providers, who are still paid for every service they provide, to work more closely with hospitals to achieve goals for both health care costs and quality, perhaps by offering incentives. The federal agency would likely work with the state to refine the plan before it could be implemented.
Developing it won't be easy. While
The stakes for finding consensus are high. The pilot program is an overhaul of the state's so-called
In every other state,
But if the state succeeds at both controlling costs and improving patient health under the expanded program, it could become a model for other states.
"The hospital system took a big risk to buy in to it, and they bought in to it -- every one of them," said
Instead of being paid for each time a patient gets something done, hospitals receive a pool of money with which they must treat the population they serve. This shift aims to better align hospital reimbursement with what's best for patients' health.
In addition to treating illness, hospitals now have a financial incentive to help patients connect with a primary-care doctor to prevent a chronic condition like high blood pressure from becoming an emergency surgery, to set them up with rehabilitation services after a procedure, and to make sure they don't get sick again.
In theory, hospitals could make more money under this system by improving their population's health, effectively limiting how much their costs are growing.
If he were to tear the cartilage in his knee playing golf, Pollyea could go to GBMC's emergency department. Through its electronic record system, the hospital would see he'd been treated for knee pain and call that doctor. A record of the visit would be sent to his primary-care physician at GBMC and a care coordinator could check up on his recovery.
GBMC has been making changes for years aimed at improving patients' health and the quality of care they receive, while reducing costs -- what analysts call the "triple aim."
But those changes would not be sustainable without also changing the way hospitals are paid, said GBMC CEO Dr.
"If we didn't change the payment system, those of us trying to get to the triple aim could do the right thing into extinction," Chessare said.
Pollyea's doctors at GBMC are motivated to support the hospital's approach because they get paid by GBMC. But if he saw a primary-care doctor at a private practice or chose another hospital, his health care experience -- and possibly his health -- could be different.
The next phase of the state's pilot program will try to better align doctors, rehabilitation centers and others who treat patients with what hospitals have begun doing, for example, by improving their communication.
"If I take my car to the shop, it accesses my records, it knows everything that's ever happened to my car," said
To encourage other providers to embrace practices that help hospitals, such as shared record systems, the plan will likely propose incentive systems because doctors don't fall under the commission's regulatory authority.
"We're trying to get different parts of the system all working toward the same goals," Kinzer said. "We don't feel like we need to control them to make that happen."
Most doctors want to work with the state, partly because
Since doctors must get on board eventually, Ransom said, many believe cooperating with the state might help them meet these new federal requirements.
"Anyone who looks at the ledger sheet, when you see the
Access to more data could help Dr. Willarda Edwards' two-doctor primary-care practice in
"You're going to get a lot more push-back from those of us in small primary-care practices, where we can't necessarily afford all the technology that we're being asked to invest in," Edwards said. "If somebody else is going to provide that, then all is well and good. But if it's coming out of my pocket and decreasing my payments if I don't give them data, then we're at a standstill."
The expanded experiment could do more to address the high cost of treating patients who qualify for both
Many of these patients are nearing the end of their lives and have multiple chronic conditions that are expensive to treat, said
"What we stand to gain is better outcomes," Firth said. "We can do right by the patients we're taking care of."
While other providers are open to working with the state, analysts and hospitals warn that
"It's a question of patience," Franey said. "Are we an industry that understands the word 'experiment'? Are we patient enough to fail?"
What's at stake? If
Why does this matter? The program is designed to stem soaring health care costs and improve patient health at the same time, while stabilizing the financial future of the health care system.
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