Ms Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.

Rachael Zimlich, RN, BSN

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For some patients, it’s a struggle to get medications, a ride to appointments, or to make a healthy meal. Unfortunately, many of these problems are beyond the reach of the traditional healthcare model.

The American healthcare system is facing an increasingly ill and elderly population. Chronic conditions plague patients across the continuum, and value-based care models demand better outcomes and lower costs. To offset this less-than-ideal situation, more healthcare systems are looking outside of traditional channels for help. Numerous studies highlight patient reports of increased satisfaction from community-health programs and clinics, and there are arguments for cost avoidance-if not direct cost savings-from these programs.

Georges C. Benjamin, MD, executive director of the American Public Health Association, says community-based care services may be the new buzz, but the premise is not new.

“The public health community has a long history of utilizing people from nurses to people with lay health skills to reach out beyond the office practice to help people improve their health,” Benjamin says. “What makes them valuable is they-particularly the lay community health workers-know the community because they generally come from that community. They have a cultural competency that the people that work in a physician practice may or may not have.”

Community health workers not only help manage costly and dangerous chronic conditions, but they also identify new issues that might not arise during a typical office visit.

“They bring information about the individuals that often is not picked up during the office visit, particularly when dealing with patients that may be underserved and have a multitude of complex social problems that have to be addressed,” Benjamin says. “It brings that information into the clinical discussion and community health workers help reach out to engage patients where they live to help them navigate a complex and disjointed health system. In many ways, they serve a support function, a social service function and-if they have the know-how-a clinical function.”

From helping individuals understand their medication regimen, to helping them prepare healthy foods or make it to their doctor’s appointments, community health workers fill an increasingly important role-particularly as value-based care becomes a priority.

“It’s about trying to get rid of the inefficiencies and deal with the complexities of the care for these patients, and to narrow the number of barriers they have to get the care they need. It’s important in order to maintain their health and offset costs,” Benjamin says.

“There’s an enormous cost avoidance opportunity there.”

While anecdotal evidence on the benefit of community-based healthcare abounds, it can be difficult to generate hard data, because many of these programs simply don’t have the resources to track their progress and because there are so many benefits beyond measurable outcomes.

However, the available research does speak to the efficacy of community-based healthcare programs.

“Community-based programs are on the rise both because we have a growing body of research demonstrating that social risk factors and community context affect health as much as-or more than-clinical risk factors, and because the ACA is putting healthcare payers and providers increasingly at risk for population health outcomes,” says Melinda Buntin, PhD, professor and chair of the Vanderbilt Department of Health Policy.

Buntin and her colleagues researched the evolution of community-based care for a report in Health Affairs, and found while most programs don’t have the resources to evaluate their impact, incremental changes are being made and the healthcare industry is noticing.

“There is some evidence that community-based health improvement programs produce improved population health outcomes,” says Carrie Fry, a doctoral candidate in Health Policy and Statistics at Harvard University and coauthor of the report. “As such, many payers are currently integrating these and other social service programs into their portfolio, particularly in Medicaid managed care, presumably because they believe that addressing social risk factors will improve health outcomes and offset the expenses of these programs. Additionally, the per-person costs of community-based health programs are often lower than healthcare interventions that produce similar health outcomes.”

The study used public data on community-based health improvement programs to assess the relationship between community-based health programs and county-level health outcomes. The research team found that while measured outcomes showed little change, there were larger gains in behavior changes in the communities studied.

According to the study, the number of community health programs grew during the study period from 14 programs serving 319 counties in 2007 to 52 programs serving 396 counties by 2012. Counties with health improvement programs had larger populations of young adults and larger populations of individuals who were unemployed or living in poverty.

The study reveals a mere 0.06% mean reduction in individuals reporting poor or fair health after the implementation of a community health program, and a mean reduction of less than 0.15% in individuals who were overweight or obese after program implementation.

While these figures may not be statistically significant, the study found that targeted community health programs were a bit more successful in changing behaviors, particularly those targeting smoking and obesity. The study also highlights the fact that changes take time in healthcare, and small improvements can yield larger results as time goes on.

