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Health care: Push for new reimbursement model is likely to continue

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The future of the Affordable Care Act may be up in the air, but regional players agree: one thing that won't be going away is value-based health care.

In spite of all the controversy surrounding health care, some see value-based care already changing a once-static system, which is at least a promise that things can improve.

Value-based models were largely born out of the 2009 Affordable Care Act, a major component of which was changing provider payments from a volume approach to one that reflects the health of a provider’s patients. But how they have begun to reduce costs is often so simple, it’s a wonder the change was so long coming.

Switching cement

“One rub that has always been against the health insurance companies is that they have so much data, but they didn’t share it with the providers,” said Dr. Mark Jacobson, medical director of Pittsburgh-based Highmark Blue Shield. “So we’re giving them the same reports we have. This gives them the tools to succeed.”

Jacobson, who once ran Lebanon’s Good Samaritan Hospital and Ephrata Hospital, said he has seen the roadblocks to reducing costs from the physicians’ and the payers’ side.

To overcome the roadblocks, Highmark recently bundled seven comparable value-based programs into a new initiative, the voluntary True Performance Program, which launched in January. About 75 percent to 80 percent of all Highmark members, both commercial and government, are covered by physicians enrolled in True Performance. Sharing best practices via data analytics is one way Jacobson expects physicians to be able to reduce costs.

In one example, he worked with two orthopedic groups. Both performed hip surgeries, and both enjoyed good outcomes, but one had significantly higher costs.

“Turns out, the cement one group was using was much more expensive than the other group’s cement,” Jacobson said. “They said, ‘Well, we don’t really know what it costs.’ Even when you look at something like sinusitis, one doctor’s treatment would be much more cost effective than another because one doctor used expensive antibiotics and the other didn’t, but the outcomes were the same. Those are the practice changes that can be done, but if you don’t look at that information, you’ll never know about it.”

Engaging patients

Another method being used to reduce costs at Harrisburg-based PinnacleHealth System is care navigators, who check in with patients between doctor visits to keep them on track with treatment and share information. Dr. Robert Nielsen is president of PinnacleHealth Medical Group, which is enrolled in several value-based models, including an accountable care arrangement with Capital BlueCross.

“The navigator can get a truer picture of that patient’s health because there’s a different level of connection with a navigator, so patients share things that they might not share with their physician,” Nielsen said. “Very few patients will tell me they can’t afford their medications, but if you get a health coach involved, many times that’s the first thing that will come up. So we can just change their medication.”

That patient piece is no small part of making value-based medicine work.

“Providers have asked us, ‘What can we do to change patient behavior?’ That’s probably one of our biggest challenges,” said Jay Simmons, vice president of provider network engagement for Harrisburg-based Capital BlueCross. “As time goes on, what you’ll see is benefits will have to be designed to put more accountability on the patient for the choices they make if they want to control out-of-pocket expenses. There’s definitely more work to be done in that area.”

Changing mindsets

As the patient mindset needs to change, so does that of the health care provider.

At Lancaster General Health, patient accountability is a concern, but providers are also considering how their approach can be tweaked to trigger greater patient engagement.

“At the highest level, if you talk about what needs to change, it’s that as health care systems, we have been traditionally incentivized at ill care,” said Stacey Youcis, senior vice president of service lines and population health at LGH. “Now it’s not about single encounters but how we’re partnering with you in your life to keep you well. It flips the whole business model on its head. We also have to take accountability that we don’t always do a good job of meeting people where they’re at.”

Youcis said surgeons who traditionally performed surgery after a patient was medically cleared are now asking patients about life goals and whole health.

“It used to be if you had arthritis and it degraded to a certain point, we did joint replacement,” Youcis said. “Now there’s a more intentional conversation with people about whether they want to run marathons or just be able to play with their grandkids without having pain. Now I have surgeons saying, ‘Your diabetes is out of control – you’re more likely to get an infection after surgery, so let’s work with your primary care doctor.’ The thought of a surgeon having that kind of conversation with a patient 10 years ago was unheard of.”

For now, new value-based models are showing promise for changing health care culture. Some don’t see it so much as a matter of choice, but of necessity – with potential.

“I don’t see this turning around,” said Dr. Jennifer Chambers chief medical officer at Capital BlueCross. “There’s been increasing recognition that we’re in an unsustainable trajectory. We have to wrap our arms around this on a national scale. The other piece that can’t be lost is the expectation of partnership between health plans, providers, members and employers. If we don’t all row together, we won’t be successful.”

The data is intentionally traveling through the network, so that it arrives at the right place at the right time, but it is not stored by the network. The purpose of the network is simply to share data, but not to store it.

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Write to the Editorial Department at editorial@cpbj.com

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