HEALTH INSURANCE – Experimenting with success – Bellin, ThedaCare team up for Medicare pilot program aimed at better patient care

Posted on Jul 1, 2012 :: Industries
Posted by , Insight on Business Staff Writer

Dr. John Toussaint knows a thing or two about health care innovation.

The CEO of the Appleton-based ThedaCare Center for HealthCare Value and an author of two books, he thinks the debate over President Obama’s health care reforms is focused on the wrong issue.

“My concern is that we spend way too much on health care – 18 percent of the nation’s GDP is tied up in health care,” Toussaint says. “We need to do something or we’re going to bankrupt ourselves. Costs are out of control.”

The best way to control costs is to reform the system, says Toussaint, who started ThedaCare on its lean journey while CEO. “There are a lot of pilots out there to test new ways for how to pay for health care. No one knows the answers yet. We just have to keep experimenting to see what will work best,” he says.

One such experiment is going on right now in Northeast Wisconsin.

Late last year, Bellin Health, ThedaCare and a network of 700 independent physicians were selected to participate in an innovative Medicare pilot payment program designed to improve health care services for patients.

The Center for Medicare Services picked Bellin Health-ThedaCare Healthcare Partners to be among the 32 organizations nationwide (and the only one in Wisconsin) to be a part of its Pioneer Accountable Care Organization (ACO) model. By organizing health care teams, technology and knowledge around patient needs, the expectation is that ACOs can achieve better care for Medicare beneficiaries while slowing cost increases.

“The end goal is to provide better care for patients,” says Dr. Dave Krueger, medical director for Bellin Health-ThedaCare Healthcare Partners. “For providers, there is a new payment structure where they can provide the best care they possibly can, not the current fee-for-service environment.”

To keep costs in control, the program encourages better coordination of patient services and care. “We’re able to save money by doing things better and differently,” Krueger says.

Working together

Bellin and ThedaCare have a history of working together. The duo jointly owned Touchpoint Health Plan until it was sold to UnitedHealthCare. They continued working together on ways to improve patient care while keeping rising costs in check.

“Bellin has always been a learning, innovative organization working to not only improve the population’s health, but also control costs and improve outcomes,” says Jim Dietsche, Bellin Health’s chief financial officer. “ThedaCare shares the same values, which has made it easy to collaborate.”

The ACO model defines a group of individuals – in this case, Medicare patients whose providers have an affiliation with Bellin Health-ThedaCare Healthcare Partners – and part of the payment to the health care organization is based on achievement of specific goals including process measures, clinical outcomes and patient satisfaction scores.

While Bellin and ThedaCare have been able to access and study patients’ medical histories – for example diabetics who met regularly with a primary care physician and had their blood sugar under control had fewer complications later on – they weren’t able to see the other side of the picture: the claims data. Now through the Pioneer ACO, they can.

“We’ve never had the information accumulate in one spot and to see what the trends were” from the claims standpoint, Dietsche says. Now with the claims information in hand, they’ll be able to get a clearer view of the impact from their changes.

The Pioneer ACO model is designed to work in coordination with private insurance companies and employers with the goal of saving money while improving care quality and outcomes. Since Medicare is the nation’s largest payer of health care costs, any changes they make will dramatically impact how health care is delivered.

“The positive changes we develop out of this pilot program will be felt by everyone since we’ll be improving the way we do things across the board,” Dietsche says.

Data in action

Health care providers know some people overuse emergency rooms and use them instead of a primary care provider. That practice can add hundreds – if not thousands – of dollars to the bill’s bottom line, Krueger says. For example, having a child’s ear infection checked out by an emergency room physician not only takes longer than seeing a provider at a local clinic, it also costs more.

“Before, we only had the data from the electronic medical records if the person was staying in the same health system. We could see, for example they went to the E.D. (emergency department) five times last year,” Dietsche says. “But once you roll in the claims data, you can suddenly see that Patient X actually went to the E.D. eight times total since they weren’t all with the same system. That kind of information tells you a lot.”

It can also help identify patterns and health care providers can then work to reverse some of the negative ones.

“By looking through all the data, we can identify opportunities on how to do things better,” Dietsche says. “We now have more information than ever before and that will help us deliver better overall outcomes.”

Getting some ink

Two new books put ThedaCare and Bellin Health in the spotlight.

Potent Medicine: The Collaborative Cure for Healthcare by Dr. John Toussaint of the ThedaCare Center for HealthCare Value focuses on payment and transparency in health care. The book (a follow-up to the award-winning On the Mend) draws on experiences of area health care providers while pulling in national data to make the case for changing the current health care system.

Bellin Health’s focus on improving population health by providing the right care at the right place and the right cost is featured in one chapter in Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better Health and Lower Costs by Maureen Bisognano and Charles Kenney. The authors talked with Bellin providers, staff members and customers about the changes made and the effect those changes had. For example, companies working with Bellin talk about how the health care provider worked with them to improve their employees’ health, which led to lower costs.