Medical groups try to offer better care at lower cost
PROVIDENCE — Louis Verdelotti felt fine, but the numbers showed danger in his blood. Diabetes was creeping up on him. With his blood sugar levels getting too high, the 74-year-old would need to start injecting insulin — or risk damage to his eyes, kidneys, heart, and blood vessels.
The needle is tricky to learn, and a busy internist such as his doctor, Amy Goldfarb, cannot spare an hour to demonstrate and cajole. But lately, Goldfarb has had help. She referred Verdelotti to Susan Plante, a pharmacist employed by Goldfarb's group, Coastal Medical, a primary-care practice with 20 offices in Rhode Island.
A minor step, it would seem. But the meeting between Verdelotti and Plante was a small, critical piece in a national experiment in changing health care.
Verdelotti is a patient in one of the more than 400 accountable care organizations made possible by the Affordable Care Act. These groups of medical professionals — known widely as ACOs, with some led by doctors, some by hospitals, some by a mix — enter into an agreement to take care of a group of people and try to keep them healthy. The medical groups make a deal with the federal government: If they lower costs for Medicare patients, they get to keep some of the savings, provided that federal standards for quality are met.
The program faced skepticism when more than a dozen early ACOs dropped out. But Coastal Medical, now in its fourth year, stands as an example of an ACO that seems to be making it work: In 2014, it saved $7.2 million while maintaining high ratings for quality.
"With the community-based kind of effort produced in Rhode Island, you can set the stage for national change," said Dr. Donald M. Berwick, former president and now senior fellow of the Institute for Healthcare Improvement in Cambridge and former administrator of the US Centers for Medicare & Medicaid Services.
Still, Berwick cautioned, Coastal is merely "en route to success. You can't say yet they've won the World Series."
No single trick makes it happen.
To prevent needless emergency room visits, Coastal has office hours 365 days a year and stays open till 9 on weeknights.
To help keep sick and recovering patients at home, nurse care managers work in hospitals and nursing homes to ensure patients have the services they need when they're discharged.
When a Coastal patient shows up in the emergency room, the hospital has immediate access to a Coastal doctor who can see the patient's medical record and help with treatment decisions.
And when someone like Verdelotti is having trouble managing an insidious and complex illness, Coastal has a team ready to guide him.
Verdelotti met with Plante, the pharmacist, in her office last March. She answered his many questions, taught him how to inject insulin, and watched as he performed his first injection.
"He left with a lot of confidence that he was going to be able to manage it," she said.
Plante also helped Verdelotti with the financial burdens of the illness, providing medication and equipment samples and helping him select a brand of medicine covered by his insurance.
She has since kept in touch by phone. All the attention prompted Verdelotti to resume swimming regularly. "They motivated me," he said.
The result: Verdelotti's average blood sugar level has fallen significantly since March. His experience will contribute to the high marks that Coastal gets for its diabetes management program.
In fact, according to federal data, Coastal (whose patients include residents in nearby Massachusetts) ranked highest in overall quality of care among the 19 ACOs working in Massachusetts and third-highest in the nation. The Medicare program measures quality based on 33 criteria, from percentage getting flu shots and mammograms to how well patients' diabetes or heart disease is being managed.
At the same time, Coastal saved money, trimming the cost of care for its Medicare beneficiaries by 7.25 percent in 2014, by reducing the use of hospitals, emergency departments, and nursing homes.
The ACO concept aims to encourage providers to take care of all their patients, not just those who come in with complaints, and to keep track of how patients are faring.
"You're making yourself accountable for the care of a population — not just the people who are in front of you, but even the people who might not have scheduled a visit all year with you," said Dr. G. Alan Kurose, Coastal's president.
That means reaching out to patients with serious health conditions — diabetes or congestive heart failure, for example — and urging them to come in for care.
It also means careful data-gathering and tracking, a task made easier at Coastal by an electronic medical records system in place since 2006.
And it means more work for everyone. Coastal increased its staff by one-third, hiring 151 new people: pharmacists, pharmacy technicians, nurses, nurse practitioners, physician assistants, and a slew of medical assistants.
Goldfarb, Verdelotti's doctor, said the program requires lots of clicking on screens and checking of boxes so that others can measure her work. It's time-consuming, but Goldfarb considers it worth the benefit to patient care.
Goldfarb recently had a patient with congestive heart failure who was in and out of the hospital over a period of months. Because Coastal keeps track of such things, Goldfarb was notified and immediately started seeing the patient more often. The practice arranged for blood pressure and weight-monitoring equipment to be delivered to the patient's home, so that problems could be detected early. The patient hasn't been back in the hospital in six months.
"I feel like I have a net that wasn't there before," Goldfarb said.
Unlike many ACOs, Coastal isn't working with Medicare alone. It has similar shared-savings arrangements with the three major health insurers in Rhode Island, and it offers the extra services to all its patients.
Has Coastal found the formula for success? Those who study ACOs say it's not that simple. ACOs come in many shapes and sizes, and the whole endeavor is new and evolving.
"It is tempting to try and figure out a right way and a wrong way," said Michael E. Chernew, health policy professor at Harvard Medical School. "I think it would be a mistake to claim that we have found the answer."
Gregory L. Kennedy, research project manager at the Dartmouth Institute for Health Policy and Clinical Practice, said ACOs are measured in so many different ways it's hard to say who's best. He noted, however, that Coastal showed enough savings to get money back in each of its three years, an uncommon achievement.
Of the $7.2 million in savings that Coastal generated for the Medicare program in 2014, it was allowed to keep $3.3 million. Two-thirds of that money covered the costs of the extra programs.
The rest? It went into employees' pockets. The company's three top executives visited every Coastal office in October, hand-delivering bonus checks with a week's pay.