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.
Vermont's blueprint for health. Retired IBM engineer Stephen Hennessey of Essex Junction, Vt., is "very, very happy" with his internist, Lucy Miller, especially since she helped him get serious about a lifestyle overhaul by providing him with extra attention, at no cost to him, from a nurse, medical social worker, health coach, and dietitian. Like many of Vermont's primary care practices, Miller's is organized as a "patient-centered medical home," where people build relationships with the doctors and can count on getting quick attention to their acute and preventive medical needs, coordinated care when specialists are warranted, and guidance in taking care of themselves. Last fall, when Miller diagnosed Hennessey, 60, with type 2 diabetes, she prescribed medicine and a better diet plus exercise. She then connected Hennessey with one of the state's new local community health teams that works in conjunction with her practice to coordinate Hennessey's care and cheerlead as he develops healthier habits. So far, Hennessey has lost 30 pounds and soon expects to stop taking two of his four drugs.
Community health teams now dot Vermont, helping to extend the reach and preventive power of primary care practices. You don't have to be served by Medicaid or have particular private health coverage to qualify; the teams take "all comers," says Lisa Dulsky Watkins, associate director of Vermont Blueprint for Health, the state's initiative to transform healthcare delivery. Early evidence suggests that Blueprint is working to contain costs. A four-year review of hospital data showed that the growth in inpatient admissions and emergency department visits has slowed.
Heart Care at Home. The first month after a hospital discharge is a vulnerable time for many people, since post-hospital care is often chaotic—even if patients are not left entirely on their own. Insurers typically have not reimbursed hospitals or doctors for coordinating care after a person leaves, and frequently have had to pay instead for costly readmissions. Approximately 1 in 4 people with heart failure are back for return visits within a month of being sent home, for example. As of October 1, Medicare starts financially dinging hospitals when certain patients are readmitted within 30 days.
The Cleveland Clinic's two-year-old Heart Care at Home program aims to bring those numbers down. When Richard Jones of Niles, Ohio, 70, was discharged in May, he was sent home with a digital scale to flag any weight fluctuations (a possible sign of fluid buildup), a blood pressure cuff, and other monitoring equipment tied into the hospital system. He was also assigned a telemonitoring support team of nurses, social workers, nutritionists, therapists, and doctors who would check his vital signs daily, remotely or in person, for up to 40 days. In phone and house calls, the team coordinated follow-up doctor visits and counseled the lifelong cheeseburger-and-fries fan on worrisome symptoms to watch for and how to make lifestyle changes stick.
"I've stopped smoking, and all these things they told me to do, I've done," says Jones. "Without them, I don't know how I would have got through this." Cleveland Clinic is not paid directly for Heart Care at Home, and does not charge patients. But so far the readmission rate for participants is running 4 percent lower than for the hospital's Medicare heart failure patients overall. And, says David Longworth, chairman of the Cleveland Clinic's Medicine Institute, it's "the right thing to do."
Patients as partners. People with complex and even life-threatening medical problems often handle them this way: The doctor diagnoses a condition and recommends a treatment, and the patient complies. Now institutions like Massachusetts General Hospital in Boston, Dartmouth-Hitchcock Medical Center in New Hampshire, and Mercy Clinics in Iowa are adding a step to the process. They're educating patients about their options, and asking them what they think. "I felt I had a choice," says David Wunsch, a Belmont, Mass., retiree who was referred by his Mass General primary care doctor to an orthopedic surgeon last March after the pain in his left knee became "intolerable." The doctor also e-prescribed a video highlighting the pros and cons of different knee pain treatment options, from pain shots to full knee replacements.
"Shared decision-making" formalizes a partnership between patients and their providers, says Leigh Simmons, co-director of Mass General's program. Jointly, they make the call on treatment paths, taking into account both the scientific evidence and the patient's values and preferences. The hospital's electronic medical records system prompts doctors when a treatment decision needs to be made for one of 35 conditions, reminding them to order educational DVDs for patients through a Netflix-type system and to invite the patients to bring up any questions. Dartmouth-Hitchcock has a shared decision-making center where patients can discuss options with staffers and consult educational aids. Mercy Clinics' health coaches meet with patients to distribute resource material and answer questions; patients then meet with their healthcare providers to plot the right path.
Wunsch watched his video and got a better understanding of his options and what surgery would entail. He opted to get his left knee replaced this spring.