CATHOLIC HEALTH INITIATIVES
A new agreement between Mercy Medical Center-Des Moines, Iowa, and Wellmark Blue Cross and Blue Shield of Iowa could slow increases in health care costs, improve patient care and, just maybe, address a source of frustration that has troubled Dr. David Swieskowski throughout his medical career.
"The physicians and the hospitals, we've often seen opportunities where we could do an intervention and prevent hospitalization at a relatively low cost," said Swieskowski, senior vice president and chief accountable care officer for the 802-bed Catholic hospital in Iowa's capital city. "But under the existing system, that intervention would not be reimbursed. And, if (the intervention is) successful, then we won't get a hospital admission, and we lose money there."
In other words, he said, the health care reimbursement system punishes providers for keeping patients well — which doesn't align with Mercy's mission of improving the health of the communities served by the Catholic hospital. Swieskowski has hope, though, that the collaboration announced in May between Mercy and Wellmark will reward doctors and hospitals for keeping Des Moines residents healthy and out of the hospital.
"Now, as a system, we react to patients' needs," he said. "We're going to switch that around and get ahead of the patients' needs."
Swieskowski's optimism is focused on a Mercy accountable care organization that will assume responsibility for managing the care quality and health care spending of about 23,000 healthy and ill patients in Mercy's nine-county service area, no matter where in the system the patients receive care. The individuals and families in the cohort are insured through Wellmark and either have selected Mercy-affiliated physicians as their primary care doctors, or have a demonstrated history of visiting Mercy-affiliated doctors.
The agreement between Mercy and Wellmark provides a shared-savings overlay to a traditional fee-for-service model, explains Mike Fay, vice president of health networks for Wellmark. In simplest terms, if the health system comes in below the average per-member, per-month cost targets for health care services, Wellmark will share the overall cost savings with Mercy at the end of the year. Wellmark will share, that is, provided the Mercy ACO does not lose ground in six predetermined quality measures. And, if those quality measures demonstrate additional improvement, the health system earns an additional bonus.
"This really works if at the end of the year they're really successful, and we write them an extra check, which seems kind of odd coming from a payer," Fay said. "But if that happens, it means the member experience, the quality of care and the financial performance is really getting better. That's what we really want to happen."
Learning curve
As the federal government implements health care finance reform through Medicare-based accountable care organizations and other demonstration projects (Mercy is also, independently, involved in a Medicare accountable care organization), many private insurers continue to move into arrangements that allow providers to accept cost and quality responsibility for groups of non-Medicare patients, Fay said. The Mercy agreement, which took effect at the same time as a similar accountable care organization agreement with Iowa Health-Des Moines, the city's other major health system, is the first for Wellmark Blue Cross and Blue Shield of Iowa, Fay said. But across the Blue Cross and Blue Shield universe there are at least 29 other such agreements either in effect or under development, he said.
These agreements vary greatly, but the fundamental mission of an accountable care organization is to "move the payments and incentives away from the existing piecemeal, fragmented delivery system," said Alwyn Cassil, director of public affairs at the Center for Studying Health System Change, and toward a system that is more responsive to the needs of patients.
"We still have a health care system designed to provide for acute episodes of illness or injury, while in reality we are a nation of people living with chronic conditions," she said.
Accountable care organizations, Cassil said, currently are based on the traditional fee-for-service model, and are an interim step toward broader payment reforms, providing an opportunity for interested providers to develop the administrative infrastructure they will need as reimbursement models move away from fee-for-service.
Swieskowski has a similar view of the evolving reimbursement system: "Eventually, we're going to be given a set budget per person. We need to jump in and do this now so we can learn how to do it."
Measuring performance
There are three components to the Wellmark-Mercy accountable care agreement, Fay explained: a quality index that sets measures for participation, cost control and continuing improvement incentives.
