Real World Health Care Blog

Tag Archives: HCR

(Medical) Home is Where the Care and Cost-Savings Are

The word “home” has many connotations: the building in which you live, the place you come from, and even the end point of a game. Now, there is a new type of home: The Patient-Centered Medical Home (PCMH).

Linda Barlow

Linda Barlow

PCMH is a model of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible and focused on quality and safety. It has become a widely accepted – and cost-effective – model for how primary care should be organized and delivered, encouraging providers to give patients the right care in the right place, at the right time and in the manner that best suits their needs.

“The magnitude of savings depends on a range of factors, including program design, enrollment, payer, target population, and implementation phase,” explains Michelle Shaljian, MPA, Chief Strategy Officer of the Patient-Centered Primary Care Collaborative (PCPCC). “Most often, the medical home’s effect on lowering costs is attributed to reducing expensive, unnecessary hospital and emergency department utilization.”

When the Affordable Care Act (ACA) was signed into law in 2010, medical homes got a boost because of numerous provisions that increased primary care payments, expanded insurance coverage and invested in medical home pilots, among other programs.

The model has been adopted by more than 90 health plans, dozens of employers, 43 state Medicaid programs, numerous federal agencies, hundreds of safety net clinics and thousands of small and large clinical practices nationwide since then. Among the results:

  • In Michigan, Blue Cross Blue Shield – the nation’s largest PCMH designation program — saved an estimated $155 million in preventative claim costs over the first three years of implementation.
  • CareFirst Blue Cross Blue Shield in Maryland reported nearly $40 million savings in 2011 and a 4.2 percent average reduction in expected patient’s overall health care costs among 60 percent of practices participating for six or more months.
  • In New York, the Priority Community Healthcare Center Medicaid Program in Chemung County saved about $150,000 or 11 percent in the first nine months of implementation, reduced hospital spending by 27 percent and reduced ER spending by 35 percent.
  • In Pennsylvania, Pinnacle Health achieved a zero percent hospital readmission rate for PCMH patients versus a 10-20 percent readmission rate for non-PCMH patients.

The PCPCC is the leading national coalition dedicated to advancing PCMH. According to PCPCC, the medical home is an approach to the delivery of primary care that is:

  • Patient-centered: A partnership among practitioners, patients and their families ensures that decisions respect patients’ wants, needs and preference, and that patients have the education and support they need to make decisions and participate in their own care.
  • Comprehensive: A team of care providers is accountable for a patient’s physical and mental health needs, including prevention and wellness, acute care, and chronic care.
  • Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports.
  • Accessible: Patients access services with shorter wait times, “after hours” care, 24/7 electronic or telephone access, and strong communication through health IT innovations.
  • Committed to quality and safety: Clinicians and staff enhance quality improvement through the use of health IT and other tools to ensure that patients and families make informed decisions about their health.

According to Melinda Abrams, Vice President of Patient-Centered Primary Care Program at the Commonwealth Fund, to have the greatest impact, a medical home must be located at the center of a “medical neighborhood” inhabited by hospitals, specialty physicians, physical therapists, social workers, long-term care facilities, mental health professionals and other service providers. She notes that it is the role of the primary care provider to coordinate care and make sure that patients don’t slip through the cracks, or receive tests or procedures they’ve already had – a particular concern for patients who see multiple doctors.

The National Committee for Quality Assurance (NCQA) – a non-profit, independent group dedicated to improving health care quality – accredits and certifies a wide range of health care organizations and is the leading national group that recognizes PCMH with the most widely adopted model. Currently, there are almost 5,000 NCQA Recognized PCMHs across the country.

Other organizations with PCMH recognition programs include Accreditation Association for Ambulatory Health Care, Inc. (AAAHC), the Joint Commission, and URACVideos from the American Association of Family Physicians (AAFP) feature family physicians who discuss practice redesign aimed at lowering costs, maximizing staff expertise and improving patient care.

“Practices seeking to initiate a patient-centered medical home will find that an assessment process is very helpful to understand where they are,” said Shaljian. “Some practices have electronic health records, a very strong history of team-based care, and strong connections with specialists, hospitals, and other stakeholders in the community, while others do not. Some are deeply affected by an internal culture of quality improvement, which makes a huge difference in how successful some medical homes are.”

Want to learn more about PCMH? Visit the U.S. Department of Health & Human Services’ Agency for Healthcare Research and Quality content-rich Resource Center.

How can health care continue to move the nation to PCMH? And how can the model tackle its number-one challenge: the current fee-for-service payment system?

