Health Care Heroes: Health professionals emphasizing wellness programs
By Carrie Ghose, Staff reporter
In small groups, the workers started a one-year program with YMCA of Central Ohio to head off the deadly disease at the pass. For the first four months, they met weekly, recorded every bite, shared healthy recipes, took up walking and forgave each other when they messed up.
In two years, 519 people have gone through the Y’s diabetes prevention program, losing a collective 6 percent of their body weight. UnitedHealthcare of Ohio paid the $250 fee for nearly all of them through its plans for both private employers and state and local government. The federal government in June approved the Central Ohio Y among 17 chapters in the country in a test to add the pre-diabetes program to Medicare coverage.
“I was shocked UnitedHealthcare was paying for a preventative program,” said Lynn Banks, a Franklin County employee.
“It seems so many of our systems are reactive in nature,” she said. “In a utopia there would be all this preventative stuff that would save so much money. But it’s not how our system is set up right now.”
By far, Banks is not the only person to have noticed that setup. The prevention her insurer paid for is one of many efforts under way to start paying for care based on how well it works. Some – such as Medicare’s test of the Y’s diabetes class – were spurred by the federal Affordable Care Act that was upheld by the U.S. Supreme Court last month. Some predated it. In fact, whether the law withstands its next phase of legislative challenge may no longer matter.
Hospital systems, physician practices, insurers, employers and, yes, patients, more often are pulling in the same direction to emphasize disease prevention and wellness over episodic response to sickness.
“It’s a competitive matter now,” said Larry Lewellen, Ohio State University’s vice president for care coordination.
“It was government-triggered,” he said. “(But) it’s become an absolute matter of competition and consumer expectation.”
Critics of the federal law say it deals too much with regulating how health insurance is sold and not enough with what it’s paying for.
“It does almost nothing to address the cost of health care,” said Roger Geiger, Ohio director of the National Federation of Independent Business. “(Health care) needs to be redone from the ground up.”
But the rebuilding has started in many ways – hospitals buying physician practices the past four years to better coordinate patient care from office to inpatient, a startup business trying to take true telemedicine to retail locations, an insurer embedding a care coordinator in a physician practice, a coalition of employers and insurers agreeing to help pay for primary care practices to get certified as medical homes, Ohio State University’s Wexner Medical Center asking the federal government if it can pay on its own to start a Medicaid-like expansion.
“The systems of health care are starting to get serious about shifting from volume to value,” said Jeff Biehl, president of Access HealthColumbus, a nonprofit organizing the medical home creation effort.
Value in health care means doing tests and procedures shown to be most effective through research instead of the buckshot approach of trying everything available, said Ken Wexiel, a national health-care practice leader for Deloitte based in Columbus. It also means using technology to find patterns in population health and deal with them.
“There are pockets of the work going on all over the place, locally, regionally, nationally,” Biehl said. “That’s not going to stop regardless of what happens with the Affordable Care Act.”
The coordinated approach “permeates our entire strategic direction as an organization,” CFO Tim Robinson said.
The network is now 290,000 children. In June the hospital won a $13 million grant created by the Affordable Care Act to help Akron Children’s Hospital manage northeast Ohio patients – a step toward taking the program statewide.
“This is market driven for us,” Robinson said. “We’re responsible for these kids. We’re going to take care of them, so let’s get as close to the dollars as possible.”
The Ohio Public Employees Retirement System, which covers 225,000 retirees, already charges a lower co-payment for a primary care office visit compared with a specialist. Starting in 2013, it will halve that co-payment to $10 if the retiree chooses a doctor within a certified medical home, an approach that calls for more coaching and prevention.“We have limited resources to pay for retiree health care,” said Sarah Durfee, clinical programs officer. “We look to value-based care and value-based plan designs to make sure we’re getting the most for our health-care dollar.”
There’s another partner in this rebuilding: the patient.
Employers who pay for insurance can design plans to reward smarter health choices, Biehl said. Deloitte’s Wexiel noted the example of employers who charge higher deductibles for smokers.
“We’ve got to build mechanisms to help patients be more accountable (and) involved in shared decision-making,” Biehl said
The $12 million grant to the YMCA branches is from the same $1 billion innovation program that awarded $13 million to Children’s.
Caroline Rankin, director of government funding and diabetes for the Central Ohio Y, said it costs $6,000 yearly to manage diabetes, vs. a few hundred for a program to prevent it. The Y gets paid only if the Medicare enrollees improve their symptoms, she said.
“It’s good for those of us in the class. It’s good for those of us who have to pay the bills,” said Andrew Roberts, Central Ohio Y president. He wasn’t speaking rhetorically; he qualified medically and enrolled.
Group members who met weekly and graduated to monthly meetings said their lives have changed. They’re eating more vegetables, reading food labels and sneaking fat-free cakes into family gatherings.
“It’s small, sustainable changes,” Rankin said.
“I’m part of my own health,” said Ellen Grubb, who paid the $150 fee for Y members after seeing a class flier. “This has nothing to do with my insurance.”
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