6 replies to this topic

[Delphi]

So this is a topic that's been buzzing about the hospital chain I work for, Intermountain Healthcare in Utah and Idaho, about changing how doctors are paid.

Basic outline is that in the past pretty much everywhere the U.S. healthcare system has been a fee for service model. You go to the doctor, the more tests and crap that gets done the more the doctor gets paid after the services.

We've seen how much Americans just "love" the fee for service model and a lot of here's have been on the bad end of that where unneeded tests were run just to drive up the bill or prescriptions that weren't needed but were given anyways.

So the insurance company SelectHealth and Intermountain have created a new payment model, a fee for value as they're calling it.

Instead of being paid after services are provided, this is what Intermountain wants to do instead: "Instead of being paid after services are provided, our delivery system is being paid ahead of time by SelectHealth for taking care of defined groups of people for a fixed time, with measures in place to ensure high-quality outcomes. Value based healthcare, and its use of prepayment, reduces the reward that exists under the fee-for-service model to provide more care and instead rewards more effective care. But value-based healthcare is not just a financial system. Its point is good health -- and good healthcare. It involves coordinated care, preventative services, more engaged patients, and healthier lifestyles, all of which are part of our Shared Accountability initiative. Across Intermountain, value-based care is giving us the same rewards as our patients: We benefit by helping them maintain better health."

So that's the spiel from the company about the goals. Thoughts on what this is trying to accomplish, have other countries already adopted and been using this format and that's why their populations seem to be happier with their healthcare, are other places in the US doing this too?

Just curious since being the first point of patient contact in my job I usually hear all the complaints and distrust from peoe frustrated with the healthcare system in the US.

I don't know what the measures are just yet since this is still in the prelaunch stage.

I know some of the early implementations is a smartphone app where after you get a username and password at your doctor's office you can sign in and see your lab test results, radiology dictations, vaccine records, ER discharge instructions and it's all connected to Intermountain's database so it doesn't matter if you were in the ER up in Salt Lake but live in St. George, you'll still see your visit from the Intermountain facility up North. It also has a graphing tool where you can select lab tests to see your results over time, like if you're trying to lower cholesterol you can see your LDL, triglycerides and such graphed out over the years and months. I know that's not unique to Intermountain but it's nice.

So yeah, thoughts? Skepticism?

[Twinrova]

I guess I'm having a hard time understanding what exactly value based means, especially for the patients. So you pay ahead of time? How much? What happens if you need more tests that are valued more than what you already paid? I'm confused. xD

[Selena]

We don't have this system here, so yeah, need a little clarification on the patient end of things. What do they pay? Does the patient pay their monthly insurance bills like always? And the difference is that SelectHealth's already set aside money specifically for that patient and their predicted needs?

 

 

Any attempt to lower healthcare costs is admirable, provided the plan works. The cost of almost every single procedure in the US is infinitely higher than most other countries. My uncle had to have some kind of dental surgery last year. Rather than have it done here ($20,000), he flew to Costa Rica and had it done there ($3,000). And when an issue cropped up later, the dentist flew my uncle back to Costa Rica at his own expense to fix it.

 

And my girlfriend was complaining of a sharp pain in her side the other night, so I was mildly worried it was appendicitis. That usually costs about $25,000+ at the local hospital -- it would have sent us into immediate bankruptcy if we were uninsured.

 

 

I'd still prefer the creation of a legitimate national health service rather than rely so heavily on insurance companies (which I feel should at most be used to cover uncommon, expensive ailments or to serve as an "express lane" into medical centers for those who can actually afford to pay premium fees). But if this program were to really help lower overall costs for everybody, then more power to them.

[Delphi]

Basically the insurance company pays up front for providing good primary care service to their patients if the patients come in like once a year for their physicals or for patients with long term conditions that need to be managed, seeing them enough times to keep an eye on the condition.

So instead of seeing you once a year and loading up on, for example, cholesterol tests for a nine year old when no symptoms of high cholesterol like yellow deposits over the eyes are present and then getting paid for every test run by the patient and their insurance, the goal is to pay the doctor regardless of the tests run just for seeing the patient the recommended amount of times for their age group and conditions.

So they're trying to cut down on doctors running every test under the sun to get more money after the labs are billed and saying, hey we're going to pay you for having good enough rapport with your patients that they actually want to see you for preventative care regardless of the tests you run. So only run what's needed because we're not rewarding you for that behavior anymore. Also listen to your patients and explain their health risks or what they're doing well so they don't hate seeing you. You'll get rewarded for being an involved doctor instead. We also won't reward you for throwing pills at them so don't do that either.

Given that the big killers like heart disease have a "silent" period before they make themselves known, Intermountain and SelectHealth's goal is to keep patients involved in their care and mitigate risk factors before they get out of control, like with obesity and prehypertensive patients. If you're prehypertensive its better to manage it with diet and excersize than medication and if you get it under control before it's full blown hypertension it's generally easier to manage without medication and the patient's quality of life is better. It also makes the community healthier so the available health resources aren't stretched so thin.

