Gail Metcalf takes her patient by the hand, leads her to the kitchen of her East Boston apartment, and helps her step onto a scale.
She checks the weight, then checks her notes. Up four pounds.
Her patient, 86-year-old Rose Fiorino, lives with lung disease and congestive heart failure. If Fiorino isn’t careful about what she eats, her body could swell with fluid, sending her to the emergency room. The last time that happened, in late 2013, Fiorino was in the hospital for a month. Metcalf is here to make sure that doesn’t happen again.
Metcalf is a nurse practitioner who makes house calls, part of a program that represents the next phase of health care, one that aims to rein in costs by managing many aspects of patient care — from diet to medications to post-operative recoveries. When Metcalf’s employer, Beth Israel Deaconess Care Organization, succeeds in keeping chronically ill patients like Fiorino out of the hospital, it earns extra money. When Fiorino’s health worsens and she requires intense and expensive medical care, the health system pays the extra costs.
Under pressure to control spending, health insurers, doctors, and hospitals are increasingly ditching the old fee-for-service system that compensates them for every test, procedure, and hospital stay, and turning instead to a more personal managed care approach that rewards providers for sticking to a budget while keeping patients healthy and out of hospital beds.
The movement gained attention when Blue Cross Blue Shield of Massachusetts, the state’s largest health insurer, began offering alternatives to the fee-for-service system in 2009. Other commercial insurers, as well as Medicare, the government program for seniors, later followed.
Now, Blue Cross is working to expand alternative contracts to hundreds of thousands of new members. Medicare has committed to shifting half of its payments to alternative models by 2018. And a national coalition of large health systems and insurers has committed to putting 75 percent of payments into such contracts by 2020.
“The traditional fee-for-service payment systems quite simply aren’t sustainable,” said Rocco Perla, a division director at the Center for Medicare and Medicaid Innovation.
Alternative payment contracts give health care providers a budget to care for large groups of patients. But unlike the last effort to control expenses through managed care in the 1990s, today’s models place more weight on the quality of care than mere cost-cutting. Doctors and hospitals get extra pay only if they perform well on a variety of measures, from reducing hospital readmissions to keeping patients’ blood pressure in check.
These changes in the way doctors get paid mean little to healthy patients. But people with chronic diseases, who frequently find themselves in doctors offices and hospitals, will see a difference.
Health systems are assembling teams of doctors, nurses, pharmacists, social workers, and health coaches to check on high-risk patients at home, by phone, and with letters and e-mails. Sometimes preventive care involves steps that may seem to have little to do with medicine, such as sending a cleaning service to remove clutter in an elderly person’s home to prevent a fall, or helping pay for medications by finding discounts for food or heating.
In Lunenburg, Cheryl Moisan, a mostly healthy 66-year-old, is insured through a Blue Cross plan that rewards doctors for scoring high on quality measures, such as ensuring that patients get preventive screenings that can detect problems early and help avoid expensive complications. As a result, Moisan regularly gets letters and phone calls reminding her it’s time for a colonoscopy, a mammogram, or a blood sugar test.
Without those reminders, Moisan concedes, “I don’t know if I would remember.”
Telling patients to keep up with their health may seem routine, but it represents a dramatic change for many doctors, said Dr. Tom Scornavacca, Moisan’s physician. Traditionally, health care providers have viewed screenings, diet, and disease management as the responsibility of the patient; under new models, it’s the responsibility of providers, too.
“It really has flipped the system on its head,” said Scornavacca, who oversees population health at UMass Memorial Health Care in Worcester.
Studies show these new payment models can save money. A Medicare pilot program called the Pioneer Accountable Care Organization saved $384 million in its first two years, according to a report from the federal government.
Fiorino gets her care through the Pioneer Accountable Care Organization run by Beth Israel Deaconess. For her, leaving the house is a project. Just getting down the 18 narrow stairs from her living room to the street, oxygen tank in tow, can take 15 minutes.
Plus, Fiorino hates hospitals; she finds them noisy and lonely at the same time. She would much rather stay at home, resting in her favorite recliner, surrounded by family photos,with her little dog, Elvis, at her side.
At least once a month, Fiorino gets a visit from Metcalf, her nurse practitioner. Metcalf checks her breathing, gait, oxygen levels, and, crucially, weight. When she noticed on a recent visit Fiorino’s weight had jumped four pounds, she suspected it was fluid buildup — a common side effect of congestive heart failure.
She asked Fiorino to increase her medication for a few days to remove the extra fluid. It’s a simple treatment that has helped Fiorino in the past.
“By seeing the person, I can intervene early,” Metcalf says. “I may be able to avoid an emergency room visit.”
Not all providers embrace new payment models and the changes they demand. Dr. Kosta Deligiannidis, a family physician at a UMass Memorial medical practice, said Blue Cross’s quality measures are too specific and not necessarily indicative of a patient’s health.
For example, Deligiannidis said, some of his diabetic patients don’t need a blood sugar test as often as the insurer requires. “It adds cost and waste to the system without any benefit,” he said.
But for Fiorino, the accountable care model appears to be helping. She had a respiratory infection this past winter, but regular visits from Metcalf, her nurse practitioner, allowed her to recover at home instead of in a hospital. When her little dog scratched Fiorino’s leg a few weeks later and caused a serious bleed, she again stayed home while Metcalf monitored the wound.
Fiorino doesn’t know what an accountable care organization is, or that she is part of one, but she knows she enjoys seeing her nurse practitioner in her home every few weeks.
“She’s so good,” Fiorino said, clutching Metcalf’s arm. “I’m so lucky she comes.”