By Jill Zorn
In his latest piece in The New Yorker, Dr. Atul Gawande writes about what can be done to stop the “avalanche of unnecessary medical care (that) is harming patients physically and financially.”
His answers may surprise to you.
For this article, Dr. Gawande returned to McAllen, Texas, to find out what had happened to the sky-high cost of health care that he described in a June 2009 article in The New Yorker. What he found is, “E.R. visits, hospital admissions, tests, and procedures all fell from the Texas stratosphere.”
Why did this happen?
The sunshine that fell on medical practice in McAllen certainly had something to do with it. Transparency led to denial and anger, but then to action and finally to results:
Some of it came from a series of fraud investigations that led to significant penalties paid by the crooks. Some of it came from the institution of new feedback loops – reports on cost and quality – that helped physicians understand the very high cost of certain services that were of dubious benefit to patients…
– Healthcare Incentives Improvement Institute, Key Drivers of Behavioral Change
But to really save money in health care AND improve outcomes at the same time, it isn’t enough to put unscrupulous providers out of business, or to use data to show providers the error of their ways. Instead, what Dr. Gawande found is that a shift to an organized, well-financed model of personalized primary care, may be the most important change underway in McAllen:
…years after the attention and embarrassment had passed, the costs continued to fall. Bad publicity, a few prosecutions, and some stiffened regulatory requirements here and there couldn’t explain that. I probed for months, talking to local doctors and poring over data. And I’ve come to think that a major reason for the change may be a collection of primary-care doctors who don’t even seem to recognize the impact of what they’ve been doing.
He describes insurers and medical groups working together to deliver and pay for care that is better for patients and for physicians: a win-win. He describes one company, WellMed, whose successful and expanding business model is built on primary care:
…what the oldest and sickest most needed in our hyper-specialized medical system was slower, more dedicated primary care. “Our philosophy is that the primary-care physician and patient should become the hub of the entire health-care-delivery system,” Hernandez said. He viewed the primary-care doctor as a kind of contractor for patients, reining in pointless testing, procedures, and emergency-room visits, coordinating treatment, and helping to find specialists who practice thoughtfully and effectively. Our technology- and specialty-intensive health system has resisted this kind of role, but countries that have higher proportions of general practitioners have better medical outcomes, better patient experiences, and, according to a European study, lower cost growth. WellMed found insurers who saw these advantages and were willing to pay for this model of care.
Insurers, large employers (including the State Employee Plan), as well as medical groups and community health centers in Connecticut are increasingly shifting their attention to the benefits of primary care, especially for patients with chronic illness in need of better care coordination and support.
This emphasis on primary care is the cornerstone of Connecticut’s State Innovation Model (SIM) project. It is even an approach that Hartford Healthcare has adopted for its own employees. They have contracted with Iora Health, a cutting edge primary care company, and so far over 600 employees have signed up.
The CEO of Iora Health reports that “spending more time with patients up front helps prevent more long-term, costly expenses like hospitalizations. He points to company metrics that show, for instance, Iora patients have reduced high blood pressure-related hospital visits by up 40 percent.”
The challenge is that improved well-financed primary care may mean less need for hospital beds, diagnostic technology and specialists. But that is a trade-off that Connecticut must be prepared to embrace in order to lower costs and improve health outcomes for everyone.