The latest, most innovative approach to medicine is decidedly low tech: it involves nothing more than the patient sitting and talking with his or her doctor. It also involves all the usual things—checkups, preventive screenings and perhaps some prescriptions. But the core idea is to help the patient build a fruitful relationship with his or her primary care provider.
Often called the “medical home” model, the primary care provider takes a stronger role in consulting with patients and directing an integrated, team approach to their care.
“It gives doctors financial incentives for spending time on care coordination, which is working with the rest of the health care team to tailor a plan for that person, spending time on counseling, as well as having coverage as we do now for office visits,” says Dr. Jennifer Leiser, a family practitioner and assistant clinical professor in the Department of Family and Preventive Medicine at the University of Utah.
The medical home is the cutting edge in a wider movement to provide individualized care for patients, and to encourage them to engage in their own health care. Experts say people who take personal health care seriously are more likely to make the lifestyle changes that can improve their overall health, which brings down costs in the system and the savings are passed onto all of us.
“If we don’t become more engaged in our health care, we are going to continue to see the double-digit trend increases that we’ve seen year after year,” says Earl Hurst, president of commercial products for Humana of Utah.
But in some ways, the idea of a medical home model is a distant dream. It is predicated on the notion that physicians have time to counsel patients, make follow-up phone calls, consult with specialists and spend time considering each specific case while insurance companies cover these activities.
“Procedures are reimbursed at a much higher rate than sitting and thinking about something,” says Leiser. “If I have a person in my office who I spend 45 minutes with, talking about diabetes and how to prevent complications, I probably won’t get paid as much as if I froze a wart off them because that’s a procedure.”
Scott Ideson, president of Regence Blue Cross Blue Shield of Utah, agrees that the current reimbursement structure does not accommodate the medical home concept.
“Keeping people on the track to health requires information exchange between the care provider and the patient,” he says. “That needs to be a part of how people are reimbursed. I don’t have the silver bullet on that, but I do think that if we’re really going to focus on health and wellness, we need to understand that the present way of paying for care, which is basically illness intervention, is not going to get us there.”
An Ounce of Prevention
More insurance companies and employers are turning to prevention and wellness programs to stabilize medical costs, with the belief that if patients are empowered to take charge of their health now, they may not need to spend as much on health care later.
“To the extent that people use less in the way of health care resources, that impacts everyone because we all make a contribution into that pool,” says Ideson. “And to the extent that we’re taking fewer dollars out of it, it means future health care costs will be lower than they would otherwise be.”
While preventative care can be expensive, Dr. Tamara Lewis, medical director of community health and prevention for Intermountain Healthcare, says the payoff may be an enhanced quality of life, rather than dollars saved. “For a certain amount of cost, we as a society believe that we gain years of life, and that’s a worthwhile cost,” she says, explaining that each preventative service is assessed to find out how many individuals are impacted, how many life years are saved and what the aggregate cost is.
“Something that’s in the range of $10,000 to $20,000 per life year saved is a valuable service,” she says, adding that most preventative services fall within that range. However, some services, like mammograms, spike into the range of $50,000 to $80,000 per life year.
Preventative measures include a range of services, such as immunizations, health screenings and high cholesterol and obesity treatments. These measures are significantly cheaper than treating an advanced health problem. As Lewis explains, when heart disease progresses to the point of open-heart surgery, that intervention costs around $60,000 per life year saved.
“There are definitely certain preventive services that save both the health plan and the employer—and society—money,” says Lewis, citing Select-Health’s tobacco cessation program as an example. “Years ago, we developed a cost benefit analysis that showed not only do you get an effect in life years saved, but that you get a return on your investment, you get a cost benefit back,” says Lewis. Unlike other insurance companies, SelectHealth, the insurance arm of Intermountain Healthcare, covers tobacco cessation classes, nicotine replacement therapy and the latest tobacco cessation medications.
At least 3,000 SelectHealth members have quit smoking, and non-smokers have a lifespan 10 to 13 years longer than smokers. “We’ve saved about 30,000 life years over the past 10 years,” says Lewis. “We’re at the point where we’re starting to have lower costs in our own members because they quit years ago.”
Health professionals say spending a few dollars now to save a few hundred dollars later—even if it’s 40 years into the future—is the ultimate dream for the health care industry. “Look at the lifetime cost of a person with diabetes and complications—the terrible cost of caring for that person—if we could prevent that one case it would save the system a lot of money,” says Leiser.
A Moment of Your Time
In a perfect world, primary care physicians would earn more for preventing diabetes and heart disease than for removing warts.
“Ideally, I would change the way we pay for medical care by focusing on the kinds of practices that manage primary care, that manage the prevention of disease and illness early on,” says Dr. Thomas Miller, chief medical officer for the University of Utah Hospitals and Clinics. “You’d be looking to provide changes in lifestyles 30 years down the road.”
