As more of the Affordable Care Act becomes a reality, rural hospitals are transitioning to a new model of reimbursement from insurers and partnerships with patients called Accountable Care Organizations (ACO).
The changes are being pushed through the Medicare and Medicaid programs, but local health leaders say the model will likely be adopted by paid insurance companies as well.
Patrick Conway, Medicare’s chief medical officer, says that nearly 8 million beneficiaries — about 20 percent of those in traditional Medicare — are now in “Accountable Care Organizations.” ACOs are recently introduced networks of doctors and hospitals that strive to deliver better quality care at lower cost.
“Five years ago there was minimal incentive to coordinate care,” said Conway. “Physicians wanted to do well for their patients, but the financial incentives were completely aligned with volume.” Under the ACO model, clinical networks get part of their reimbursement for meeting quality or cost targets.
Pioneer Community Hospital of Stokes is currently in a two year transition phase, working toward a comprehensive ACO system.
“Managed care has been around for a long time but really it has not been that effective because the purpose was for insurance companies to save money,” said Pioneer Community Hospital of Stokes County CEO David McCormack. “What we are trying to focus on now is improving the health of this nation. We are the wealthiest nation in the world and unfortunately we are one of the least healthy countries in the world. A lot of it is a result of our personal choices and lifestyles.”
McCormack said under the ACO model local physicians would be more focused on the overall health of their patients instead of just treating illnesses when patients came for an appointment.
“We hope to bring people in more often and help them monitor their healthcare better,” he said. “If a patient has diabetes we want them to check their sugar levels everyday so that if they start to get out of whack then we can address that quickly and they don’t get into a critical situation. If we can get situations identified sooner, rather than later, then they don’t get into the acute phase where the money is really being spent and they don’t have to come into the emergency room.
“When a patient calls into the office to get their medicine refilled we might ask them to come into the office to check their blood levels to make sure the medicine is being effective,” he added. “It is part education and part maintenance.”
Pioneer Community Hospital of Stokes County Assistant CEO Pam Tillman said under the new system Medicare would eventually pay the hospital a lump sum to provide care for the area based on the patient base instead of reimbursing for specific procedures.
“There will be a per member, per month amount that we would get for the people who are attributed to our physicians and clinics,” she said. “We are just now getting our attribution list and our community care coordinator has taken that list and we are looking at quality care measures.”
She said the end goal for the new system was to focus on high price health issues like stroke, high blood pressure and diabetes which could be prevented, saving the system money, through more careful management by patients and physicians.
“We will have a claims history on what has been paid out for members of the ACO and see how much it has been costing for their care,” said Tillman. “Then we will work to reduce that cost for the ones that we can and that is where you get on a one-to-one level with the patient and the physician. So if you are a member who is attributed to our office and it costs $10 to take care of me and it costs $100,000 to take care of you then we will need to look at you and see what is happening and find out if that is someone who has fallen through the cracks. Often times we see that those people, instead of coming into the office once every three months, they go to the emergency department 50-60 times a year.
“This is all about how we partner with the patients, and how the system can work with those folks to help them improve and maintain their health,” she added. “They are not going to put us at financial risk for the first couple of year, but then it will get to a point where we will be asked to assume the risk for these patients.”
“The goal is for the healthcare providers to partner with the recipients of their healthcare,” added McCormack. “Eventually the providers will be given a set amount of money and told, based on the data, this is what it is going to cost for you to provide healthcare for this population. Then we are responsible for caring for the population. So our goal is to work with that population to help improve their care. The onus is certainly going to be on the providers because they are the ones holding the bag at the end of the day.”
Tillman said the hospital had recently created several new positions, including a community care coordinator and discharge planning specialists, to help with the transition to the ACO model.
“The discharge planners are doing a transition of care to help the folks who are discharged from the hospital,” she said, noting that they would make sure that all discharge instructions were clearly understood and that there were no questions about how to take prescribed medications. She said the community care coordinator followed up with patients once they were home and helped to identify patients who may need more frequent check ups.
Tillman said there have even been instances where the community care coordinator visited a patient at home to make sure they had all the correct medications.
“It is really changing the way we all think, from having people come to us to helping to identify those people who need extra help,” said Tillman. “There are just a few people who utilize most of the dollars in health care. We want to tackle the top people who need our help. If we can make an intervention with them then that is a lot of savings.”
She said the hospital would continue to do other outreach programs like health fairs and screenings at local businesses, as well as start reaching out to patients who might be at risk of developing a more serious and costly condition.
“The patient should feel a partnership with their medical provider,” said Tillman. “We are going to be reaching out and trying to get them to come in for wellness visits. We are going to try to get them to identify things they could do better as an individual so that they feel it is more of a partnership than just going to see the doctor when you are sick.”
Pioneer considering other changes, but still committed to Stokes County
McCormack said the transition to an ACO model is just one of the many financial issues rural hospitals across the country are facing in today’s rapidly evolving health care industry, but noted that Pioneer Health Services were dedicated to making the changes needed to continue to provide services in Stokes County.
“We need healthcare in this community,” he said. “Every community is facing the same issues we are. How can we do what we do under these pressures? We have to do it more efficiently. Nobody knows what tomorrow is going to be , but we want to provide the best care that we can to the people of this community. We want to make sure the people in this community get what they want.”
He said his company has spent the last year looking at how to more efficiently offer the same level of care for the Stokes community, citing the recent decision to convert the King area emergency room into an urgent care facility.
“The cost associated with an emergency room is much higher than the cost associated with an urgent care,” said McCormack. “We are doing the exact same thing it is just the cost is lower for us. It was a really good decision to make.”
McCormack said the King area could expect additional changes in where and how services are offered in the coming months.
“We are looking at moving some of the services we provide to one location so we can improve services at a different location,” he said, noting that the hospital was waiting on resolving “red tape” with state and federal agencies before making the changes. “We have one facility where we provide radiology, imaging, x-rays and surgery services and it is kind cramping things. We have two centers a mile away from each other where we are doing imaging and labs at both and it does not make sense. If we can combine the imaging in one that will reduce costs and still provide the same services.
“By dealing with duplication of services we can reduce costs and open up the surgery area to give them more space and make it a more efficient operation,” said McCormack. “Ideas like that will streamline our processes, make it more efficient for our providers and more efficient for the patients. The end result will be lower costs to us and the patients but better services and hopefully if the patients in this community support those things we will have better volume.”
McCormack said the community had all the pieces needed for an effective community hospital to succeed.
“We know this community needs the services,” he said. “It certainly can support it with what is here. We have the physical assets to do that. We have everything, now it is our responsibility to put those pieces together and make it work. It looks very promising to us. We are in a lot better shape than a lot of communities in similar situations to us.”
Nicholas Elmes may be reached at 336-591-8191 or on Twitter @NicholasElmes.