Health reform means that much of what health insurance plans did is being taken on by providers. An obvious example is the Choosing Wisely campaign, an effort by physician professional organizations to cut down on overtreatment and overtesting.
The Affordable Care Act shifts a lot of the responsibility and financial risk onto providers, and some doctor groups are rising to the challenge, says John Cuddeback, MD, PhD, chief medical informatics officer for the American Medical Group Association. The AMGA represents a variety of physician group types. More than 130,000 physicians practice in AMGA member organizations, providing health care services for 120 million patients, approximately one in three Americans.
Cuddeback cites the Holston Medical Group (HMG), of Kingsport, Tenn., which has about 150 primary care physicians, specialists, and mid-level providers. In about 2.5 years, HMG reduced hospital admissions per month by 20% for Medicare fee-for-service patients and by 28% for Medicare Advantage and commercial patients. It’s saving about $23 per member, per month overall.
Part of this was achieved by creating an ambulatory intensive care option – a place to keep patients for a few hours who are too ill to be managed in a physician’s office, but who don’t require inpatient hospital care. “They get them stabilized, even let them go home to sleep in their own bed – hospitals can be disorienting, especially for elderly patients, not to mention the risk of infection – and come back tomorrow for more treatment,” says Cuddeback. “The overall cost is much less, and the outcomes are better.”
For commercial contracts, HMG is 3.2% better than market in quality performance, 8.1% better than market in total medical cost. This is a good example of how compensation models are changing, says Cuddeback.
Frank Diamond is managing editor of Managed Care.