The quality index is based on six distinct groups of measures, known as domains (a term borrowed from Medicare): member experience, primary and secondary prevention, tertiary prevention, continuity of care, chronic and follow-up care and patient health status. In order to participate in the shared savings, the hospital or health system must maintain or improve in these areas, Fay said.
According to the agreement, the health system will need to meet metrics in primary and secondary prevention and chronic and follow-up care in the first year — while performance accountability on the remaining domains will be phased in over the next three years.
Both sides wanted to focus on improving quality of care and avoid negative comparison with health maintenance organizations of the 1990s and perceptions that patients were denied necessary care in order to control costs.
"We want to make sure the quality of care doesn't go down in order to meet the financial goals," Fay said. "We all want to do this in a way that makes sure the member is getting the appropriate care."
Annual accounting
But cost control is definitely part of the equation, Fay said. In the second component of the Mercy-Wellmark agreement, the health system's annual per-member, per-month costs for the health system's attributed members will be compared against targets based on historic performance and other economic indicators.
Throughout the year, Mercy will be paid under the traditional fee-for-service model, but at the end of the year, if the quality scores are the same or better and if costs are below the target, Wellmark will pay Mercy a portion of the savings.
Eventually Mercy will share upside risk too, and may have to return some payments to Wellmark if costs come in above the target. That aspect of the plan won't take effect until year three, Fay said.
The third component of the plan involves continuing improvement. If the health system demonstrates progress in quality scores — over and above what is required to participate in the program — this could lead to additional payments to the health system beyond the shared savings.
Swieskowski doesn't expect miracles. "If we can save 3 percent of the total costs of care (measured against projections for growth), I'll consider that a big win," he said. More important to Mercy's patients, he said, is that the accountable care organization will give hospitals more flexibility in how they provide care.
For example, the health system is planning to provide health coaches for all patients, with a special emphasis on high-risk patients — those with two or more chronic diseases. The coaches will help make sure the patients take their medications and follow treatment plans and receive the appropriate tests at the right time.
"Then we're going to have patients who have better control over blood sugar, better control over blood pressure, for example," he said. "We think we'll have a much better chance of preventing strokes."
Ministry members participating in CMS' ACO programs
Catholic health care providers are among those forming accountable care organizations being certified by the Centers for Medicare and Medicaid Services.
The CMS' Pioneer ACO Model program is for early entrants into the ACO field. It enables them to move more rapidly from a shared-savings, Medicare payment model to a population-based payment model. Catholic providers that are part of Pioneer ACOs include:
-
Genesys Physician Hospital Organization, Flint, Mich., a collaboration between Genesys Health System of Grand Blanc, Mich., and Genesys Physicians Group Practice.
-
Seton Health Alliance, an ACO involving Seton Healthcare Family of Austin, Texas; the Austin Regional Clinic; community physicians and other providers.
CMS' Medicare Shared Savings Program incents participating organizations to coordinate care along the care continuum so that providers improve the quality of care for Medicare fee-for-service beneficiaries and reduce unnecessary costs and service duplications. Catholic providers that are part of shared savings ACOs include:
-
Dean Clinic and St. Mary's Hospital Accountable Care Organization, Madison, Wis.
-
Mercy Health Select, Cincinnati, the managed care organization of Mercy Health of Cincinnati
-
MissionPoint Health Partners, an ACO involving Saint Thomas Health of Nashville, Tenn.
-
University of Iowa Health Alliance, an ACO that includes Des Moines, Iowa-based Mercy Health Network; Genesis Health System and Genesis Health Group of Davenport, Iowa; Mercy – Cedar Rapids, Iowa; and University of Iowa Health Care, based in Iowa City, Iowa.
-
Catholic Medical Partners, Buffalo, N.Y., an ACO involving Catholic Health of Buffalo; Mount St. Mary's Hospital and Health Center of Lewiston, N.Y.; and more than 900 independent physicians.
Copyright © 2012 by the Catholic Health Association
of the United States
For reprint permission, contact Betty Crosby
or call (314) 253-3477.