You've Just Had a Heart Attack! Who Makes Sure You Get Your Life Back?
Category: Cost of Healthcare, Government Programs, Health Insurance

You’ve Just had a Heart Attack! Who Makes Sure You Get Your Life Back?

Editor’s Note: This is the second part of our interview with interim Blue Cross Medical Director Dr. Paul Murphree. 

In the second part of our interview with interim Blue Cross Medical Director Dr. Paul Murphree, he tells us how that old non-coordinated system is being gradually pushed back, and the exciting new ways medical providers are COORDINATING their care across all those different practice boundaries are becoming a reality. Dr. Murphree says that without Blue Cross to motivate them and tie payments into how well they coordinate care, it might never have happened.

It’s Monday morning, and you are at work early. While you are typing away, you notice a pain in your left shoulder that seems to be radiating down your arm. Suddenly, tightness in your chest goes way beyond any normal feelings. It’s like you’ve got an elephant sitting on you! Are you having a heart attack?

Let’s get to the emergency room quickly and find out.

Wouldn’t you like (all of your doctors) to be on the exact same page when it comes to your medical condition, what’s wrong with you, what surgery/treatments you’ve had?

Naturally, when you arrive, you are scared and feel poorly. Your life is now dependent on a lot of medical professionals and their facilities to help save your life and get you back on your feet. You are going to find yourself being “handed-off” to different folks in that process. A lot.

Once you get there, you might be admitted through an emergency room and seen by the ER doctors. They will quickly figure out what’s wrong with you. A technician will draw your blood, and the laboratory in the hospital will test for enzymes present after heart damage. Once they determine your heart is the problem, they will call in a cardiologist. He’ll want to know what’s going on, so he’ll order scans or imaging tests from other technicians. Radiologists will interpret the tests. The cardiologist will read the reports and determine your best course of treatment. Drugs might be injected, dispensed by the pharmacist in the hospital. You might have an operation or other procedure, and then be admitted to the hospital to recover. While you are in the hospital, your care will be managed by a variety of doctors, nurses and aides, depending on what day of the week you are admitted.

Once you are well and stable, some rehabilitation and exercise might be ordered for you at an inpatient facility staffed by physical and occupational therapists. This may or may not be part of the same hospital as your initial treatment. Then, once you are pretty much well, you will be discharged back home with medication and some new orders to live your life differently. Perhaps you will have a primary care doctor visit in the next few weeks or a follow-up office visit with a cardiologist. Maybe more physical therapy on an outpatient basis, too.

Whew! How many times did you get “handed-off” as a patient in that process? How many different people “touched” you as a patient? When you are probably the most vulnerable you will ever be in your life, I counted more than 10 times someone new would need to read and understand your condition and treatments. So I have to ask, who’s keeping score on your health? Do these people talk to each other? Do they have a meeting to plan out how to make you well? Do they all know what the other one is doing to you?

How do we incent better care, more economical care in the marketplace?

Wouldn’t you like all of them to be on the exact same page when it comes to your medical condition, what’s wrong with you, what surgery/treatments you’ve had? Don’t you want them to COORDINATE their efforts in making sure you get your life back? I sure would. PLEASE!

Surprisingly, until just a few years ago, there were no systems or incentives to get all the medical providers we mentioned above to partner and coordinate your care across all of their different responsibilities. Can you imagine the care gaps and medical errors that happen in a system like that? What if  all those different people charged to get you well don’t talk to each other?

Scary. Very scary!

Fear not! I have good news! Blue Cross is driving change in that process for our patients here in Louisiana.

Iinterim Blue Cross Medical Director Dr. Paul Murphree tells us how that old non-coordinated system is being gradually pushed back, and the exciting new ways medical providers are COORDINATING their care across all those different practice boundaries are becoming a reality. Dr. Murphree says that without Blue Cross to motivate them and tie payments into how well they coordinate care, it might never have happened.

It began with an important, simple question: How do we incent better care, more economical care in the marketplace?

Murphree says. “We started with Quality Blue Primary Care [QBPC] to encourage primary care physicians to improve the health of people with diabetes, heart disease and high blood pressure and keep them OUT of the hospital. Now we’re moving on to hospitals and the rest of the healthcare system to incent safety and efficiency in our network agreements. Now that Medicare, for example, won’t pay if a patient is re-admitted within 30 days for the same problems, the coordination of care for discharged patients is a huge deal.

“We’ve created this program called the Quality Blue Value Partnerships (QBVP), and it puts an expectation on the docs, hospitals, and a variety of other medical providers that we contract with, to share the risk of caring for the patient across traditional care boundaries. When we put the right financial incentives in place, they work hard to make sure those handoffs are smooth and that the ENTIRE patient care cycle is being coordinated.”

The government has actually helped the process along. “When CMS created Accountable Care Organizations [ACOs], they actually set up a template that allowed these different organizations to share information, coordinate care and share the savings the system gets by avoiding lots of medical errors and gaps in care. This allows for treating the patients’ episode of care [the heart attack, for example] holistically among all their medical providers,” Murphree said.

Murphree says coordination of care can be a simple change. “ACOs can even have a hospital-run committee to coordinate care for specific conditions, like heart failure management, across the entire healthcare value stream: PCP, hospital, rehab, even at home, how to keep them home. It opens up incentives to view the ENTIRE patient’s spectrum of care, and if we structure the incentives properly, they are motivated to view the patient’s care across all the providers in the ACO.”

Coordination of care is the future of medicine.

(I can tell already where I want to have MY heart attack…Where is the nearest ACO?)

Turns out there are eight of these ACOs set up around the state already, and since Blue Cross is the largest private payer in the state, we were able to use our marketing clout to incentivize them to  partner with us. Done properly, it’s much better for the patient, and it turns out, the healthcare system. And the kicker is, it SAVES money AND reduces medical errors at the same time. Cool!

“We set financial expectations for each ACO in the state, a sensible rate of growth in their healthcare spending, and, if they coordinate care properly [and if] they exceed our expectations, then the financial savings are shared with them,” Murphree explained. “This really gives them a way to maximize their revenue and focus on patient safety instead of just the volume of care they are delivering. It is value and safety all rolled into one.” And sharing data AND responsibility for the patient’s outcomes across these traditional practice boundaries are the key.

It’s worth noting that the “old” way of doing things described in the beginning of this post is still out there in Louisiana, nowhere near extinct just yet. Without the ACO structure and the expectations for care coordination across these traditional boundaries, Murphree says, the new programs make no sense for medical providers. “In fact, the old incentives pay facilities better when they DON’T coordinate care, which is why Blue Cross, as the largest payer, was so critical in making Quality Blue Value Partnerships a reality for Louisiana. For patient safety and the effectiveness of medicine, we had to do it. And nobody else in Louisiana had the power but Blue Cross.”

And it’s already starting to have an impact:

The five ACOs that participated in the first full program year of Quality Blue Value Partnerships saved 1.7% in their total healthcare costs. The most successful groups saved 3.8% on average. Those are small percentages, but they amount to tens of millions in total dollars saved. Even more promising, the ACOs with the best health outcomes for their patients had the highest total savings.

Three more ACOs have signed on for the second year, and Blue Cross hopes to form even more successful partnerships going forward.

Coordination of care is the future of medicine. It’s up to payers like Blue Cross to make sure that information and responsibility for care coordination are shared among every medical provider who touches the patient. You WANT that to happen when you have your heart attack. Trust me!

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