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Provision lets hospitals, physician groups share risk, reward

| Friday, June 14, 2013, 12:01 a.m.

At hospitals and physician practices who have signed on, individual patients like Gerald Medlin, 69, are seeing a higher level of service and better care. When Medlin's health began failing in January, his daughter, Beth Medlin-Jackson, found herself in a bind. Her dad, suffering from kidney failure, respiratory illness and dementia, lives by himself in New Bern, North Carolina. She lives in San Diego.

Eyes and Ears

Medlin's physicians at Coastal Carolina Health Care, a participant in the accountable care program, assigned Debbie Sutton to take charge of him. Sutton's job, which exists only because of the health law, is to manage care for patients considered at high risk of hospitalization. She made sure Medlin's hospital doctors and his primary-care physician were coordinating care, that Medlin kept up with his prescription medicines and that his daughter was in the loop. “She's kind of the eyes and ears on the ground there,” Medlin-Jackson said in a phone interview.

Hackensack University Medical Center, meanwhile, has been hiring nurses to identify high-risk patients. Those patients are now instructed to call their nurses directly when they feel ill, instead of their doctors' offices. That's because physicians' offices often recommend that such patients make unnecessary visits to the emergency room, where they are likely to be admitted to the hospital, said Peter Gross, chairman of the HackensackAlliance ACO's board of managers.

High Rate

“We have a very high admission rate at the ER, about 40 percent, which is probably too high,” he said in a phone interview.

Mount Sinai Hospital in New York employed a multimillion- dollar supercomputer called “Minerva,” originally built three years ago for genomic studies, to mine patients' medical claims data and identify those at highest risk to be admitted to the hospital, said Davis, the hospital's president.

A dozen care coordinators hired starting last year by the hospital work with patients identified by Minerva to make sure they fill prescriptions, take their drugs and make it to doctors' appointments. The coordinators also help patients take steps to monitor their conditions, such as weighing themselves daily if they suffer from congestive heart failure, a condition for which weight gain is an indicator of increasing severity.

‘Right Foods'

The powerful computer system is a key to success. Programmers developed an algorithm to identify patients at the highest risk of being admitted to the hospital, Davis said. The supercomputer, built with parts from Dell Inc. and Data Direct Networks, contains hundreds of terabytes of memory. Minerva applies that computational power to consider indicators including patients' life-threatening health conditions, their age, medications they use, where they live and whether they live alone, Davis said.

“We do this for impoverished communities with frayed social networks,” Davis said. “Are they buying and eating the right foods, taking their medicines?”

Accountable care is not a new idea. It was tried with limited success in the 1990s as part of the drive to cut costs through Health Maintenance Organizations, closed networks of doctors and hospitals managed by insurers. This time, advocates, say, there's a greater chance of success.

Davis said that earlier coordinated-care efforts often failed because they were largely run by insurance companies, and the programs weren't perceived to be in the best interests of patients.

‘Adversarial Situation'

“It was an adversarial situation from Day 1,” he said. “There was no sense that decisions were being made in the patient's best interest rather than in the interest of saving money.”

Under the U.S. health reform law, Medicare's accountable- care program requires hospitals and doctors to show they are improving or maintaining the quality of their care before they are paid any bonuses, Blum said. More powerful technology will also help. And unlike in the ‘90s, today's programs are backed by a new law, providing “some surety that the agency will have a commitment to the program,” Blum said.

Still, critics say health providers aren't likely to do any better today than 20 years ago.

‘Expensive' Work

“This stuff is expensive to do. It's very people- intensive,” said Lawton Robert Burns, the chairman of the Health Management Department at the Wharton School of the University of Pennsylvania. “The handful of programs that work -- and they're just a handful -- you have to get nurses and other people like that in front of the patient, not through electronic means, working with the patient, coaching, hovering. That's what it takes and it's very costly.”

There also have been no scientific studies showing whether cost savings reported by hospitals and doctors are attributable to the new programs or some other reasons, Burns said.

“It could be a temporary fluctuation. It could be random,” he said. “They don't know, but they'll take credit for it.”

At Coastal Carolina, care manager Sutton insists it's different this time. The physician group of about 50 doctors signed on with the Obama administration more than a year ago to become an accountable-care organization and hired care managers, including Sutton in July. With degrees in business and nursing, she focuses on the sickest and costliest of Coastal Carolina's patients.

“We're kind of a missing piece of the puzzle,” Sutton said in a phone interview. Each day, she meets or calls some of the 85 patients under her watch, making sure they make doctors' appointments, take medications and stay out of the hospital unless necessary.

“Being a business person, I like people being accountable to me,” she said. “I make the patients accountable to me. It works.”

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