“The Status Quo is Not an Option.”–Barack Obama

Most people agree with the President that the health care system has to change.  If we want people to be healthier and use health care efficiently, it’s just upside down to pay doctors primarily for treating people when they’re sick.  We need to turn this irrational arrangement on its head…but in a way that keeps doctors whole while they keep patients well.  We know what we want. All we have to do is get serious and pay for it.

CareSource Has a Solution that Works for Members and Providers

It’s not as if either our members or the physicians we work with are any happier with the status quo than the President is. But so far, no solution has worked well for everyone concerned—no one has found a way to balance access, quality, and cost.

In our role as care coordinators as well as payers, however, we at CareSource have realized we are ideally positioned to perform reconstructive surgery on the broken system, making effective doctor patient relationships financially possible, changing focus from treatment to outcome, and providing resources that help each medical practice become a true ‘health care home’ for its patients.  That’s why we’re piloting a bold new approach; it’s a big up-front investment, but it’s good for doctors and patients alike.  Ultimately, that’s good for us, too.

Here’s our 4-part plan:

One: help the patient trust that their doctor is truly there for them, and even more, empower them to take a responsible role in their own health.

When CareSource members meet their Primary Care Physician for the first time, they’ll get a simple written agreement—a “contract,” that they and the doctor both sign. The doctor will provide realistic, responsive access to quality care. The patient will follow instructions, check back with the doctor with questions and call that doctor first when an urgent situation arises. In addition to building the relationship, this approach has been shown to reduce no-shows by 50%.

Two: help the practice change its approach to primary care

It takes extra staff and hours to fit patients in as needed, to follow up on instructions and medications, to provide wellness education, to focus on outcomes rather than treatments. It takes extra time just to talk to patients as much as they need. Providers participating in this CareSource program have agreed to do all that and more for our members, because we are paying them extra fees for two years to cover the costs of a complex transition.

Three: change our own approach to care management!

Strange but true: we are actually changing our own practices to make things easier for providers and members alike. One of the most significant innovations is to assign case managers to the provider practice, rather than the individual patients So our providers will have a dedicated resource to help them connect the dots on the members’ care, reaching out to social services, carefully reviewing the records for difficult and chronic cases and to alert providers to any anomalies, redundancies or challenges that apply.  Our new Member Profiles will play a role here, too.

Four: transition to payment for outcomes

We’re giving our docs time to adjust and staff for this new way of doing things while they are still paid the old-fashioned way. But after that, they’ll be paid for outcomes. When well-child visits go up, or E.R. visits go down, when blood pressure, blood sugar or cholesterol are under control, doctors will earn more. So the incentives are for better care instead of just more.

Sounds Excellent:  But There’s a Problem

The CareSource restructuring of provider service and payments activates the best and highest use of each participant: physicians are empowered to provide the best possible care for their patients…and care management keeps the wheels turning and the process organized.  What could be better than that?

From the physicians’ point of view, actually, it could be lots better.  We are hardly the only plan they work with, but we are one of the few that pay for outcomes and support a transition—complicating the business of running a practice   We’ve done what we can to help the whole system change, by structuring it around national HEDIS standards, so other companies potentially could participate.

We’re making as good a start as possible on our own turf.  How to help the system change in similar directions is the great question of the current debate.

CareSource is among the largest non-profit, public sector health plans in America with a scalable model ideal for health care reform.

One Response to “Pay for the Health Care We Want? What a Concept!”

1. Dan says:

   September 15, 2009 at 1:40 pm

   I like Caresource’s plan to pay MDs based on outcomes, and the companies strategy. The truth is that Caresource or government run insurance is not the biggest problem in health care.

   Take my family for instance; me and my wife both work full time and we have a 4 year old son. We pay over $400 a month for insurance through UHC. This does not seem like insurance since I have to pay over $3000 out of my pocket to pay for what my insurance dosent pay of a simple colonoscopy and endoscopy. I HAVE TO PAY $3000 TO BE DIAGNOSED WITH ACID REFLUX! Plus my 4 year old had ear tubes and a adenoidectomy. Why did we have to pay like $1500 for that too.

   Bottom line is that an employer can give someone health insurance, or you can buy health insurance…but if the insurance doesnt pay for anything or even give you a reasonable discount whats the point. This will break my family, AND WE HAD COVERAGE!!

   EVERYONE SHOULD HAVE ACCESS TO FREE HEALTH INSURANCE LIKE CARESOURCE REGARDLESS OF SOCIOECONOMIC STATUS

Author : Craig Thiele, M.D.

Chief Medical Officer, CareSource Over 16 years of clinical leadership experience with a strong background in case and disease management. Oversees clinical and quality initiatives at CareSource and manages medical policy, clinical care guidelines, utilization parameters, and quality assurance for its health plans.