Posts Tagged ‘care management’
Pay for the Health Care We Want? What a Concept!
Author : Craig Thiele, M.D.
Aug 18th, 2009 | by
“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.
Physician-Know Thy Patients!
Author : Craig Thiele, M.D.
Aug 18th, 2009 | by
So here’s an interesting story:
A doctor I work with encountered a pretty common situation with a patient. She’d prescribed an inhaler for a patient complaining of shortness of breath. On a follow-up visit, the patient said his symptoms had not changed. Normally, the doctor’s response would be increased dosage, new medication, or perhaps additional tests. But in this case, the physician had the Member Profile CareSource provides at hand, showing that the patient had not filled the first prescription in the first place. What ensued was five minutes of patient education explaining the importance of the medication, exploring why the prescription was not filled, a new copy of the prescription, and a successful treatment at no unnecessary cost.
We hear a lot about the need for digital medical records to provide complete, detailed, accessible record of treatment: they will certainly help cut costs and improve care in the long term.
But valuable as such records are, what they can’t provide is the topline overview of an individual’s health status that can help doctors when they first meet a patient or provide information for quality ongoing care…the kind of broad-spectrum profile of age, family status and other personal information, prescriptions ordered and filled, preventive screenings, previous providers, even non-medical issues affecting health and well-being.
With such a record in hand, any doctor—whether, in any emergency room, urgent care facility, clinic or private office in the U.S.—could jump-start the process of caring for a new patient, or providing quality long-term care for a current patient with a holistic picture that goes beyond the medical situation at hand.
A concise profile like the one CareSource has developed gives physicians, specialists and other providers integrated, up to date information about their patients electronically, so they can provide faster, more accurate assessments and diagnosis, treatment decisions that integrate with the patient’s other care, insights into behaviors that could affect outcomes, and potential problems that may not be presented in the office visits. All that adds up to better information, better care…and lower costs.
Care Management: Where Aggregated Patient Information Lives
The reason currently utilized personal health records, valuable as they will be, can’t do this job alone is simple: they may or may not be accurate or complete. Physician records are more reliable, but only cover care the specific doctor provided directly. They likely don’t contain information about which prescriptions were filled (and who prescribed them), what emergency room visits transpired across the state, nor important medical diagnoses from the patient’s past. Knowledge of this information can affect patient diagnosis, care and health.
But that’s precisely the information CareSource gathers using multiple information sources. We realized that the information we already have on our members could be put to excellent use by providers to the benefit of their practice, their patients, and health care costs overall.
Granted, it was no simple matter to find a way to make all this information easily available to providers. But now, CareSource Member Profiles are up and running. Physicians now have critical information at their fingertips including:
- Member demographics
- Primary care provider information
- Prior prescribing information (updated daily)
- Historical diagnoses
- Patient-specific quality metrics (such as mammography screening, A1C value, and more)
- Prior hospital admissions
- Emergency room visits
- Specialist visits
- Case management activity
It’s About Relationships, Too
What we’ve already discovered since CareSource Member Profiles have been available is that they create a virtuous cycle. Patients have a better feeling about a doctor who understands them, so they rely on that doctor’s opinion more, in lieu of using providers who are not familiar with their medical history. In addition to reaching positive outcomes, physicians with enough information can empower patients to take better care of themselves. By investing in tools physicians appreciate and use every day, CareSource builds stronger relationships with providers based on a lot more than making payments to providers caring for our members. And that means, as our nation moves toward health care reform, we will be able to work together to evolve a system that puts the resources of physicians and care management companies to their best and highest use.
As an emergency room doctor asked when we first presented Member Profiles, “why don’t all care management companies do what CareSource is doing?” The answer: I hope someday they will.
