Guest commentary: WellPoint's primary care-centered approach

Lisa Latts

Lisa Latts

How many of us would choose to feed our family at a multitude of different drive-throughs to meet our individual needs if we had the option of all the care and customization a personal chef could offer? Many of us wouldn't opt for the former. But this is the choice we have made for our healthcare system as accountability for care has been split into many disparate parts, leaving patients traveling to one place for their appetizers, another for their main course and yet another for dessert. It's no wonder that the food is often cold, key menu items are missing and individual dietary requirements and preferences are not respected.

Our current health system is complex, lacks coordination and may lose the very patients it is supposed to be serving. One of every two Americans is living today with one or more chronic diseases. Managing these conditions takes daily thought, planning and effort. Success leads to more health and longer life; failure can lead to disability and death. Too often today, patients do not have the tools and resources they need to achieve success in the management of their health. Significant transformation is necessary if the American healthcare system is to help patients be successful. Health plans can be important partners in making this happen in many ways, including increasing provider accountability for patient care and outcomes through the use of incentives.

A key to improved health is the accountable primary care physician. The primary care physician, along with a supporting team of providers, must become accountable for that patient and the management of his or her health, including coordination with and between different subspecialists and healthcare settings. Health plans can enable this strategy by rewarding doctors and hospitals for value over volume, encouraging providers to invest in improving patient safety and quality across the entire healthcare system.

Patient-centered medical homes (PCMH) and accountable care organizations are two approaches used today by WellPoint's affiliated health plans to implement this system change. More recently, WellPoint has taken steps to scale the medical home concept so that every member and network physician potentially can benefit from this approach.

Most patients with diabetes in a traditional care setting see their physician four to five times a year. A healthcare worker takes their vital signs, and then patients spend about 15 minutes of face time with their doctor where they share their concerns. The whole process is repeated in a few months.

In a typical visit to a practice operating as a patient-centered medical home, by contrast, a patient first runs through a check-in sheet providing accounts of his or her health between this visit and the last. A healthcare worker takes a patient's vital signs and asks whether the patient had received a recent flu shot, eye exam and visited the podiatrist. Then the patient watches a video on diabetes while waiting to share health updates with the doctor. The nurse practitioner talks to the patient about potential modification of medications based on blood sugar test results. A dietitian then reviews a patient's diet and provides recommendations based on test outcomes. In a few days, the office follows up with the patient to ensure there are no questions and the patient understood all the information from the visit. A patient also can reach out to the doctor in person, by phone or through e-mail with questions about medications and receive prompt responses.

WellPoint's new primary-care centered approach will provide the appropriate resources--both in data and in staff--and reimburse physicians in a way that makes it possible to institute the principles of the medical home on a national scale.

The health plan's role in this transition is not just to change the way care is reimbursed, although obviously, that is critically important. A health plan also can enable the accountability by sharing data on other care a patient has received, other medications he or she is taking and potential red flags or warnings. In addition, the health plan can share data with patients to allow them to make more informed choices about where and how they receive their healthcare.

Early results from WellPoint health plans' PCMH pilots have demonstrated improvement in nearly every quality measure for diabetes. We have seen decreases in acute inpatient admissions, ER visits, specialist visits and increases in the appropriate use of medications for long-term conditions. We anticipate that these initiatives will lead to improved quality without increasing overall healthcare costs.

For example, a medical home pilot operated by our affiliated plan in New York demonstrated an inpatient readmission rate 12 to 23 percent lower for PCMH providers, while the ER rate is between 11 to 17 percent lower. Likewise, medical and pharmacy costs are 14.5 percent lower for members seeing PCMH providers as compared to those seeing traditional providers. And, the numbers appear to get better the longer the pilots are in place. In the second year of our Colorado health plan's pilot, we reported an 18 percent decrease in acute in-patient admissions compared with an 18 percent increase for the control group.

Together, with diligence, we can find the answers, but it will take time. In the interim, these approaches help to minimize our drive-through exposure as we find varied routes to our personal chef.

Lisa Latts is vice president, public policy for WellPoint.