“Improving population-level health outcomes is difficult, and it takes time to ‘move the needle’ on health outcomes,” the report notes.

The role of community-based healthcare services will only continue to grow as the traditional healthcare model struggles to care for the increasingly aging, sick population in the U.S., according to Fry.

“As healthcare organizations are increasingly at risk for population health outcomes, community health programs will play a bigger role in the ‘traditional’ healthcare model. We see these organizations are now being integrated into value-based payment contracts, such as accountable care organizations,” says Fry. “In these arrangements, community-based programs provide services that healthcare organizations typically do not provide-housing and food assistance-as well as more healthcare-oriented services such as medication adherence and outreach for high-risk patients. The integration of community-based health improvement programs with traditional healthcare organizations is likely going to continue being the trend.”

The transition to value-based care will also play a role in the continued utilization of community-based services, she says.

“As the healthcare system continues to move toward value-based payment, healthcare and payer organizations are going to have to address these social risk factors in order to meet population health goals set for these organizations. The trend toward partnering and/or integrating with community-based health promotion programs and social service agencies is one way to address these factors,” Fry says. “Partnering and integrating is more likely to produce improved health outcomes than keeping traditional healthcare organizations and these programs separate.”

The cost of community-based care services may seem overwhelming and not altogether justified to some payers or networks, but Benjamin says the cost benefits come more in cost avoidance than direct savings.

“Everything has a cost, and even if something doesn’t always save money, it may improve quality of life, and you can often offset upstream health costs,” he says. “While the cost savings appear to be elusive, if you really do the cost accounting, you will find it. Sometimes, the savings is in the wrong pocket-it might not be in your pocket, but it’s clearly in the system.”

Some organizations are recognizing the value of these programs, though, and investing in local services.

Nicole Cooper, DrPH, MPH, senior director of social responsibility at UnitedHealthcare, says community health workers are an important part of the health continuum-so much so that United Healthcare funded several multi-million dollar grants to fund community health services in several states. These grants include $1.5 million to hire 15 community health workers at the Daughters of Charity Health Center in New Orleans and $1.5 million to hire 15 community health workers at the Jordan Valley Healthcare Center in Missouri.

For Daughters of Charity, these were the first community health workers they were able to hire, and the grant fully funded all 15 new employees, Cooper says. At Jordan Valley, the health system had three community health workers already, but the grant supports an additional 15 workers. United Healthcare has also supported food banks and pantries, mobile dental clinics, immunization programs, transportation programs, and more across its networks, recognizing the value of supporting members outside of clinical care.

“We employ many community health workers in almost every market and community we serve, Cooper says, adding that facilities that have increased community health programs have reported improvements in many areas. “They’ve shared stories about improved relationships and trust, an increase in visits and integration of services, improved efficiency across the levels of engagement, and they are starting to see improved quality scores.”

Cooper says UnitedHealthcare has recognized that patient care isn’t just about clinical care, and there are a number of ways to improve outcomes while lowering health costs.

“UnitedHealthcare by and large has made a commitment to help redefine access for communities that are particularly underserved or underinsured. We cannot just focus on clinical care. We also need to have a focus on the many areas that have an impact on health and quality of life, like food, housing, and transportation,” Cooper says. “We’re actively pursuing making investments in organizations that serve on the front lines and have chosen to fund community healthcare. We know community health workers are a powerful tool to help communities.”

While there is room for more data collection and evidence on outcomes and cost savings, Benjamin says the benefit of community-based services is abundantly clear already.

“The train has left the station on this and the truth of the matter is that people aren’t going to continue to pay for volume-based care anymore. They want to pay for outcomes,” Benjamin says. “We can influence outcomes through the system-wide things we do, and we’re going to have to be more assertive in this space.”

Rachael Zimlich, RN, is a writer in Columbia Station, Ohio.

Articles

Integrating programs that address social risk factors will improve health.