Most SelectHealth plans include free yearly physicals, gyno or urology appointments, and vaccinations so that's also an incentive to bring patients in to be seen because they're not out anything. Anyone on SelectHealth insurance (they're working with other insurance companies but SelectHealth started out as Intermountain's health insurance so they still work closely) also gets five free sessions with the hospital's dietician to help them eat better for their lifestyle and risk factors. Like if you have heart disease or colon cancer in your family history you can start younger to reduce your risk.

So basically the value based care means the patient should be getting better care with more doctor/patient communication because the doctors are getting incentives for keeping a good eye on their patients.

[Delphi]

Sorry for the double post but I realized it would probably help if I explained some of the differences in healthcare here because it really is different from anywhere else I've lived.


First off, Intermountain Health Care is the majority provider in the Utah and Eastern Idaho areas. It was originally founded by the Mormon Church, kind of like the Providence chain of hospitals in Oregon and Washington run by I think it's a Catholic group.

In the mid 70s the LDS church decided it didn't want to continue being the operators of the chain of hospitals and offered to donate its fifteen facilities to the state of Utah but only under the following condition: that a not-for-profit organization run the hospitals on behalf of the communities served.

Since this time all the board members have been unpaid volunteers and raising funds was done through the bond market. All profits that don't go back into improving the hospitals and clinics goes back into the community in several ways.

First is patient financial assistance. For things like lab work this works in two ways.

One, they can get a voucher from certain clinics, usually the free clinics, for screening and diagnostic lab work the patient pays a flat fee (usually around $50) depending on their income level and that covers all their tests, including the big expensive ones like vitamin and hormone tests if necessary for diagnosis.

Two, any patient that is uninsured is automatically given 25% off their bill. Now if they pay up front they get an additional 15% off for a 40% discount.

So let's say I have the worst flank pain and I'm wondering if it's my stupid kidney acting up again. Is it an infection or am I passing stones again? Well doc wants to see my renal function along with checking for blood and bacteria and because I'm a woman of reproductive age I should probably get a pregnancy test to make sure its not an ectopic pregnancy either. So to get that done let's say it runs around $170 for all those tests up front. Well crap, that's a lot of cash to just throw out. But automatically if I don't have insurance it will cost $127.50 instead. If I pay up front then I only have to pay $102.00. Still a big chunk of change but a lot better than paying full price. Saving $68 means a tank of gas and some food.


I've heard of quite a few times where a huge chunk of the bill was written off as charity in cases like having to Lifeflight a child to Primary Children's and the bill was in the $10,000+ range.

The hospitals and clinics also provide free community health fairs with free screenings for blood pressure, blood sugars and cholesterol after filling out disclosure forms and all that fun legal stuff.

So probably just that right there is about as shocking as it was to me.

The doctors have also been transitioned to salary pay as another incentive not to order unnecessary tests or meds. If a doctor contributes a new best practice that benefits patients or shows good results, they are given bonuses to keep them motivated on being focused on the best care possible.


The other part that makes Intermountain different is how we use our electronic medical records system.

Part of the health reform was all medical providers transitioning to electronic medical records by a certain date but they don't do much with it. If you read up about the guy who died from Ebola in Texas there's a lot of fingers pointing at the EMS. But that's if you're not utilizing it to its fullest potential.

Intermountain started digitizing its records back in the mid 80s so they already went through a lot of the growing pains other medical centers are going through a long time ago.

Ours is called the EMPI (Enterprise Master Person Index) and each patient has a unique number that links any information entered about to patient from any Intermountain facility. My job in registration works mostly with keeping the EMPI records accurate during registration regarding demographics, insurance, the service being rendered, and the doctors the results go to.

The rules and responsibilities for registration are pretty strict since if we make a bad enough mistake, we could actually end up accidently killing someone. If we end up registering someone under the wrong EMPI and changing all their information we call it a tromp, as in we tromped all over it.

So let's say someone goes in to register for surgery and instead of pulling up Mary Jane Doe they pull up Marie Jane Doe who happens to have the same birthday. Normally a registrar will catch their error before going any further by verifying the patient's address and insurance information or social security number since that will always be different. If these two were twins and in the same house, the EMPI has a warning note that pops up saying they are a twin so make sure to verify it even more thoroughly lime through the SSN. So we'll also check spelling and middle names with the SSN and so on just to be sure. We also have warnings for family members with similar names like my husband who has Grandpa Joseph, my father in law Joe, and then there's Joey. They're all Joseph, none of them have middle names, and all have the same last name. That'd flag the EMPI system to have someone check for a duplicate first and then flag all three medical record numbers with the similar name flag.

