When Otis Small of Hampden recently found himself suffering from a “horrendous” headache, he didn’t call his doctor. After a week of pain, the 81-year-old retired teacher finally mentioned to Cynthia Herrick, a nurse who calls him regularly to monitor his health, that his head was pounding.
Herrick, well versed in Small’s history of diabetes and heart and breathing problems, asked him about his blood sugar levels, blood pressure, and whether he’d experienced any chest pain. He was otherwise fine, he said, so Herrick, unable to pinpoint the source of his discomfort, told Small it might be time to call his doctor.
Just then, Small mentioned offhand that he’d recently given up coffee.
“She said, ‘Forget the doctor. How much coffee do you drink?’” Small recalled. Six or seven cups a day, he told Herrick, before stopping cold turkey. “She said, ‘I want you to drink two cups a day.’ I cheated, I drank three,” he said, grinning.
As it turned out, Small was suffering from run-of-the-mill caffeine withdrawal. He took Herrick’s advice, the headache went away and he never had to visit the doctor’s office.
By avoiding an unnecessary visit to his physician, Small helped his health care provider to achieve a small victory in a much larger effort to transform health care in Maine and across the country.
Small’s doctor’s office, Husson Internal Medicine in Bangor, is part of a new experiment in health care undertaken by its parent organization, Eastern Maine Healthcare Systems of Brewer. The goal is to keep patients healthier and happier by rewarding doctors and nurses for keeping them well rather than for ordering more visits and procedures.
One way health systems throughout the U.S. are working toward that goal is by forming alliances of doctors and hospitals called “accountable care organizations.” ACOs are a cornerstone of the federal health reform law that many hold up as the country’s best hope for hitting the brakes on rising health care costs that are eating up more and more of Americans’ paychecks.
Others fear that ACOs — by requiring hospitals to band together, further consolidating their already considerable market power — will free health providers to hike prices. Carnegie Mellon economist Martin Gaynor went to far as to say ACOs have the potential to be “an anti-competitive sham.”
“Nobody defines an ACO quite the same way, so it’s very much experimental,” said Trish Riley, senior fellow in health policy at the University of Southern Maine’s Muskie School for Public Service and former health policy advisor to Gov. John Baldacci. “It’s about getting the incentives right, instead of paying for widgets you pay for care and you pay for keeping people well.”
EMHS was one of 32 organizations nationally chosen by Medicare, the government health insurance program for seniors, to pioneer the model. The system’s hospitals can earn financial incentives for cutting costs and improving care, rather than steering patients toward expensive medical services.
Roughly 14,000 Medicare patients are part of the project at EMHS. The system also has extended similar coverage to employees on its health plan.
The health system points out that the ACO will not skimp on services that patients need or restrict which doctors and specialists they can see. The ACO doesn’t affect Medicare patients’ benefits, and enrollees have the option to prevent Medicare from sharing their insurance claims history, which doctors use to better manage their care.
As complex as the model is, its strategy is fairly simple. Patients’ care should be better “coordinated,” meaning all the providers caring for an individual — doctors, nurses, specialists, home health aides and more — talk to each other. That communication leads to better preventive care, such as cancer screenings and vaccinations, which can keep a patient from needing much costlier care in the doctor’s office, emergency room or hospital. It also reduces the chances of medical mistakes, prescription errors, duplicative tests and other expensive drains on the health care system while, in theory, making the patient happier and healthier.
Herrick, Small’s nurse who coordinates care for a number of patients and doctors under the EMHS ACO, described her work as “the best job I’ve ever had.”
“I just knew that it was the right thing to do,” she said.
After visiting with Small on a rainy day earlier this month, Herrick picked up the phone to make her rounds with other patients. She spends much of her time calling patients to make sure they’re taking their medications and feeling well, passing along any issues to their physicians.
During one call, she learned that a diabetic patient who’s legally blind and caring for his wife with Alzheimer’s disease was lying to her about his blood sugar levels. He couldn’t read the test strip on his glucose meter, but feared if he admitted it he and his wife would be taken from their house and placed in a nursing home, she said.
