August 6, 2010

State health commission hopes pilot program brings quality care, lower costs

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By Barbara Pash

For MarylandReporter.com

The Maryland Health Care Commission recently launched an experiment that could change the way patients receive health care, increase reimbursements to physicians, and generate cost savings for insurance companies.

The commission, which is an an independent regulatory agency, is studying how to improve quality of health care by utilizing primary care physicians through its Patient Centered Medical Home pilot program. Study results will help model future state health care plans.

The goal of the study is to have primary care physicians coordinate 100% of a patient’s care — instead of just seeing them for illnesses or one-time issues. In the study, primary care practices include family medicine, internal and pediatrics.

Physicians participating in this program will essentially manage patients’ medical conditions. They will provide 24/7 telephone response with clinicians, and offer same-day appointments. They will also coordinate patient medications, and use electronic medical records.

Patients will immediately benefit from the program by having more services available from their primary care physicians, said Ben Steffen, director of the commission’s Center for Information Services and Analysis. This part of the commission formulated the pilot program and is overseeing it.

Because the health care providers in this program will be doing more, the model that insurance companies use to reimburse them will also change, Steffen said. Low reimbursement levels are a common frustration among primary care providers.

How much more a provider will receive varies, but estimates come in at an additional $50,000 to $75,000 annually for a single practice, Steffen said. The estimates don’t include the physician’s regular office visit fees.

“The pilot is designed to test a model of primary care that, if successful, would be suitable for broader implementation in the state,” he said. “Primary care services are a central element in [federal] health care law.”

Plans for this study predate the passage of the federal health care law. In 2008, Gov. Martin O’Malley issued an executive order to form a council to examine various health care initiatives then being floated nationally, and determine if any would work in Maryland.

The 2010 General Assembly passed the administration-backed bills that established the pilot.

Steffen said the pilot program is based on a model that dates to the late 1960 that has been gaining steam over the last four decades. In 2006, the national Patient-Centered Primary Care Collaborative was formed to promote pilot programs like this one.

The three-year pilot program has two phases. Phase 1 began last June, with an information campaign and recruitment of primary care practices. Phase 2 begins in January, with the implementation of the model.

By law, the program must enroll about 50 practices across the state, serving at least 200,000 patients. The program is looking for a variety of practices: big and small, urban and rural. Steffen does not doubt the enrollment goal will be met. “More than 50 sites have already expressed interest,” he said.

Among them are two hospital-owned providers: Johns Hopkins Community Physicians and University Physicians, Inc. Both are faculty groups; the first is part of the Johns Hopkins Health System, and the second is affiliated with the University of Maryland School of Medicine.

According to Dr. David Stewart, chairman of the Family and Community Medicine at the University of Maryland School of Medicine, the model is designed for all patients of primary care practices. But “the biggest benefit and the largest impact” will be on patients with chronic conditions, he said.

“The vast majority of conditions in our society that are driving the system, and not in the best way, is managing chronic disease,” said Stewart, echoing the opinion that the model not only encourages better patient care, but also reduces health care costs by reducing emergency department and hospital admissions.

The law specified carriers to participate in the pilot program: private insurers CareFirst BlueCross/BlueShield, Aetna, Coventry, United Health Care and Cigna, and public carrier Medicaid. These five designated commercial carriers cover more than 90 percent of the Marylanders who have health insurance, said Elizabeth Sammis, acting commissioner of the Maryland Insurance Administration.

Steffen said the commission also intends to approach Medicare about participating.

Insurers are interested in participating in the pilot because it offers the hope of reducing health care costs for hospital stays, Steffen said. How much the insurers will save remains to be seen.

“We are not starting with the expectation of certain savings to carriers. We are starting with the idea that savings have to be generated” for the model to succeed, said Steffen.

“We recognize that in year one, we hope to break even. Savings accruing in years two and three, that’s the type of evidence we’ve seen in states where the program is underway,” he added, citing similar programs in Pennsylvania and Massachusetts.

Sammis said that exactly how insurers will reimburse physicians through this program has not yet been determined.

Whatever the method, “doctors need to know this will be supported by the insurers they are likely to deal with,” said Sammis. She called the initiative a “new way of thinking” about delivering quality health care.

Dr. Steven Kravet, president of Johns Hopkins Community Physicians, said that the medical community is in favor of the model.

University of Maryland’s Dr. Stewart agreed that physicians are “enthusiastic” about it.

“It gives legitimacy to what we’ve been trying to do with patients, but it’s not been easy to get paid for,” he said. “The model brings together a number of concepts in a logical manner and [for which] practices get payment.”

As for the fiscal outcome, Kravet said that will be will harder to evaluate — especially for chronic diseases.

“We won’t save money in the short-run. For example, the cost of medication might go up if the patient is more compliant with medical needs. We’re also paying more attention to preventive measures like colonoscopies, mammograms and vaccinations,” said Dr. Kravet. But, he added, “in the long run, it will save money.”