Improving Medicare starts with care coordination

ACHP President and CEO Patricia Smith promoted the importance of coordinated care yesterday at an AARP forum on responsible ways to find savings in Medicare. The panel discussion, moderated by television personality Lark McCarthy, was broadcast to 16 AARP state offices, where local opinion leaders convened to learn about and discuss options to cut Medicare costs while retaining benefits and improving the quality of care. Stephen Schondelmeyer, director of the PRIME Institute for pharmaceutical research, and Jim Frogue, Medicare fraud expert and partner at FrogueClark, joined Smith on the panel.

Smith’s interview was prefaced with a video clip of a Medicare beneficiary suffering a preventable condition he says was brought on by lack of cohesion between various specialty doctors. “What we have here is a failure to communicate,” the patient’s wife paraphrased.

McCarthy kicked off the forum by asking Smith whether a lack of communication between providers is a common problem facing older Americans. “This happens all too often but it doesn’t have to. If we begin to build the right systems and supports around patients, then we can prevent it,” Smith said, describing a team-based approach to care.

Smith advocated focusing resources on patients with multiple chronic illnesses – the 20 percent of Americans accounting for 80 percent of health care costs – and then creating a team of providers around those patients to help navigate their care. “Once you break apart that group, then you have to look at what really good care for the individual patient is,” Smith said. With the primary care provider at its center, the care team may include doctors, nurses, hospital staff and professionals outside of the clinic walls. “That group could include a social worker, because the patient might need transportation,” said Smith. “With a team around each person, that is not cookbook medicine. That is individual medicine.”

As McCarthy fielded questions from the audience, Smith spoke on related issues, including prescription drug costs, social determinants of health and making sure innovations reach rural hospitals.

Her answers consistently came down to one principle: Changing care delivery yields savings and puts the patient’s needs first. Health insurance plans, by creating payment and care models that focus on quality and outcomes instead of volume, are in an ideal position to deliver the most effective care coordination.

To support her argument, Smith pointed to successful models of coordinated care among ACHP member plans, which care for approximately 17 million Americans, including 2.1 million Medicare beneficiaries.

Geisinger Health Plan’s evidence-based ProvenHealth Navigator program serves virtually all the plan’s Medicare beneficiaries. The program not only has “very, very good reception among patients,” Smith said, it has decreased hospital admissions and readmissions, stabilized emergency department visits and netted $3.7 million in savings.

The medication management program at Capital District Physicians Health Plan (CDPHP) works with community pharmacists to optimize the medication experience for patients and reduce the total cost of care. Patients experienced a 19 percent drop in hospital admissions and a 27 percent decrease in readmissions. “Let’s make sure the health care provider is following up with the patient when they leave the hospital,” Smith said. “Let’s make sure medications prescribed after a hospital stay are in sync with the medications the patient was taking prior to their stay.”

Coordinated care is not the only way to curb Medicare costs. Smith also spoke about changing the way Medicare is paid. “The fee-for-service system has been historically not a good system,” she said. Smith praised Medicare Advantage, in which consumers pay for a package of benefits rather than individual services. “The bidding process that is used in Medicare Advantage has begun to address payment reform. It says: ‘Here is what I think is an appropriate price for an entire Medicare package.’” The concept is not new to many ACHP plans, who are pioneers in advancing payment reform.

Evidence-based care and payment models already exist, Smith emphasized. “Tufts Health Plan, Kaiser Permanente and many other health plans have fabulous best practices and have been developing these practices literally for decades. The question is how to spread that across the system.”

As the broadcast concluded, Smith and her peers considered Medicare’s declining solvency, a challenge compounded by the nation’s aging baby boomers and rising health care costs. The panelists were hopeful that rigorously redesigning care delivery will put the program on a better path. “What we shouldn’t do is jump to conclusions and get into a panic,” she said. “We should push ourselves to implement the strategies that we are talking about today.”


Panelists Stephen Schondelmeyer, Patricia Smith and Jim Frogue
at the AARP Medicare Solutions Forum

-Sophie Schwadron
ACHP Intern