Herrick promised to look into getting the man a talking glucose meter. That one small step could prevent his diabetes from worsening down the road and leading to physically devastating and costly complications, such as amputation and stroke, she said.
“It’s impossible to prove how much money I’m saving 10 years from now by helping to manage this guy’s diabetes,” Herrick said.
Under the model, hospitals and physician practices are responsible for tracking the health of elderly and disabled patients. If they reduce costs while providing high-quality care, they can share in the savings. Likewise, if they fail to cut costs or miss certain quality targets, hospitals get pinched financially.
The federal government anticipates the savings to reach up to nearly $2 billion between 2012 and 2015.
Hospitals can take on the risk and potential losses immediately, or forgo taking on risk initially and accept a lower portion of the savings.
Last year, EMHS and the other “Pioneer ACOs” received payments just for reporting data on 33 quality measures tracked by Medicare. The metrics include how many patients wind up back in the hospital a month after being discharged and how well providers monitor patients with high cholesterol.
This year, the second in the five-year project, payments are tied to hospitals’ actual performance on costs and quality. Under EMHS’ arrangement, the seven-hospital system agreed to a 70-30 split with the federal government, meaning as of July it will be rewarded with 70 percent of any cost savings it achieves, but also is on the hook for paying back 70 percent of any cost overruns. If EMHS fails to meet the quality targets, the federal government will hold back some of the savings available to the ACO.
So far, the results appear promising. Out of the 32 Pioneer ACOs, EMHS ranks fifth for reducing costs, realizing savings of at least 1.5 percent. EMHS officials declined to disclose the exact percentage and dollar amount, saying they would share the information when the federal Centers for Medicare and Medicaid Services authorizes its release, expected later this summer.
The health system released data on two of the 33 quality metrics, hospital readmissions and a coronary heart disease measure. Hospital readmissions, a costly and often avoidable situation in which patients return to the hospital soon after discharge, are down from about 57 out of every 1,000 patients to 49. The system also said it has surpassed goals it set for better tracking patients at risk for heart disease, a condition that accounts for one dollar out of every six dollars spent on health care in the U.S.
How much information ACOs will have to provide to the public remains in question as they get off the ground, said the Muskie School’s Riley. Even the basic ACO model varies depending on the company or health organization creating it, she said.
ACOs have formed at a rapid pace nationally since EMHS and its fellow Pioneer ACOs were launched. An estimated 400-plus accountable care organizations now cover millions of Medicare enrollees, as well as people with private insurance. In Maine, Portland’s MaineHealth, Central Maine Healthcare in Lewiston and several physician groups are experimenting with ACOs.
States and the federal government are still feeling out what consumer protections, licensing requirements and potentially price regulations may be needed without squashing the innovative goals of the program, Riley said.
“One of the worries about ACOs is when you integrate all these activities under a hospital rubric, you’ve taken the most expensive part of care and put it as the gatekeeper of care,” she said. “So the question becomes where’s the check and balance? How are we assured that the costs will be right? It gives an awful lot of authority to a semi-monopolistic delivery system.”
The ACO effort is “a very important, very exciting initiative but we ought not to think it’s the silver bullet, because there’s lots to learn from this,” she added.
Dr. Iyad Sabbagh, Small’s primary care provider and senior medical director of the EMHS ACO, sees great promise in the program, by allowing medical providers to intervene before patients grow sicker. Nurse “care coordinators” including Herrick constantly update him on his patients’ health and wellbeing, he said.
“What we’re trying to do here is rebuild that connectivity with the patient outside the office … They know their bodies, patients know when things aren’t working well, and that’s the best alert for us,” Sabbagh said.
While upending the way the country pays for and delivers health care has caused great anxiety among some medical providers, insurers and businesses, “It is achievable, we can get there, we can work on quality and satisfaction while decreasing costs,” Sabbagh said.
For Otis Small, this massive transformation comes down to a simple comfort — knowing that Herrick will call him back before the day is over when he has a question.
“If it doesn’t help me physically, which it does, it helps me mentally, knowing that my life preserver’s right there,” he said. “It seems small until you’re the one that has the problem.”