News & Events

Managed care taken to next level

State can learn from Blue Cross approach

By Ed Moscovitch | Wednesday, February 16, 2011 |

The very promising early results from Blue Cross/Blue Shield of Massachusetts’s imaginative new approach to managed care have major lessons for the broader push to control health care costs.

I’ve spoken at length with the doctors leading three of the most successful provider groups participating in the AQC (Alternative Quality Contract) — the Hampden County Physician Associates, the Cambridge Independent Practice Association associated with Mount Auburn Hospital, and the Lowell General Physician Hospital Organization.

What struck me in all three practices was how excited these doctors were. They feel liberated from the fee-for-service treadmill — the prevailing payment system under which doctors rarely have time to talk with one another or with their sicker patients.

Each of these groups has built an extensive network of nurses and data people to help doctors make sure patients get needed care. This includes making sure primary care physicians (PCP) know when patients use the emergency room, are admitted to the hospital or see specialists — and making sure that the PCP follows up quickly. Psychiatrists are working with primary care docs on how to diagnose and treat depression, how to choose the right drug and how to adjust the dosage.

Cardiologists and orthopedists are talking with PCPs about what symptoms indicate it’s time to call in a specialist. Far from limiting access, all three groups are encouraging PCPs to get specialists involved early. Getting patients right to the appropriate specialist is better care — and can avoid costly tests that may not be needed and expose patients to unnecessary radiation.

Keeping blood sugar and cholesterol levels at appropriate levels is essential to good care of diabetes and heart conditions. Each of these three medical groups has nurses who call or visit patients to ask how they are, to check on their meds, to schedule needed appointments and even to help them find a way to get in to the doctor. If a diabetic patient shows up in the emergency room, the case managers will work with the PCP to make sure the patient has frequent visits to monitor blood sugar and adjust meds as needed.

In traditional medicine, too many patients self-refer.

Someone with a frequent cough and breathing pain may assume the problem is in the lungs (and not the heart), and make an appointment with a pulmonologist; this may take a month or more. Had this patient gone instead to the PCP, he or she could have been referred immediately to a cardiologist — and possibly prevented a heart attack. Blue Cross collects data on 18 quality measures, including patient blood sugar, blood pressure and cholesterol, whether patients receive timely mammograms and colonoscopies, and how satisfied patients are with their care.

The six participating medical groups scored far higher on these measures than other providers in their first year; their rate of improvement on monitoring for diabetes and cardiovascular disease was more than four times what they’d accomplished prior to the contract!

In the program’s first year, AQC groups also met their financial goal — meaning they’d cut cost growth by 50 percent or more — with funds left over to invest in the staff needed to manage care effectively.

The savings come from reductions in emergency room use, hospital re-admissions and costly tests, and in the redirection to community hospitals of patients who don’t need to go downtown.

Over the next few months, state policy makers will be debating how to encourage the growth of such contracts.

They should take care to retain the flexibility Blue Cross has given each group of doctors to innovate and to work out for themselves the best way to manage care in the interests of patients.

A good first step would be to concentrate the state’s own purchase of health care — for state employees, Medicaid, and through the Connector — in contracts similar to the AQC groups.

Perhaps Gov. Deval Patrick will lead the discussion in that direction when he addresses the Greater Boston Chamber of Commerce tomorrow.

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