Physicians’ initiative tackles cost through coordinated care
An Anchorage-based physicians’ initiative is aiming at improving health and reducing medical costs through a coordinated care program, mainly by reducing reliance on hospital emergency rooms for routine or non-emergency problems.
The goal is to steer patients toward more effective care, typically through primary care and better use of specialists, reducing the burden on hospital emergency rooms, the most expensive form of health care.
Alaska Innovative Medicine, or AIM, formed four years ago by six Anchorage physicians and Jocelyn Pemberton, a medical administrator, now has an active caseload of about 270 and has helped about 5,000 patients since the project started in January 2015.
Premera Blue Cross Blue Shield helped inspire the initiative and remains a strong supporter, Pemberton said. Most of the patients being assisted are Blue Cross members with costs paid through their health insurance.
“This all started four or five years ago in discussions within the physician community about how to improve the health care system and reduce waste through collaboration,” Pemberton said.
The founders were Anchorage physicians Jeremy Gitomer, Noah Laufer, Eric Miknich, Kathy Hurlburt, Tim Bateman and Terry Lester, along with Pemberton.
“We created the concept of clinically-driven care coordination out of these discussions,” she said. “The idea was to provide a multi-disciplinary approach that would allow us to be flexible and match the needs of each patient. The social worker or the case manager often takes the lead with the patient and can pull in resources as they are needed.
“We are not a clinic, although we have an office for our staff to meet with patients who aren’t comfortable with a home visit.”
Most of AIM’s work is with patients in their home setting after they have met with them in the hospital at discharge.
“Our role is to help coordinate the patient’s integration back into the primary care system from the hospital and to ensure the continuity of the care,” Pemberton said.
The belief is that coordinated care, compared with ad hoc visits to emergency rooms or medical specialists, will lead to more effective care and in the long run, lower costs.
Pemberton said it is physicians’ referrals that generate the bulk of new patients for AIM because they have an established relationship and trust with the patient.
In this, the group has a ready-made referral network of physicians who work in Southcentral Alaska hospitals through The Hospitalist Group, a collaborative of about 80 physicians contracted to provide in-hospital service. Pemberton is also CEO of the Hospitalist Group.
In addition to the hospitalists, there are 49 local primary care physicians now participating with AIM.
The idea of coordinated care — the right care at the right time — has long been talked about in Alaska’s health care community but has never been actually done, at least in a formal way.
In other states managed care is done through health maintenance organizations, or HMOs. These organizations are typically led by insurers and are aimed mostly at lowering costs. HMOs are not allowed under Alaska laws.
What’s different about AIM’s approach, Pemberton said, is that it is led by physicians focused on health care rather than insurance companies who are concerned more with costs and the bottom line, at least in the minds of many consumers.
The difference has led to a higher level of trust for AIM’s approach among those being served, Pemberton believes. The evidence for this, she said, lies in “call back” rates, or phone inquiries from patients, a kind of rough consumer satisfaction indicator.
Phone calls from patients in managed-care HMOs typically average about 15 percent to 20 percent but average 85 percent to 90 percent for AIM, when there is a physician referral.
Premera Blue Cross, which is a nonprofit insurance company, has supported AIM’s project from its inception because it believes the coordinated care approach in sound and will improve health for its members, said Jim Grazko, Premera’s CEO for Alaska.
Premera steers members it believes can be helped by coordinated care to Alaska Innovative Medicine and also shares claims data, which documents medical experience.
“We sometimes see a high degree of emergency room use. There are always times when people do need the ER but also times when it is not really necessary. We try to deflect some of that to more appropriate care,” typically primary care but also specialists, Grazko said.
“We’re talking about people who are at their most vulnerable state, facing a medical emergency or actually in the hospital. It’s important to have an advocate at that point to help people navigate the system.”
Pemberton said, “We do a lot of medication counseling. Our goal is to help a patient understand a health plan and how to navigate the system, but we can help with calls to physicians to get follow-up care. If there are problems getting appointments, we can help.”
Having physicians (through AIM) make calls can often open doors to get appointments or get patients in earlier to see specialists, she said. AIM’s engagement also varies with the individual.
“Some patients need just one visit to go over the health plan but we’ve been involved for as long as two years with others,” she said.
There have been surprises, however.
“When we started we thought the needs would be mostly clinical,” she said. “What we found, though, is that most of our needs have involved social workers,” for health issues related to lifestyle and behavior.
If there are mental health issues, referrals are made to providers in those fields.
“Our support is in getting the patient to recognize that he or she needs help, then help get it,” Pemberton said.
One area where a real need has been identified is when patients travel out-of-state for medical procedures and need support integrating back into the provider system at home.
“Many out-of-state hospitals have good support systems while patients are there, but once people are discharged and headed home it’s ‘you’re on your own,’” she said. “AIM can provide that transition help.”
Pemberton said it may be too early to demonstrate cost savings but there is substantial anecdotal evidence that some ER visits are being avoided.
One indicator of that such intervention can save money comes from the state Department of Health and Social Service Medicaid Services Division, which launched an intervention service two years ago for state Medicaid recipients identified as high-ER users, and who volunteered for special assistance.
Margaret Brodie, director of the state Medicaid division, said the state program resulted in $6.6 million in savings last year and $8.6 million in savings are projected this year. The comparison is with what was estimated to have been spent in ER visits.
At this point the state program is at a preliminary level involving telephone consultations of Medicaid recipients who volunteer with a registered nurse mainly reminders about medication and appointments. Brodie said the department program also includes nurses who make home visits for a small number of people who need special assistance.
The state is now looking at ways to expand its program with more intensive care coordination, Brodie said.
“We’ve all learned a lot over the last two to three years (with AIM’s program) and our goal now is to widen the number of people being served with these kind of services,” Grazko said.
Coordinated care, involving integration of health services, is well established in the Alaska tribal health organizations — Southcentral Foundation’s “Nuka” system of integrated care is now recognized nationally — but the idea is in its infancy outside the Tribal system.
It is also done at a smaller scale in places like Juneau’s Bartlett Hospital, which contracts with social workers to bring behavioral expertise into the hospital.
A formal physician-led coordinated care model like that developed by AIM is a first for Alaska, at least outside the tribal health system, Pemberton believes.
“We’re an experiment,” she said. “Our idea was to start it and demonstrate its success.”
Tim Bradner is co-publisher of Alaska Legislative Digest and a contributor to the Journal of Commerce. He can be reached at [email protected].