The difficulty is assessing a dollar value for this kind of medical care. One method may be to pay doctors based on their patient outcomes. Of course, outcomes may not be obvious for decades.
Medicare, in many cases, now bases its reimbursements on a pay-for¬-performance model. Doctors and hospitals are evaluated on whether key services, such as flu shots and blood pressure monitoring, are given to patients.
“In hospitals, we have to report on about 20 different measures,” says Dr. Scott Williams, chief medical officer for MountainStar Healthcare, adding that Medicare is often the trailblazer for new treatment and reimbursement models, and so he expects insurance companies will eventually establish their own pay-for-performance metrics.
Pay-for-performance will very likely lead to better outcomes for patients. Dr. Williams cites a 2003 New England Journal of Medicine study that found that recommended services are provided only 55 percent of the time.
SelectHealth has already launched an incentive program rewarding doctors for providing recommended services, such as immunizations and preventive screenings to the right people at the right time. “The health plan says, ‘If you can meet these quality goals, we will fund an incentive for you,’” says Lewis.
SelectHealth also alerts primary care physicians when members have not received the recommended preventative services.
A New Plan
Insurance companies aren’t just providing new incentives to doctors; they are also crafting benefit plans that offer rewards to patients actively pursuing good health.
A prime example is the “Regence Activate” plan, which rewards members with medical dollars for participating in wellness activities such as joining a weight loss program, exercising, getting immunizations or even getting their teeth cleaned. Each year, activate plan members can earn up to $600 in funds for out-of-pocket medical expenses.
“The philosophy is to try and provide direct incentives to people for engaging in healthier behavior,” says Ideson. “The idea is to encourage people to change behavior because there is in fact something in it for them. And that’s fairly new in the health care field.”
With rising health insurance premiums, plans like this give consumers some control over their medical expenditures.
“It really is changing the conversation,” says Ideson. “People are more concerned about how they are using health care services and what they can do to stay healthier so that their out-of-pocket expenses and future premium costs can be less than they would otherwise be.”
Hurst believes that high-deductible plans, combined with Health Savings Accounts (HSAs), encourage patients to shoulder more responsibility for their own health—and to become educated about the true cost of care.
“Our market is permeated with low deductible health plans,” says Hurst. “Once a $250 or $500 deductible has been satisfied, you as a consumer become less engaged [in your health care] and someone else is going to pay for it.”
While some have expressed concern about how much patients have to pay out-of-pocket with HSA plans, Humana HSA plans cover 100 percent of all preventive care. “When it’s set up that way, it does not dissuade employees from getting the basic care they need,” says Hurst.
In fact, a Humana member survey found that HSA members were more likely to use preventive services and less likely to need costly services like hospital stays.
“We think the future for affordable health care is getting the consumer more engaged, and we think the HSA is an excellent tool for that to happen,” says Hurst. “There is something about being an active consumer in health care that changes the way you think about it.”
The Buck Stops…With You
The bottom line is that it’s the patient who has to actually make doctor appointments or head to the clinic for flu shots.
“Patients have to be fully participating: seeing their doctor, filling their prescriptions, following their doctor’s advice and recommendations,” says Williams. “Patients have all the responsibility because they are going to experience all the consequences.”
However, some patients feel more overwhelmed than empowered. When facing an illness, many are left wondering what questions to ask their doctor, what their insurance will cover and how to access a specialist.
In fact, most people don’t have a clear understanding of health insurance concepts, according to recent research released by Regence. Only 4 percent of respondents in the Regence study achieved an 80 percent score when asked to define insurance terms and calculate their bill. The majority, 60 percent, could accurately answer only half or fewer of the questions.
“[The industry] has made it pretty complex, and even the language is often pretty complex,” says Ideson, adding that’s why the company created MyRegence.com, which provides in-formation to members about conditions, treatment options, facilities and the relative quality of provider care. “It’s an attempt to make the information about health and health care more transparent. That includes inform-ation about the cost of services,” she says.
Most insurers provide tools to help members navigate the health care system. SelectHealth sends newsletters with information about immunizations and tips for making positive lifestyle changes, among other things. And, Humana of Utah sends patients a “Smart Summary” that details their services and related costs.
Miller at the U of U encourages consumers to browse Websites, such as WebMD.com, to find information about conditions and preventative care, saying that as a physician, he welcomes people bringing him information from the Internet because it indicates their efforts toward improving their lives and staying healthy.
“We tend to apply our greatest desire to receive care when we most need it,” he says. “So when people are sickest, that’s when they want the most concentrated, the best care they can get. We don’t tend to think about getting the best care we can possibly get early on so we don’t have to deal with those issues down the road.”