Implementation of Health Care Law Expanding Coverage to More Young Adults

LJB head shot 03

Linda Barlow

For the first time in nearly a decade, the number of 19-25 year-olds gaining access to health insurance is on the rise, according to the Commonwealth Fund 2012 Biennial Health Insurance Survey. Researchers point to a provision in the 2010 Patient Protection and Affordable Care Act (PPACA or ACA), which allows young adults to stay on their parents’ health insurance until age 26, as a likely cause of this groundbreaking trend.

“The early provisions of the Affordable Care Act are helping young adults gain coverage and improving the affordability of health care during difficult economic times for American families,” said Sara Collins, Ph.D., a Commonwealth Fund vice president and lead author of the Biennial Survey’s report, Insuring the Future: Current Trends in Health Coverage and the Effects of Implementing the Affordable Care Act.

The improvements in young adult health coverage are significant, according to the Biennial Survey:

  • Nearly eight in 10 (79 percent) of Americans ages 19-25 reported that they were insured at the time of the survey in 2012, up from 69 percent in 2010, or a gain in health insurance coverage for an estimated 3.4 million young adults.
  • The share of young adults in this same age group who were uninsured for any time during the year prior to the survey fell from 48 percent in 2010 to 41 percent in 2012 – an estimated decline of 1.9 million, from 13.6 million uninsured young adults in 2010 to 11.7 million in 2012.

Of the estimated 3.1 million young adults who are now covered through the ACA, 60 percent are leveraging it for mental health, substance abuse, or pregnancy treatment, according to a study from the Employee Benefits Research Institute (EBRI). For one large, national employer profiled in the study, the newly-covered young adults used about $2 million in health care services in 2011 – about 0.2 percent of the employer’s total health spending.

Access is a major barrier to care for young adults, who were previously terminated from their parents’ plans when they turned 19. According to the Henry J. Kaiser Family Foundation (KFF), young adults typically face difficulties obtaining their own coverage because they work in entry-level, low-wage or temporary jobs that are less likely to provide health insurance. Lack of insurance makes it harder for young adults to receive adequate medical care –  a problem that plagued one in five young adults before the ACA began to take effect.

“Young adult women have additional health needs and are particularly vulnerable when they are uninsured, as they are at an age when they require reproductive health services,” noted Karyn Schwartz and Tanya Schwartz, authors of KFF’s Issue Paper, How Will Health Reform Impact Young Adults? “Having health insurance and consistent access to the medical system may increase the likelihood that they receive timely pre-natal care if they become pregnant.”

Meanwhile, some skeptics are expressing concerns about key aspects and implications of the Act, from objecting to young single males being required to purchase a plan including maternity benefits and well-baby coverage – to others saying that full implementation of the ACA in 2014 will mean much higher premiums for young adults. Many have challenged these assertions, however, noting that the ACA’s age-based pricing requirements are largely in line with premiums individuals are paying now.

Although the news for young adults is mostly good, the survey also found that 84 million people – nearly half of all working age U.S. adults – went without health insurance in 2012, or faced out-of-pocket costs that were so high relative to their income that they were considered “underinsured.”

The survey did indicate that 87 percent of the 55 million uninsured Americans in 2012 are eligible for subsidized health insurance through the insurance marketplaces or expanded Medicaid under the ACA. Up to 85 percent of the 30 million uninsured adults also might be eligible for either Medicaid or subsidized health insurance plans with reduced out-of-pocket costs.

Click here to learn more about pricing options for young adults seeking health insurance coverage.

Now it’s your turn. Does rollout of the ACA mean more accessible and affordable health insurance coverage, or will it drive up costs, particularly for younger Americans? Get the conversation started.

Categories: Access to Care

Making Costly – and Deadly – Medical Errors and Unnecessary Hospital Visits Something Only Grandparents Can Remember

“She died from a breakdown in the system. She died from a breakdown in communications.”

These heartbreaking words, from patient safety advocate Sorrel King about the loss of her young daughter Josie King, are words that no one should ever have to say or hear.

Her 10-year commitment to end hospital errors led to a $1 billion war on errors, funded through the Affordable Care Act.  The resulting Partnership for Patients program has already signed up more than 8,000 partners – including organizations and individual medical care providers – in a shared effort to save thousands of lives, prevent millions of injuries and take important steps toward a more dependable and affordable health care system.  According to the Centers for Medicare and Medicaid Services (CMS), the participants include:

  • Hospitals and national organizations representing physicians, nurses and other frontline health care and social services providers committed to improving their care processes and systems, and enhancing communication and coordination to reduce complication for patients.
  • Patient and consumer organizations committed to raising public awareness and developing information, tools and resources to help patients and families effectively engage with their providers and avoid preventable complications.
  • Employers and States committed to providing the incentives and support that will enable clinicians and hospitals to deliver high-quality health care to their patients, with minimal burdens.