Community-Based Care Programs Fill Gaps in Traditional Health Services 

	Collaborative, coordinated care is the catchphrase of the decade in healthcare, but for cancer patients one area of Western Pennsylvania, it has become much more.

, payers and providers are working together in a new way, removing barriers that for too long have prevented true progress in affordable and accessible cancer care.

David S. Parda, MD, FACP, professor and system chair of the department of oncology and the 

Cancer Institute at Allegheny Health Network

 (AHN), which is part of the collaborative, says he hopes the partnership will help overcome what the Institute of Medicine (IOM) calls a “cancer care crisis” in the United States.

, IOM wrote that despite remarkable advances in cancer care over the last 50 years-leading to a nearly 70% cure rate-cancer care is still inadequate and being delivered at unsustainable costs.

	“We agree with this assessment and the tough solutions that are required. We need to improve patient-centered, accessible, coordinated, and evidence-based treatment and care. We need to increase the focus on prevention and psychosocial wellness as some estimates indicate that 50% of cancers may be preventable,” Parda says.

	The collaborative is made up of a partnership between AHN, Highmark Blue Cross Blue Shield, and the Johns Hopkins Sidney Kimmel Comprehensive Cancer.

	The premise is that Highmark is providing AHN physicians with a system for identifying evidence-based cancer care pathways based on patients’ individual information. Incentives for ineffective, or unproven treatments are removed and instead value-based care is pursued. Highmark is also removing pre-authorizations for cancer patients, and it is streamlining the claims and payment process to help providers get paid faster.

	AHN and Highmark will focus on bringing experts together to advance cancer care on all levels-quality of care, access, experience and value for all stakeholders, says Parda.

LangbaumCancer patients can be sure that they get the most appropriate earliest treatment by getting a second opinion or confirmation of their cancer diagnosis and staging by specialists at Johns Hopkins. Johns Hopkins is also collaborating on patient cases-particularly in rare or complex cases-through direct physician peer-to-peer review and other virtual methods. It also offers joint educational programs, and participation in collaborative research projects and clinical trials.

	Terry Langbaum, MHS, chief administrative office at Johns Hopkins Kimmel Cancer Center, says Johns Hopkins has had a partnership with AHN for the past two years, but the new collaboration expands the possibilities. “We are bringing together a lot of assets and all working together toward better outcomes for cancer patients,” Langbaum says.

	Patients will not necessarily receive treatment at Johns Hopkins-which sees 8,000 new cancer patients each year-with the exception of rare or complex cancers, or patients who are eligible and elect to participate in a clinical trial. The majority of cancer care can and should be delivered at facilities within the patient’s community, like at AHN, she says.

	“Really the whole point of it is to make sure each patient has the right diagnosis and right stage to drive the correct treatment plan, and that they are getting their treatment in the right place,” Langbaum says.

	AHN and Johns Hopkins are integrating their electronic health record (EHR)/IT platforms. to help providers communicate more rapidly and efficiently.

	The collaborative will utilize a Web-based tool that connects to an EHR network and the physician, accessing patient information, physician, demographic, and genetic input to match it to an appropriate pathway. Physicians can even use the system for patients not in the Highmark system.

The system will also allow physicians access to cost information, so that they can discuss it with concerned patients. “Those kind of discussions are critically important, and patients want to have those discussions with their clinical team. What are the options, and what are the side effects, and what is going to be their quality of life?” says Virginia Calega, MD, MBA, FACP, vice president of strategic clinical solutions at Highmark Blue Cross Blue Shield. “If you can make the payment more predictable both for the doctor and the patient, it takes that worry away from them.”

	Calega says the collaboration brings providers and payers together in a new way to really focus on improving access, affordability, and appropriateness of care.

	For example, she points to the use of therapeutic radiation. For years, providers have used six-week courses of radiation to treat breast cancer, but now research shows that a three-week course can be just as effective with less negative effects, says Calega. “Outcomes are equivalent with less toxicity,” she says, adding the shorter course is just as effective as the longer one but is easier for the patient and more affordable.

