Medical home: Better health at same or reduced cost? - Grand Island Independent

The first year of the Blue Cross Blue Shield "medical home" program was successful enough that the insurance company is expanding the program.

The first year of the program focused solely on Blue Cross Blue Shield patients with diabetes, beginning with clinics in nine communities that managed the care of 1,243 Blue Cross Blue Shield patients.

Blue Cross Blue Shield reported that participating patients had 10 percent fewer hospital visits and 27 percent few-

er emergency room visits, compared to patients who did not participate in the medical home program, said Dr. Dave Filipi, medical director of quality advancement for Blue Cross Blue Shield of Nebraska.

"We're trying to reduce waste," said Filipi, who said it is "waste" whenever a person is hospitalized or makes an emergency room visit when such care could have been avoided. He said whenever people talk about "health care reform," what they really mean is trying to "bend the cost curve down."

Because hospitalizations and emergency room visits are so much more expensive than routine doctor office visits, avoiding them bends the cost curve down, Filipi said. During the initial year, Blue Cross Blue Shield did not try to quantify cost savings, although that will eventually be done.

One physician who participated in the medical home program was Dr. Tom Werner of the Grand Island Clinic. While Blue Cross Blue Shield provided a small financial incentive for doctors to participate, Werner said he wanted to participate because "it's the right thing to do. I think it's better for patients and a better way to practice medicine."

Blue Cross Blue Shield said the medical home program was designed to reward doctors for achieving better patient outcomes, rather than receiving income from the traditional fee-for-service model.

If a person was to ask most doctors whether their diabetic patients are well-controlled, Werner said, they would reply, "Yes."

However, that affirmative answer would be applicable only for the diabetic patients whom a doctor sees on a regular basis, Werner said. It is easy for a doctor to forget about the diabetic patients he doesn't see that often.

Those are the patients who may schedule an appointment only when they have a specific problem, he said. They also are the ones whose diabetes may not be well-controlled.

He said the Blue Cross Blue Shield program paid a very small amount per patient for his clinic's care coordinator to review patient records and discover which ones had not had a doctor's appointment for a long time.

The care coordinator contacted patients and asked if they would make an appointment, he said. Many diabetics know they should see their doctor regularly, but it is easy for people to lose track of how long it has been since their last appointment.

"They may think it's three months, but it's been a year," he said.

Patients who made the appointments had their blood sugars or A1C checked, as well as their blood pressure and cholesterol. They also had their kidney function checked, Werner said.

He said he also was responsible for ensuring his patients saw other health care professionals regularly, especially their eye doctors. Diabetic retinopathy is the most common diabetic eye disease and a leading cause of blindness for diabetics.

For Werner and the Grand Island Clinic, the financial incentives for improved patient outcomes were a mixed bag. He said he's not sure the per-patient reimbursement for contacting diabetic patients ended up providing full compensation for the labor involved. However, that expense was partially offset by revenue generated by additional patient visits.

Werner said the financial incentives for "good patient outcomes" were paid to doctors if they could show a positive trend line for patients for A1C or blood sugar results, blood pressure, cholesterol, kidney function and so on.

While documenting the positive trend lines on those key tests was not a big problem for clinic personnel, documenting that patients had seen other medical professionals was a bigger problem, he said. Grand Island Clinic had letters between the various offices to show his patients had kept their other appointments.

However, Werner said the clinic's electronic file system did not mesh with the Blue Cross Blue Shield system when it came to documenting patient visits to other doctors. As a result, the clinic did not earn the incentive for good patient outcomes. The clinic now has its system aligned so it can provide the correct documentation.

Werner said he is participating in the BCBS-Nebraska program for a second year.

He believes a medical home program saves money for both patients and an insurance company because of the high costs associated with poor diabetic control.

The most severe complications include amputation of limbs, dialysis in case of kidney failure or perhaps even a kidney transplant, heart attack, stroke and blindness, he said.

In some ways, Blue Cross Blue Shield decided to enter "one room" — diabetes — of a medical home program, Werner said. For its second year, Blue Cross Blue Shield will enter many more rooms.

He said the Nebraska Medicaid program is using a different approach with pilot medical home programs in Kearney and Lexington. Those programs are striving to reduce hospitalizations and ER visits regardless of the medical condition a patient might have. The financial incentives for the program are also structured differently, emphasizing a per-patient reimbursement for bringing Medicaid into a medical home.

State Sen. Mike Gloor noted in The Independent on March 15 that Werner has been working with the Department of Health and Human Services, Medicaid Division, on the pilot program.

Because hospitalizations and ER visits are so expensive, Werner said, he believes a properly operated medical home program can provide people with "better health at the same or reduced cost."

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