The program, which was reviewed favorably by Harvard medical researchers, has changed the health payment structure in Massachusetts from the conventional "pay for service" model to a "pay for quality" system that rewards the insurer and its provider network for keeping patients healthy.
Dreyfus said that 85 percent of Blue Cross health providers in Massachusetts now use the new contracts, which cover all medical services. The insurer pays a "global budget" fee per member, per month -- depending on a person's health status. Cost-effective management of that person's health is a "shared risk" undertaken by Blue Cross and its network of health providers. If a patient's care runs over budget, Blue Cross and its health providers share the excess costs. If the patient's care is under budget, the insurer and providers share the savings.
"It's starting to work. It's a good model," said Dreyfus, adding that the new contracts have held price increases to a 2 percent to 3 percent increase for the last couple of years. "But it's a means, not an end."
Similar arrangements called Accountable Care Organizations are cropping up in various states, including Missouri. The Affordable Care Act has provided seed money for some of these experimental projects.
Partners, which is Massachusetts' largest hospital system, has participated in a Medicare demonstration project that identified its highest-risk patients. With an average age of 75, they took on average 12 medications, and among the patients' problems were many cases of dementia, Parkinson's disease and heart failure.
Partners' Ferris said the health system hired "care managers" to focus on these patients and explored ways to maintain their health. After three years, he said, the program was able to lower the hospitalization rate of these high-risk patients by 20 percent, resulting in substantial cost savings.
Pediatric cardiologists at Boston Children's Hospital have pursued a novel effort to eliminate unnecessary costs and provide the highest quality care.
Several years ago they first tried clinical practice guidelines, a tool meant to standardize "best practices" and reduce variation in health care. But medicine is constantly changing. The doctors found the guidelines often obsolete, offering few insights into improving care or how to deal with unexpected findings.
So the 10 pediatric cardiologists began gathering data on their own clinical decisions in treating children's symptoms and conditions. They created Standardized Clinical Assessment and Management Plans (SCAMPs), a quality improvement program that collects and analyzes data on clinical decisions and poses clinical questions for further evaluation.
For dozens of medical conditions, SCAMP software has an algorithm with a decision tree that guides doctors in how to treat each patient. Departures from recommended care are expected. Doctors write explanations for their decisions, which can be used to adjust and refine the SCAMP.
Clinicians need "flexible, evidence-based standards" that continually improve care while decreasing unnecessary testing and reducing costs, said Dr. Kathy Jenkins, senior vice president and chief quality and safety officer at Boston Children's and a professor of pediatrics at Harvard University. She credited SCAMPs with a reduction of about 26 percent in certain patient charges at Boston Children's.
SCAMPs programs have been adopted at other New England hospitals and leading institutions across the country, including the Children's National Medical Center in Washington.
Donald Berwick, a Massachusetts health reformer and the former director of the Centers for Medicare & Medicaid Services in Obama's administration, agreed that increased quality of care could result in savings.
"Better care costs less than worse care," he said, pointing to such examples as the Nuka tribal health system in Alaska as well as Project Echo in New Mexico, an innovative health project aimed at rural and under-served areas. "Better care. Better health. Lower costs. It exists."
Still, key players in Massachusetts' lucrative health industry acknowledge that cutting costs will not be easy.
"We're in for a rocky road, nationally," Blue Cross' Dreyfus said.
"The key here is pace," Partners' executive Ferris said. "If we go too fast, we'll lose the (health care) providers and the patients."
(c)2013 the St. Louis Post-Dispatch
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