	Under the collaborative, providers get paid the same for a six-week course of treatment or a three-week course. Prior authorizations are removed, and providers get half of the payment up front and half at the end of treatment.

	While care pathways have received some criticisms for impinging on physicians’ autonomy, Calega says that is not the case in this collaboration. “It’s not just about pathways, but it models and incentives to get people the care they need,” she says. “You don’t use pathways as a prior authorization, you use them to help people get better.”

	Physicians are usually pleasantly surprised once they understand how the collaboration works; that they no longer need to deal with prior authorizations, and that they will be rewarded for caring for patients in accordance with 

	Highmark also plans to sit down with physicians and look at historic data to come up with a payment rate for patients in various cancer groups. “We’re going to pull prior authorization and we’re going to sit down with [physicians] and say, ‘How are we doing?’” Calega says. “We’re really able to not just look at pathways but how we reimburse differently for pathways. That’s the piece where I think having a partnership with an insurance [company] changes the conversation in the marketplace.”

	The formation of the collaboration was not without challenges, though.

	“A collaborative model of this scope across provider and payer environments has never been done to my knowledge so that was a challenge. And it was a new type of collaboration for Hopkins which required a lot of due diligence for an iconic medical institution like Hopkins to work with a new health system (AHN) and a new integrated delivery and finance system (Highmark Health),” Parda says. “We were able to consummate an innovative collaboration like this due to the forward-thinking expertise, and trusted collaborative/patient-centered values of both institutions.”

	Administrative burdens are a common hurdle in healthcare processes for both caregivers patients. Parda says AHN, Highmark, and Johns Hopkins are all working together to try and make the process more seamless.

	“We are trying to optimize our processes and connections on both provider and payer sides to facilitate efficient collaborative work between both institutions and many people. We are explicitly working on eliminating as many administrative burdens as possible to improve value and experience for both cancer patients and the healthcare professionals who care for them,” Parda says. “This is helping to ease the administrative burden of seeking second opinions for both patients and physicians and making many other collaborations easier to do. We are also working together on reimbursement methods like episode of care and bundled payments to limit administrative burdens for patients, providers, and payers.”

	The easing of administrative burdens not only reduces stress for the patient and the physician, but also for support staff through less initial administrative hoops, but also less work in re-filing paperwork or handling any claim rejections. Highmark will also be tracking how fast physicians are paid, and breaking down the payment cycle to identify and resolve any obstacles.

	“Cash flow is critical right now to the provider, and it’s helpful to get it as fast as possible,” Calega says. “For us, it’s about being at the forefront of changing how we deliver and pay for cancer treatment. How do we move people more onto to value-based reimbursement where we’re focused on the outcomes of the patient and removing those emergency room visits?”

	The collaborative is also looking at more ways to improve care under the cancer care umbrella, including opening after-hours cancer care centers to try and keep patients out of emergency rooms, and home-care to help patients move out of the inpatient setting sooner.

	“This model is different than others as we are working together to accelerate advances in patient care, education, research, clinical trials, genomics, and care transformation across provider and payer environments in a way to provide better care for cancer patients within integrated community and quaternary care delivery settings,” Parda says. “What makes it work is the leading expertise of the collaborators and the intense focus on improving care, outcomes, and value for cancer patients.”

Rachael Zimlich is a writer in Columbia Station, Ohio.

Cancer care has made great strides in the U.S., but effective care is still too expensive and inaccessible for many Americans. Now, payers and providers at Highmark, Allegheny Health Network and Johns Hopkins are launching a new model that could change cancer collaboration.

New cancer care approach: Highmark’s cancer collaborative

As  the nation stares over the edge of a $600 billion “fiscal cliff,” financial  experts say consolidation, cooperation and planning for the worst are the best  strategies for physicians to employ next year.

“It seems to me that there’s a perfect storm brewing for  physicians in 2013,” says Bill Lewis, CPA, partner with New Jersey-based  Cohn-Reznick, a firm specializing in healthcare accounting and business. “Lower  income, more compliance costs, higher tax rates, fewer deductions-it’s a recipe  for disaster.”

