As health care costs continue to rise faster than the rate of inflation, officials are turning to new and innovative ways to control medical spending.
Evergreen Family Health is located in Williston. It’s an independent practice headed by physician Paul Reiss.
Reiss is committed to finding out if a new health care service delivery model, known as an accountable care organization, can reduce costs and provide a higher quality of care for patients.
To find out, he’s become the medical director of the Accountable Care Coalition of the Green Mountains.
Here’s how it works. His ACO is comprised of 10 medical practices from St. Albans to Middlebury. The ACO has 34 physicians and is implementing the new system exclusively with roughly 6,500 Medicare patients.
The federal government keeps detailed records of all Medicare patients. With this data, it can predict the kinds of medical services an individual patient is likely to need in the coming year based on the patient’s age, his or her current health condition and previous claims history.
Reiss says the first thing that happens is that Medicare looks at the patients in the ACO and makes these projections.
“If you can predict those trends relatively accurately, then you can with some confidence see that less costs of care resulted from your interventions,” Reiss said.
"If we can keep a patient from being hospitalized then that is what really saves the system money and it is much better for the patients." - Dr. Paul Reiss, medical director of the Accountable Care Coalition of the Green Mountains
Most current health care financing models reimburse providers only when a patient is sick, Reiss says. But the ACO model includes financial incentives to keep a patient healthy.
Here’s how: If the treatment plan results in lower costs than the annual estimate for the patient, then the ACO gets to “share” in some of the savings. Reiss thinks it’s a good arrangement.
“So if your interventions are on target and you truly reduce the cost of care but yet provide high quality care nonetheless then that makes sense,” said Reiss. “Perhaps you should share in the savings because you did a lot of work to make those changes to provide better care.”
Remember that the goal of the ACO is to reduce the growth rate of health care costs while providing high quality care. Dr. Reiss says this often means taking steps to keep patients out of the hospital because he says it’s one of the most expensive forms of care for a Medicare patient.
“If we can keep her home from being hospitalized and then being transitioned to a nursing home for a few weeks or months until she can get back home, if we can prevent that by keeping her healthier at home then that’s what really saves the system money and it’s much better for the patients,” he said.
So let’s look at a specific example of how patient care could change under an ACO.
Deborah Gaylord is the care coordinator at the Green Mountain ACO. She describes her job as being the point person for virtually all of a patient’s needs as soon as the person leaves the hospital.
In this case, the patient is Mary, a 66-year-old woman with congestive heart failure. Gaylord’s initial responsibility is to establish a treatment plan for Mary after she’s discharged from the hospital.
“I follow her through that process and work with the case managers in the hospital,” said Gaylord. “To make sure that when she gets home she has everything she needs in terms of understanding her medical care.”
Gaylord is delighted to learn that Mary has a caregiver looking after her – a younger woman named Jess Weatherby.
“Jess knew a lot of the things to do to help Mary with her CHF but she really didn’t know how to connect the dots meaning when to call the doctor, what were the danger signs,” said Gaylord. “So we did a lot of education. My role was to connect all of the resources and identify the resources to keep Mary at home.”
Having the ACO as a resource makes all the difference in the world to Weatherby.
“I know that if we need anything or you know if anything is happening with Mary’s CHF that there’s somebody I can call,” said Weatherby. “There are resources there to help her and to be able to keep her healthy and out of the hospital.”
It’s clear that Mary would not be able to stay at home without the coordinated care services that the ACO provides. And the opportunity to remain at home means a lot to Mary.
“I like to stay at home I have a little kitty so I like to stay at home with her,” she said.
Remember that the goal of the ACO is to provide Mary with quality home based care to help keep her out of the hospital.
In Mary’s case this is critical, because Weatherby explains that Mary had been in and out of the hospital until she hooked up with the ACO.
“We were visiting the hospital a lot. Three times in the last three months?" said Weatherby. “It’s really just come together, especially since the last discharge was in the last few weeks. It’s really been helpful to have Deb and other support through nurses coming in and PT and just everything has really come together with this program.”
The big question is if this new financing model will actually help reduce costs and provide better care for the patients.
In July, this ACO marks its second anniversary and Dr. Reiss says it will take another year or two to make a comprehensive evaluation of this system.
In the meantime, patients like Mary are able to stay at home with an array of services provided by a team of health care workers.
