Sarah Holobaugh, 80, has diabetes, heart disease, hypertension, and chronic obstructive pulmonary disease. To keep her safe and out of the hospital, a team of healthcare providers—a doctor, high-risk home healthcare nurse, social worker, and patient care manager—monitors her blood pressure, blood sugar, and other vitals daily. With the help of people in her Peoria, Ill., community, they're also arranging for a new roof. For free.
Welcome to one of several experiments going on across America, transforming the way healthcare is delivered. One big problem that health reform has taken on is the fee-for-service payment system, which tends to encourage a piling-on of tests and treatments when less care (and preventive care and better-coordinated care) would often produce better results at lower cost. Now, health insurers and Medicare are beginning to turn that system on its head, paying doctors and hospitals based on how successfully they treat patients and keep them out of the hospital. "They are all so concerned personally," Holobaugh says of her team's determination to make sure that mold caused by a leaky roof doesn't worsen her lung disease. Holobaugh is served by OSF Healthcare System, which includes eight hospitals and more than 600 doctors.
What will this movement mean for you? "It means getting to see a doctor the same day you have a problem," says Elliott Fisher, director of the Center for Population Health at the Dartmouth Institute for Health Policy and Clinical Practice. It means more timely responses from your healthcare team by E-mail, text, or telemedicine. It may mean you have a personal health coach, and that you notice your doctor nudging you more energetically about that flu shot and less-than-ideal blood pressure and working harder to keep you exercising and eating well; Holobaugh's team has connected her with local food pantries, for instance. You shouldn't even be surprised to see house calls come back. Here's a sampling of places where healthcare is changing for the better.
A pioneering spirit. "This is how healthcare should be," says Emily Hill, the OSF nurse who is Holobaugh's patient care manager. Whereas most hospitals and doctors are paid only for providing direct care, and not for any time and effort they spend trying to prevent illness, doctors here are rewarded in part for making sure people suffering from diabetes or other chronic maladies are taking the steps they need to take to keep their conditions in check. Patient satisfaction counts in the compensation equation, as does how quickly people can get appointments. So, for instance, heart failure patients are contacted within two days of their discharge from the hospital to be sure they're taking their medicine and have scheduled follow-up doctor appointments. Care managers like Hill track children's immunization history in electronic patient registries and call families that fall behind schedule to remind them to come in. Aligning payment with the interests of patients and payers makes providers more accountable, experts say—one big goal of health reform.
Medicare, the nation's largest health insurer, has committed to a new payment system based on the principle that an ounce of prevention is much more cost-effective than a pound of cure. In January, program officials formally gave OSF, Partners HealthCare in Boston, Presbyterian Healthcare Services in New Mexico, and 29 other hospitals, large physician groups, and health systems the designation "Pioneer Accountable Care Organizations" along with the flexibility to figure out how to better organize care delivery around patients' best interests. The agency is tracking their performance on 33 quality and performance measures, from patient satisfaction to hospital readmission rates to how reliably people with asthma, for example, get the care they need.
Already, some 20 percent of the money OSF receives from Medicare and other insurers is for performance-based care. As more insurers fall into step, the goal is to expand high-touch prevention to all patients, and add coaching, house calls, and greater attention to the realities of daily life—like transportation and financial issues and Holobaugh's leaky roof—that hinder people from staying well.