Looming  are the potential expiration of the 2001 and 2003 tax cuts implemented by  former President George W. Bush; nearly $1 trillion in across-the-board budget  cuts (sequestration), including 2% for Medicare; a new 3.8% Medicare tax on  wages and investment income for high-income taxpayers; an excise tax on medical  device makers; expiration of the current extended unemployment insurance; a  possible 27% cut to Medicare payments due to the sustainable growth rate (SGR);  the possible end of a 2% reduction in payroll taxes; the retroactive extension  of expired provisions such as the alternative minimum tax patch;  and changes to current estate and gift tax  rules.

Among  the major changes in store for next year, three areas in particular-the  so-called fiscal cliff consisting of decreased deductions and higher taxes,  Patient Protection and Affordable Care Act (PPACA) implementation costs, and  the potential for Congress not to postpone SGR cutbacks-could have a  significant impact on most practicing physicians.

  • Fiscal cliff.  One of the biggest concerns regarding the fiscal cliff is that top income  tax rates-currently at 35%-will return to their pre-Bush levels of 39.6%, and  today’s 15% capital gains rate will increase to 20%. In addition, tax rates on  qualified dividends would rise from 15% to 30% or more, Lewis says. Physician  income and investments could be greatly affected by these changes. 

  Mark  Master, CPA, a partner specializing in healthcare at Eisner-Amper in  Philadelphia, Pennsylvania, says the fiscal cliff could “turn out to be another  Y2K”-mostly hype and little substance. Nonetheless, uncertainty breeds fear,  and plenty of that is circulating in healthcare now.

  • PPACA implementation. PPACA implementation will  continue full-steam ahead with the re-election of President Barack Obama.  Scheduled in 2013 are the Medicaid bundled payment demonstration, increased  Medicaid payments for primary care providers, Physician Payment Sunshine Act  reports, a 2.3% medical device excise tax, the elimination of the employer Part  D retiree drug subsidy deduction, a tax increase for high-income beneficiaries  of Medicare Part A, and open enrollment for the health insurance exchanges  stemming from the PPACA.

  In  a recent report, PricewaterhouseCoopers (PwC) says the impending deadlines and  increased national financial pressures are leading to speculation that the  federal government may delay the implementation of state health insurance  exchanges. A 1-year delay could save the federal government $23 billion,  according to PwC.

  Although  delaying the exchanges would save money for the government, other stakeholders  would suffer, the report notes. Physicians would bear the burden of providing  more uncompensated care, and insurance companies would lose out on the $55  billion in health premiums the exchanges are expected to generate in 2014.

• SGR. Congress  is being urged, as in years past, to postpone cuts to the SGR in the short term  and to fix the Medicare reimbursement system-the current formula was enacted in  1997 as part of the Balanced Budget Act-in the long term. This year’s SGR  reduction stands at 27%, plus the 2% proposed cut to Medicare through  sequestration. Congress historically has stepped in at the last minute to  postpone SGR cuts, but that action would come with an $11 billion price tag this  year, PwC reports.

Experts say consolidation, cooperation and planning for the worst are the best strategies to prepare for 2013.

Healthcare is on Washington's fiscal cliff

 (NCQA) has released a new evaluation of more than 500 private health plans, ranking 474 of them based on clinical performance, member satisfaction, and NCQA accreditation.

Eligibility for the rankings depended on each health plan’s public release of performance information and the submission of enough data for statistically valid analysis, according to NCQA. The top 10 health plans:

Tufts Associated Health Maintenance Organization

Kaiser Foundation Health Plan of Colorado

Harvard Pilgrim Health Care of New England

Kaiser Foundation Health Plan of Northern California

Group Health Cooperative of South Central Wisconsin

Kaiser Foundation Health Plan of Southern California

 to see a full, detailed list of NCQA’s new rankings.