Now if the registrar didn't do that and then changed all that information, we now have a problem. Fortunately our nurses are required to ask our patients their name and date of birth as soon as they introduce themselves and before medication is administered or procedures done. It does piss some of our patients off to have to verify that all the time but we have caught tromps before the patient ever got undressed by following that practice.

Now if the registrar catches it they can call back to the medical people and tell them to stop while they relink the account to the proper person. While you may still get talked to if this happens more than once in a blue moon, it's normally not something you get a final written for. Now if you don't catch it, you're in trouble.

At our facility and most others you are only allowed two tromps a year. Any more and you are fired. They're both written warnings regardless in most cases. So even if you do it two years in a row, yku may not be working in registration a third.

So that's just in registration, not even doctors. Because of our little mistake up front we could cause someone to get their tonsils removed when they were supposed to remove a leukemia ridden spleen. So we end up being extremely thorough. Most of those mistakes won't make it to the point of even getting an IV put in due to the verification system of confirming verbally and confirming the information matches their arm band or lab sheets. There's also an entire analyst team up north trained to recognize certain patterns in account changes to investigate possible tromps.

So that's how we keep our EMPI safe but what benefits are there?

Well a couple years back a person from here in Southern Utah was traveling in North Utah and got in an accident. Some major arteries were injured and she was bleeding out so quickly they didn't even have time to type her blood. And just her luck they were out of O- blood at the scene. Luckily they were able to pull up her Intermountain file and see what her blood type was in literal seconds. (Also a PSA, donate blood especially if you're O-! There's never enough!)

They can also pull records of what medications your doctor has prescribed to avoid drug interactions if you're unconscious and you can't tell them.

So that's on the individual level. On the community and hospital wide level they've used the system to improve care all over.

Just down here at Dixie Regional after going over records for patients that were being readmitted within I think it was 72 hours for stroke symptoms, management didn't like what they were seeing. St. George is basically a retirement and snowbird community with a large population of people over sixty, so that's a lot of people with a higher risk of stroke. So that led to a period of observation, reviewing what the doctors who had lower readmission rates were doing or not doing and then seeing what the doctors with the highest readmission rates were doing or not doing. Also checking if these people were down winders, what medication protocol they were on, which doctor was their primary care doc if they even had one, and a lot of other variables to see what patterns emerged. After that it was observing if the patterns meant anything since correlation does not mean causation to rule out more variables that weren't actually related.

After they'd gathered enough data they implemented a plan based on the best practices of the successful doctors and the date that proved to actually impact patient outcomss. There was a huge change in the amount of readmissions and the doctors who the best practices were observed from were given bonuses. The doctors who weren't on board and wouldn't go with the new protocol and continued to have a readmission rate above the hospital average were put on performance plans.

Intermountain has also done this with ventilator acquired pneumonia, observations of preterm deliveries to see what could he done to prevent them, and really who knows what else.

That also means while Intermountain may not always have the most advanced toys, the machines we do have are proven to be worth the cost. It's also why we may not always be doing the trendy new surgery with the newest, shiniest equipment after a test period. If we see that the new surgery with its new tools is not improving patient outcomes any more than a cheaper and just as effective alternative with similar recovery, we don't use the new one. There's no incentive since the board members can't be bought by medical equipment or pharmaceutical companies.

Now Intermountain isn't perfect but I do like what I see even on the non-patient side. There's a lot of incentives to provide patients the best experience if the patient being happy just isn't enough.

So hopefully that helps paint a better picture of what Intermountain stands for.

[Alastair]

Not much to add on the subject of this initiative by Intermountain Healthcare: it is quite clearly a very good idea. The only reason to oppose it would be an idealogical commitment to favouring free-market economics in all circumstances.

 

For those who need convincing that free-market provision is not optimal for state healthcare take a look at this article. While some of the measures for quality of service in a healthcare system are debatable, the cost of providing the service is less open to interpretation. The U.S. spends almost double the amount per capita on healthcare as do comparable developed nations. The service is not twice as good.

[Egann]

It strikes me as a servicable approach. There will still need to be services billed afterwards, so there will always need to be a hybrid model, but it will simplify things.

 

The problem is that this isn't the problem with America's healthcare. It--like tort reform--is a minuscule optimization.

 

Healthcare--especially emergency healthcare--is a highly inelastic good. As an individual you can't really negotiate against a doctor or an insurance provider to lower your costs when they're selling you potentially life-saving medicines. This is THE reason I switched from saying healthcare is a bad idea to state-sized single-payer systems; governments can and do have the clout to negotiate with insurance and medical providers, and can do it in bulk.

 

There's also a reason I think the state is the correct place to do this (even if you give it federal funding assistance): 50 options much lower risk than 1 which applies to everyone; if one state's approach is bad, it will be changed quickly and if one is good, it will get adopted all over. If the federal government does something (like Obamacare) we're all stuck with it, whether you like it or not.