In the April 2011 announcement launching the program, Health and Human Services Secretary Kathleen Sebelius shared two goals of the Partnership for Patients:

  1. To reduce preventable injuries in hospitals by 40 percent by the end of 2013, preventing 1.8 million injuries and saving 60,000 lives.
  2. To cut hospital readmissions by 20 percent, saving 1.6 million patient complications that force them to return to the hospital.  Achieving this goal by the end of this year would mean more than 1.6 million patients will recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.

{For a video of Ms. King explaining her work and Secretary Sebelius announcing the Partnership for Patients program, please click here.}

According to CMS, a recent study by the Office of the Inspector General (OIG) (PDF) found that 13.5% of hospitalized Medicare beneficiaries experience adverse events resulting in prolonged hospital stay, permanent harm, life-sustaining intervention, or death. Almost half of those events are considered preventable.

A recent article in the Journal of the American Medical Association showed that specific community-wide quality improvement activities are proven to reduce hospital readmissions.

Do you want to find providers and hospitals near you who have signed the pledge? It’s as easy as clicking here.

Do you want to learn more about the specifics of what actions will be taken to reduce accidents and re-admittance, and the studies conducted to determine the solutions?  Check out Altarum Institute’s blog post on the topic.

Three Pillars of Health Care Success: Cost Savings, Prevention/Patient-Centered Care, and Access to Care

Welcome to www.RealWorldHealthCare.org, a blog dedicated to showing what’s working to  improve health care in the U.S.

Why are we talking about improving access to good medical care? Rising costs could bankrupt us, and most people need to do a better job of preventing illness. But digging deeper, you may be surprised to learn that almost 10 percent of the U.S. population (that’s 29 million Americans) can’t afford the health insurance copayments, coinsurances and deductibles required to cover out-of-pocket costs for necessary treatments of certain chronic and life-altering medical conditions. The situation is so dire that about 60 percent of the personal bankruptcies filed in the U.S. are due to medical expenses.

As we see every day in the news, patients are facing more obstacles in accessing affordable, quality care. As across-the-board cuts to health care programs are now taking effect with implementation of the sequester – along with projected layoffs to health providers across fields – available funds to cover the rising cost of care will be strained even further. Staying abreast of the latest proven solutions to the increasingly complex challenges of our health care system is more important than ever, for patients and providers alike.

We want our blog to be the go-to source for demonstrating what’s working in our health care system by focusing on three important pillars of health care success:  Cost Savings, Prevention/Patient-Centered Care, and Access to Care.

Cost Savings: No patient – adult or child – should go without health care because he or she cannot afford it. The first step to finding solutions to the increasing cost of care is enabling health care systems and health care professionals to share their practical knowledge with one another as well as the patients who often have to choose between paying their medical bills and putting food on the table. From paying for prescription drug copayments and deductibles to affording health insurance premiums, our Cost Savings posts will explore proven strategies to help patients and families reduce the financial strain associated with the rising price of care.

Prevention/Patient-Centered Care: What’s the first thing you think of when given the words “health care?” Most people think “trip to the doctor,” or “medication.” Our attention has to shift more aggressively to find ways to help people stay healthy. Seeing a dietitian could be vital for millions of Americans hoping to live healthier and longer. Annual lab work can find vitamin deficiencies. Sometimes very simple things, like removing carpeting from the home, can contribute to better cardiovascular health, resulting in increased life expectancy. It takes a village to care for a patient. Partnerships among practitioners, payers, patients and their families are crucial for ensuring that health care decisions are made in a way that respects patients’ needs and that patients have the knowledge and support they need to make reasoned decisions and participate in their own care. In our Prevention/Patient-Centered Care blog posts, we’ll focus on the many strategies available for staying healthy and recognize ways that patients are taking an active role in decision-making about treatment options.

Access to Care: We are so fortunate to live in a world where scientists are developing novel, breakthrough therapies. But those therapies can’t result in positive health outcomes if the patients who so desperately need them can’t access them. The evidence is clear: Proper medication compliance and adherence – consistently the right medication, at the right dosage, for the right patient – is essential to mitigating chronic disease. Continued and properly managed care and staying on treatment will be the focus of our Access to Care blog posts.

We’ll be sharing real-life examples of positive health outcomes in this space, and we encourage you to join in the dialogue. How would you tackle the problem of unaffordable health care? How can business and philanthropy work together to reduce the financial burden on patients? Have you or someone you know received help paying for needed therapies? Let us know in the comments section.

Categories: General