The National Committee on Quality Assurance has released a new ranking of nearly 500 private health insurance plans.

Four of five top-ranked health plans operate in Mass., NCQA says

Providers, especially primary care physicians, are struggling to meet increasing demands. Not surprisingly, stress factors include healthcare reform, Medicare and Medicaid policies, and dealing with uninsured patients, according to a study conducted by Physician Wellness Services (PWS) and Cejka Search. 

"This study shows that healthcare organizations are not providing support for their physicians, and the physicians don't know where to go for help," says Alan Rosenstein, MD, medical director of PWS.  

Payers, too, can contribute to the support providers need to deliver cost-effective, efficient care. Today's trends indicate payers and providers will have to work together more often on coordinated care, payment reform and emerging delivery models. 

"We've seen an increased level of cooperation in the last few years," says Tennant. "But if it's a health plan giving advice, there's a natural wariness of providers. We have to balance the needs of the patient and the professional judgment of the physician and the desire of the health plan to generate efficiency and cut costs." 

Generally, Tennant says payers could offer more IT resources-for example, moving to machine-readable member insurance cards. Such innovations would save time and resources at the provider level, decrease room for human error and save the healthcare industry billions-even though the cards come at a cost to payers, Tennant says. 

MGMA launched Project SwipeIT in 2009 as an industrywide effort to get health plans, vendors and healthcare providers to initiate processes to adopt standardized, machine-readable patient identification cards based on guidelines developed by the Workgroup for Electronic Data Interchange (WEDI). Guidelines call for cards featuring either magnetic strips or bar codes. MGMA adds that the card should contain all the information necessary to register a patient and initiate an insurance eligibility inquiry.  

The average practice now spends about 10 minutes to register each patient. MGMA says that time could be reduced to five minutes with swipe cards, plus it would generate nearly $300 million in savings for the 60 million claims that have to be resubmitted to payers each year due to incorrect patient information. For the average six-physician practice, MGMA says electronic ID cards could save staff members an estimated seven hours worth of work each day.  

MGMA has collected industry pledges to move to electronic ID cards, including agreement from eight payers. 

Independence Blue Cross (IBC) has begun offering a growing number of online tools to help practices evolve into Patient Centered Medical Homes (PCMH). Richard L. Snyder, MD, IBC's senior vice president and chief medical officer, says the company has teamed with the American College of Physicians to offer online resources that will help physicians analyze how they currently deliver patient care and identify way to increase efficiency.  

One such resource is the Medical Home Builder 2.0 (MHB), which aims to help physicians adopt a patient-centered care model. Practices can use this tool to analyze how they currently deliver patient care and identify ways to be more efficient, including improved scheduling, patient education and coordination of care, says Snyder. Physicians can access instructional videos as well as a library of more than 500 resources and policy templates. The ultimate goal of this tool is to streamline administrative processes. 

Snyder says IBC also has recently enhanced its Quality Incentive Payment System (QIPS). The QIPS program offers financial rewards to primary care practices that meet some, or all, of the National Committee for Quality Assurance's core requirements to become a nationally recognized medical home. The incentive program was put in place to motivate and encourage doctors to improve patient care and operate in a more efficient manner, which helps control rising healthcare costs, he says. 

Another online tool offered by IBC is access for network primary care physicians to Clinical Care Reports. The reports are available through IBC's provider portal and may be accessed only at a centralized, secure location through a designated security officer in a doctor's office. An example of the benefit of the reports, Snyder says, is that physicians could be alerted about a patient's medical history, including recent tests, medications or gaps in care.  

But aside from IBC's internal programs, Dr. Snyder agrees that more overall changes in the healthcare industry are what's needed to turn around the physician burnout trend. 

Health insurers should be looking to provide more process standardization and automation that can help physicians become more efficient and focus on patient care, he says. Case managers and disease managers help serve as an additional physician resource, but supplemental reimbursement and support could also offset the resources physicians must provide in order to become a PCMH, he adds. 

Providers, especially primary care physicians, are struggling to meet increasing demands.