Many people wonder what will happen as the Patient Protection and Affordable Care Act of 2011 is put into effect, with coverage for currently uninsured people beginning Jan. 1, 2014.
Mike Cracovaner and two other members of the local Jewish community are part of a team developing new approaches in line with the act’s goal of providing better care that is also less costly because it reduces hospital admissions.
Cracovaner is the CEO of New Pueblo Medicine, where Dr. Jeffrey Selwyn has served patients for 39 years. New Pueblo is part of Arizona Connected Care, a collaboration between Tucson Medical Center and three physician groups with more than 150 local doctors. It is an accountable care organization or ACO, a health-care approach promoted in the Affordable Care Act. Cracovaner and Selwyn both also hold positions with Arizona Connected Care, where Nina Trasoff serves as communications liaison.
An ounce of prevention
In 2003, New Pueblo started transitioning from paper files to electronic health records to more easily monitor patients’ progress and help them make diet and lifestyle changes or take appropriate medications that can help keep them well. When a patient goes to the emergency room, electronic health records give doctors immediate access to their health information, so they don’t have to start with a battery of tests. This prevents some admissions, and when people need to be admitted to the hospital, the stays tend to be shorter, with lower readmission rates, says Cracovaner. New Pueblo also has a lab on site, which allows doctors to get test results immediately. Post-surgical patients can be monitored at the office, which allows them to be discharged from the hospital sooner.
With these new approaches in place, New Pueblo was positioned to be part of a pilot program through UnitedHealthcare of Arizona; in June 2009 it became the first patient-centered medical home in Arizona. When patients visit their primary care provider at New Pueblo, electronic records allow the doctor to readily check for interactions between medications that may be prescribed by different specialists. Doctors can make the most of appointment time by focusing on listening to patients, explaining what their health problems are, what health care providers can do and what the patient can do, says Selwyn.
The doctor then hands off patients to other members of the home’s team, such as nutritionists and educators. Care coordinators track patients from beginning to end of procedures like hip replacements, cutting down on hospital readmissions. For people with multiple health conditions, frequent check-ins can help prevent a hospital stay, which can cost $20,000 or more.
To make this approach effective, New Pueblo also needed to work with specialists and hospitals, so they approached Tucson Medical Center in 2008. TMC and its affiliated physician groups were one of three organizations nationally selected for an ACO pilot project that began in January 2010 through the Engelberg Center for Health Care Reform at the Brookings Institution and the Dartmouth Institute for Health Policy and Clinical Practice. Arizona Connected Care became a legal entity on Jan. 1, 2011.
Better outcomes rewarded
Among ACOs, Arizona Connected Care is unusual in having doctors as its primary shareholders. Shareholders in an ACO only receive bonuses for cost savings when they hit quality measures. Blood pressure levels, appropriate weight, tobacco cessation, screening for depression and ratings of how well doctors communicate are only a few of the 33 Quality Performance Standards that the Centers for Medicare and Medicaid Services use in its evaluations. The better the scores, the better the bonuses for the ACO.
This approach, says Selwyn, is a big change from the way he was trained 40 years ago, when the paradigm was fees-for services: do more, get paid more. He says many doctors have been asking since the 1970s to be paid for outcomes instead.
Selwyn will retire from seeing patients Jan. 1, but will continue serving as one of two medical co-directors of Arizona Connected Care.
A focus on education and wellness means that doctors must learn to help patients be engaged in their own healthcare, says Selwyn. Since patients may not always be honest about how well their diseases are being managed, Arizona Connected Care also involves spouses and other family members in patient education.
As part of the pilot program, a therapist from Jewish Family & Children’s Services is seeing patients at New Pueblo. This makes it easier for patients to address issues such as the anxiety that contributes to many health conditions, and the depression found in about 30 to 50 percent of any doctor’s patients, says Selwyn.
Arizona Connected Care’s initial focus is on diabetes, chronic obstructive pulmonary disease and congestive heart failure, since these illnesses make the biggest impact on patient outcomes and costs. If the ACO concept helps doctors do a better job with Medicare and Medicaid patients, these programs can stay viable, says Selwyn.
There’s a lot to figure out and it’s exciting to be part of a start-up, says Trasoff, communications liaison for Arizona Connected Care. As well as pioneering the use of data collected on the ACO’s patients to improve care, Arizona Connected Care is also asking potential providers to show evidence that treatments such as physical therapy improve function and reduce pain before they join the network. This approach ripples out, says Trasoff.
No numbers on improved care or savings are available yet specifically for Arizona Connected Care. But a report on ACOs that started in 2012 found that all outperformed industry benchmarks in delivering higher quality care. The individual ACOs varied in whether they saved money or not. The biggest cost savings came from reduced hospital admissions and readmissions.
Deborah Mayaan is an energy work and flower essence practitioner based in Tucson. www.deborahmayaan.com