In June, a partnership involving every major medical provider in the Colorado Springs region will launch a pilot project aimed at changing the way Medicaid patients receive care.
If you’re not on Medicaid, it might not seem like a big deal, but the pilot is a trial run for a new approach to providing, tracking and paying for health care that, if it works, is expected to be the future of health care for all of us.
What’s being set up is called a Regional Care Collaborative Organization (RCCO), one of seven launching this spring across the state. If you’ve followed the debate over health care reform, you might be familiar with the concept by a different name: accountable care organization, or ACO.
Today, if a patient has a problem, they’ll typically see their primary care physician, who might run some tests and refer them to a specialist, who might run some tests and refer them to a hospital, which might run some tests and then release the patient. Those providers generally aren’t talking with each other or sharing the test results, and the specialist and hospital usually have little ability to follow up with the patient after he or she leaves their care.
In an ACO, there’s a lot of talking. The primary care physician will know what tests have been ordered and what treatment has been suggested, and will track the patient after discharge to make sure that regimen is being followed.
In a perfect world, there would be no duplicate tests and no miscommunication, and the patients themselves would follow through on discharge instructions so they never have to be readmitted to the hospital or rushed to the emergency room for a problem their primary care doctor could have handled. If everything works, patients will be healthier and there could be significant cost savings.
“That is the main theory behind it, that you provide better care for the individual because it’s all coordinated and all the different providers are talking to each other,” said Carol Bruce-Fritz, executive director of the Community Health Partnership in Colorado Springs, the organization that is leading the RCCO. The Community Health Partnership was formed in 1992 to foster a coordinated approach to health care issues in El Paso County.
“One of the main problems with our current health care system is there is poor communication between providers,” said Dr. Judy Zerzan, chief medical officer for the state Department of Health Care Policy and Financing, which oversees the state’s Medicaid program and initiated the pilot program.
“This model will also allow there to be earlier screening of chronic conditions so those can be addressed earlier and save us money. It’s really a win-win for everybody.”
Although ACOs play a part in the Patient Protection and Accountable Care Act (PPACA), the controversial health reform bill passed a year ago, what’s happening locally comes from the state Department of Health Care Policy and Financing (or HCPF, pronounced “hickpuff”). While the PPACA is expected to spur the creation of ACOs for Medicare patients (400 pages of guidelines for Medicare ACOs were released last month), the state effort was already in the works before the federal bill was finished.
“Because we were thinking about how to improve care for Colorado before the Affordable Care Act passed, we’re kind of ahead of the curve,” Zerzan said.
HCPF is counting on the ACO pilot program to shave more than $8 million off the state’s Medicaid budget over the next two years — over and above the roughly $27 million needed to implement the program. That’s a tiny fraction of the $4.6 billion Colorado spends on Medicaid, but if you look at just the 123,000 patients statewide slated to participate in the two-year pilot, it will flatten out the skyrocketing costs of providing care. In health care circles, that’s called “bending the curve” on cost growth.
In the pilot, HCPF divided the state into seven regions and asked for bids to set up and run an ACO in each. In many areas, large health plans or providers led the effort. In Colorado Springs, there’s no one dominant provider or health plan, so all of the players teamed up, Bruce-Fritz said.
An ACO isn’t something any piece of the health care puzzle can do on its own, since the biggest cost savings come from reducing use of specialists and hospital services, while the burden of coordinating a patient’s care falls on the primary care physician’s office (with some help from the RCCO).
“The whole idea is that if you spend more time managing the patient at the primary care level, making sure they’re getting their preventative care done when they have diabetes or high blood pressure, you should be able to reduce the expenses involved with hospitalizations and specialty services. The big savings isn’t in primary care,” said Debbie Chandler, CEO of Colorado Springs Health Partners, which, along with Mountain View Medical Group, will be providing specialty services to the regional collaborative.
Jackie Driscoll, chief business development officer in Southern Colorado for Centura Health, Penrose-St. Francis Health Services’ parent company, said hospitals can benefit by providing less unnecessary care.
“We do know that, in the long term, (ACOs) may bring emergency room utilization down,” she said. “That’s fine. It’s best for us if our emergency rooms are available for trauma care patients.”
Getting doctors and hospitals and other providers on the same page is no easy task, however. Everyone has their own electronic medical record systems, none of which talk to each other. There’s not a system yet for managing patients in this way, such as making follow-up calls or tracking outcomes. If costs are saved, whose pocket does that money come out of? If there’s money left over, who gets it?
The Community Health Partnership is working to find solution to those problems by June 1, when 8,600 Medicaid patients kick off the program. Peak Vista Community Health Centers will provide most of the primary care and the care coordination for most of those patients, while the Community Health Partnership is the umbrella organization in charge of the regional collaborative.
In the first year of the collaborative, all of the patients will be in Colorado Springs. Peak Vista and the Community Health Partnership will receive a $12 per-patient, per-month payment from the state to pay for additional staff and resources needed to run the collaborative. Participation in the pilot is voluntary, although patients will have to opt out if they don’t want to join.
