Ann Finley has faced a host of challenges since her daughter, Mikayla, came into the world 13 weeks early, weighing barely a pound and a half.
Her daughter, now 12, suffers from asthma, attention-deficit hyperactivity disorder and Asperger’s, an autism spectrum disorder. The multitude of appointments with various specialists Mikayla must see makes scheduling complex and overwhelming.
But one thing Finley doesn’t have to worry about now is keeping up with appointments at Mikayla’s pediatrician’s office in Gainesville. A nurse there tracks Mikayla’s records from specialists and calls Finley when it’s time to come in for a checkup.
“A lot of times, I don’t even know it’s time,” Finley said. “And they’ll call to check up on her, just to see how she’s doing.”
The practice, The Longstreet Clinic, is one of a growing number of primary care providers in Georgia teaming up with insurers, specialists, hospitals and others to improve patients' health by better overseeing their overall care and, the theory goes, rein in out-of-control health care costs in the process.
Both Longstreet in Gainesville and Emory Healthcare in metro Atlanta have partnered with Blue Cross and Blue Shield of Georgia to do just that. Launched in 2013, a program through Blue Cross is experimenting with paying doctors based on how patients fare rather than the traditional model of reimbursing for every service, test, and office visit. The program, called Enhanced Personal Health Care, has nearly 1,000 providers participating so far.
Similar programs are popping up across the country.
Insurers like paying doctors based on quality of care versus quantity of services because healthier patients are less expensive to cover. Providers like it because they get paid more for improved patient health. Patients, especially those suffering from chronic diseases like diabetes, benefit from more personalized attention from their doctors.
Critics of the traditional “fee-for-service” model say the outdated system has helped drive up U.S. health care costs far higher than those of other industrialized nations. It’s also led, they argue, to unnecessary tests and lab work that may not really be needed.
The five-year-old Affordable Care Act is helping to accelerate this push toward rewarding providers based on the quality, not quantity, of their care. Under the law, for example, Medicare (the government health program for Americans age 65 and older) is beginning to pay — or penalize — hospitals based on quality of care.
Sharing data
It’s too early to tell conclusively if the partnerships between Blue Cross and providers are succeeding, but early feedback is promising.
Costs have fallen roughly 6 percent among primary care doctors at Emory. The health care system has also seen an about 6 percent improvement in quality measures being tracked.
Insurers and providers sharing information with each other is critical for the Blue Cross program and others like it to work, experts say.
One element that particularly helps is a website with real-time data, said Dr. Christopher Apostol, who practices near Augusta and is participating in the Blue Cross program. It allows a care coordinator in his office to check on what has happened medically with a patient since his or her last visit.
Many practices are also adding care coordinators to further improve the flow of information and to follow up with patients.
When a prescription is ordered, for instance, the coordinator can see whether a patient follows through with filling it. The coordinator can also see when a patient visits another doctor or is admitted to the hospital.
That information gives primary care doctors a more complete picture of patients' health, particularly those who suffer from chronic illnesses, such as diabetes or hypertension.
“Ninety percent of health care is spent on chronic illnesses, and eighty percent of those are preventable,” said Morgan Kendrick, president of Blue Cross and Blue Shield of Georgia.
The strategy is not only about insurance companies saving money; it's also about containing costs so that people can afford medical care they need, Kendrick added.
Challenges remain
Despite some successes, experts say it’s still unclear if the enhanced primary care model can achieve significant savings.
Cost-saving is difficult because while some patients will benefit and end up in the hospital less, others may not need the additional oversight, said David Howard, a health policy expert at Emory University.
“The challenge is to identify which patients do we have to target,” Howard said.
Still, insurers and doctors remain hopeful the approach will help patients stay healthier.
Dr. Jeffrey Reinhardt is seeing some success at The Longstreet Clinic.
The practice has reduced the number of patients readmitted to hospitals and knows if a patient ends up in the emergency department, said Reinhardt, an OB/GYN at the Gainesville practice.
“It gives me the info that I didn’t know about a patient and the ability to take a lot better care of my patients,” he said.
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