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Massachusetts health care — wonky, with a healthy dose of reality

Moving from Fee-for-Service to Coordinated Care: How to cut costs without cost shifting or shrinking networks

Moving from Fee-for-Service to Coordinated Care: How to cut costs without cost shifting or shrinking networks

June 5, 2012

Guest Blogger, Anne DiNoto, HCFA Activist and Arlington Resident 

There’s a healthcare revolution happening in Massachusetts currently being debated in the House about the best way to provide quality care and save money.  But how will this impact you and me and our families?  The hope is to integrate all care to a coordinated care model.

In February, my Uncle Bob was diagnosed with Acute Myeloid Leukemia (AML).  AML is a cancer of the bone marrow and the blood that progresses quickly without treatment.  I visited my uncle at a fee-for-service hospital in Philadelphia last weekend with my sister.  When we met the night nurse, she asked my uncle what meds he was on. She said she hadn’t read his chart yet but had a general sense of his ‘type’ of case.

In his recent interview on MSNBC , Joe Klein talks about his cover article in the latest issue of TIME provocatively titled, , “How to Die,  What I learned from the last days of my Mom and Dad.”

Klein talks about the flaws in the fee-for-service health care system and how doctors at Geisinger Medical System, which uses a coordinated care model, helped him through some of the toughest decisions he ever had to make. “I had a Flotilla of doctors to deal with before bringing them to the nursing home with the coordinated care model.” When he moved to coordinated care, he writes, “All of a sudden people stopped sticking needles in my parents. I became part of the team making the basic life and death decisions about my parents’ lives.  It made this very difficult process a lot better.”

Over the course of his parents’ care at Geisinger, Klein also saw a drop in his parents’ hospitalizations—Klein’s parents had been rushed to the hospital three or four times because of conflicting drugs prescribed by different docs. His parents had case managers, who visited two, three or four times a week.

By reducing preventable hospital admissions and unnecessary testing in the accountable care model for chronic elderly care, The Geisinger Medical System ultimately cut costs by 7% overall.

As the house begins debate on payment reform today, I hope they emphasize the Accountable Care Model, especially for people with chronic issues and at end of life.  I hope my uncle’s story will shed light on the impact of changing the health care system from fee-for-service to coordinated care.

But there is also something big at stake if this bill isn’t done correctly that could limit care and shrink networks, instead of improving coordination and preventing unnecessary hospital spending.

In 2012, my employer switched to a tiered-network.  The plan network is the same. What’s different is that I pay different copays based on how much my physician charges to the insurance company for my care. But the problem is much bigger than that. Physicians don’t choose how much they charge to insurance companies. Most physicians are part of unions of doctors that join together to try and get the best reimbursement for each visit. And the bigger the union of doctors, the more leverage they have to negotiate higher rates from the insurance companies. My doctor has no say in the matter.

Because my primary care doctor is affiliated with a big group of doctors that charge too much, my copays jumped significantly higher. So high, in fact, that soon, I will not be able to afford to go to my primary care doctor who I have a long-standing relationship with and coordinates my care using electronic medical records.

The goal of tiered networks is to get people to choose low-cost doctors. The sacrifice of tiered networks is my continuity of care.

As the House debates payment reform, I hope they continue to really emphasize how to coordinate care for those patients spending a lot of time at the hospital. However, as they get into market driven forces and tiered networks, I hope they are careful to not sacrifice the patient experience for cutting costs.