Bruce-Fritz hopes most participants will see the program providing improved care and services, not just cost-cutting.
“The really important thing about an accountable care organization is that it is patient-centered,” she said. “It’s going to save money, but more importantly it’s going to provide better health care outcomes.”
Later this year, an additional 9,000 patients locally (63,000 statewide) will be enrolled in the collaborative and the local partnership will be responsible for a larger area, incorporating Teller, Park and Elbert counties.
If a RCCO meets its goals, there will be a $1 per-member, per-month bonus payment, which the collaborative can split up however it likes. If the program moves beyond the pilot phase, the intention is to expand those bonus payments so that providers will have an ongoing incentive to control costs and coordinate care, said Laurel Karabatsos, deputy director of HCPF.
“This is a little, teensy baby step of payment reform,” she said. “When we’re able to establish that the program is saving us money, we’ll be able to share that back with providers.”
In many ways, Medicaid patients are a good test case for ACOs. There’s a single payer — the government — who can track costs and outcomes. Many Medicaid patients have chronic health problems that could be better managed at a lower cost with a coordinated approach. And, for many medical providers, Medicaid pays less than what providing care actually costs, meaning that there’s an incentive to keep Medicaid patients as healthy as possible so they don’t lose money seeing them over and over again.
The flip side is that most Medicaid patients are, by definition, poor and have health problems, which means they’re facing stiff challenges in their daily lives. That’s why working with patients is just as important as getting providers on the same page, said Bruce-Fritz of the Community Health Partnership.
“If there are other barriers to care, there will be resources available,” Bruce-Fritz said.
“If a barrier to care is that you don’t have transportation, then we’ll help you figure out transportation. If a barrier to care is that you need someone to translate for you, then we’ll do that. It’s a comprehensive look, because you can’t isolate somebody’s health from the rest of their life.”
If the Medicaid RCCO pilot is successful, HCPF hopes to expand it to incorporate other needs such as behavioral health and dental care, Karabatsos said.
Meanwhile, the Community Health Partnership and its members see this program as a vital test-run for how the local health care system can pull together for the day when private insurers and other payers demand accountable care.
“I think the health plans are all looking for strong networks like this that are willing to work with them on projects like this,” said Centura’s Driscoll.
“Many, many hospital systems, health care systems and provider groups have been moving in this direction anyway, because it’s the right thing to do.”
And Colorado’s test will be closely watched by the country, said Dr. Michael Welch, Peak Vista’s vice president of medical and dental services and the medical director for the RCCO.
“This collaborative approach will no doubt become a model for other communities throughout the country as we look to enhance our health care system,” Welch said.
Beyond that, the regional collaborative is getting local health care providers to work together more closely than they ever have before, said CSHP’s Chandler.
That’s likely to improve the system for everyone, whether it’s Medicaid, Medicare or someone else paying the bills.
“We do hope that it will help us change the way we take care of these patients as a community,” Chandler said. “Obviously, you don’t just design the system for the Medicare patients — other patients are in the same system.”
It’s an ambitious plan and the clock is ticking. In many respects, the partnership will be building the ACO ambulance while it’s speeding down the highway.
“I don’t think anybody really knows how all of this is going to play out,” Bruce-Fritz said. “There’s an agreement that the way we’re doing this now is not sustainable.”
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HEALTH CARE REFORM GLOSSARY
Talk to a health care expert for more than a minute and you’ll get enough acronyms to make your head spin. ACO? RCCO? PPACA? What the heck does it all mean?
Here are a few of the more common terms being bandied about:
Accountable care organization (ACO) — An umbrella organization that combines primary care physicians, specialists and hospitals in an attempt to coordinate care and reduce unnecessary costs.
Regional Care Collaborative Organization (RCCO) — One of seven regional organizations selected by the state to oversee a Medicaid ACO pilot program. The first RCCOs begin operating on May 1.
Patient-centered medical home (PCMH) — The basic building block of an accountable care organization. In the medical home model, a patient’s primary care office coordinates and tracks the care being provided by specialists and hospitals, and also makes sure that patients follow through on care regimens and follow-up care.
Patient Protection and Affordable Care Act (PPACA) — The 2010 health care reform bill. Among the many measures in its 900-plus pages is a push to set up accountable care organizations for Medicare patients.
Centers for Medicare and Medicaid Services (CMS) — The federal agency responsible for Medicare and Medicaid. Charged in the PPACA with implementing ACO trial programs.
Department for Health Care Policy and Financing (HCPF) — The Colorado agency that oversees the state’s Medicaid program and set up the care collaborative pilot programs.
Community Health Partnership — An alliance of the major health care providers in El Paso County. It was formed 18 years ago to foster a coordinated approach to local health care issues; earlier this year, it won the HCPF contract to run the local RCCO.