Many physicians and health policy analysts agree that improving care and reducing medical costs requires greater integration between primary care and subspecialist physicians, but the right pathway appears to remain far off.
The results of new delivery models are mixed, according to physicians and health analysts on a recent panel hosted by the Brookings Institution(www.brookings.edu) to discuss various health care models, such as integrated health systems and accountable care organizations (ACOs), and their likelihood to improve patient care and reduce costs.
The consequences of failing to integrate care, especially for patients with multiple ailments, are clear. For instance, hospital admission rates increase by 50 percent when a patient has a social or psychological problem, according to Carlos Hernandez, M.D., president of WellMed Medical Group, which has clinics in Texas and Florida.
"Social, psychiatric and medical," Hernandez said during the forum. "Those three are what integrated care is all about."
Hernandez also pointed to models such as the Peers for Progress diabetes program as an example of how integration can improve health outcomes. In the Indian state of Kerala, he said, about 20 percent of the population is affected by diabetes. A total of 500 patients participated in the peer program, which led to a slight improvement in care compared with traditional treatment protocols.
- Physicians and health analysts discussed integrated health care models at a recent forum hosted by the Brookings Institution.
- The panelists discussed the desire to move away from fee-for-service payment but noted challenges in adopting other payment models.
- Although panelists praised Medicare Advantage for its success, they said accountable care organization results have been mixed.
Hernandez said physicians in the program work with patients to accomplish reasonable goals, such as walking to the mailbox or eating one piece of bread instead of two. Hernandez said it is often best for a diabetes patient to listen to someone who already has the disease instead of receiving a medical explanation from a physician.
"You can't just say, 'Lose 50 pounds and come back in three months,'" Hernandez said. "You need to make sure the patient understands the complexity of the disease."
It's worth noting that discussions about integrated care typically touch on moving away from fee-for-service payments, the model most physicians rely on.
"Fee-for-service is alive and well," said Brent Asplin, M.D., M.P.H., chief clinical officer for Mercy Health, Ohio's largest health system. "There is no perfect reimbursement model. Global and bundled payments have their downside."
Asplin said investment in primary care is critical but cautioned that making a full transition to new payment models is difficult when large health systems such as Mercy Health continue to rely on fee-for-service for 90 percent of their revenue.
"If only 10 percent of your revenue is coming from global payments or bundled payments, it's a challenge to invest in them," he said.
Citing a recent study(www.nasi.org) by the National Academy of Social Insurance, Thomas Miller, J.D., a resident fellow at the American Enterprise Institute, said the findings indicated that integrated care between hospitals and physicians at large not-for-profit health institutions is not demonstrating savings. He said it is important to separate the high-performing practices and institutions from the poor performers.
According to Miller, Medicare Advantage has performed better than expected, while results for ACOs have been mixed in part because patients can drop out of them without even knowing they were in an ACO.
However, continued cuts to Medicare Advantage by CMS, including a planned 1 percent cut for 2016, have forced many seniors to seek other insurance coverage. Seniors in the program also face higher premiums and greater out-of-pocket expenses for 2015, according to a study(kff.org) by the Kaiser Family Foundation.
Another potential benefit of integrated care is that prevention efforts might increase with greater institutional resources. Asplin said wellness programs are effective for overall population management but are not as important as improving care delivery. Given the existing demands on a primary care physician's time, discussing prevention methods at length with one patient would limit time with others.
Each of the panelists was asked where the health care field might be in three years in terms of quality improvements. Hernandez was skeptical that new ACOs such as the Next Generation model will change outcomes or reduce costs as long as patients have the freedom to choose any primary care physician or subspecialist.
"If you can go to any doctor or specialist, it will lead to the same result," he said. "I don't think we'll see any difference three years from now."
The panelists mentioned the importance of continuing to invest in primary care and the need to increase the number of medical students who enter the field. With the average primary care physician being 50 years old, Hernandez said the ranks could decline unless something is done to reverse the trend.
"We are at a crossroads," Hernandez said. "Most young graduates opt to do something else. We have to incentivize medical school graduates to enter primary care."
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