Baylor embracing a new health care approach
By JASON ROBERSON and JIM LANDERS / The Dallas Morning News, November 30, 2009
North Texas health industry leaders will gather for an unprecedented meeting Monday to see if they can shake Dallas out of its declining health and soaring medical spending.
One option they'll hear about, called an accountable-care organization, attacks those problems by pushing family doctors, hospitals, surgeons and other specialists to work together using evidence-based medicine and even sharing payments.
Baylor Health Care System is already embracing such an approach. Baylor says it will convert its 13 hospitals and 4,500 network physicians into an accountable-care organization by 2015.
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William Roberts, a Baylor senior vice president chosen to lead the transition, calls it "a sea change" for the nonprofit corporation and its patients.
In an accountable-care organization, doctors and hospitals share a financial incentive to control costs and improve quality by coordinating care for a defined patient group.
Today, most medical care in Dallas and across the nation is delivered piecemeal. Doctors are paid for each patient visit. Hospitals are paid for each procedure. This "fee-for-service" model rewards caregivers for how much they do rather than how well they do it.
Health economists say it does too little to ensure that the people treating a patient know what's been done by other caregivers. Too often, the result is duplication, waste and mistakes that are both expensive and dangerous to a patient's health.
But what sounds like a commonsense approach is full of complications. Accountable care relies on a single, bundled payment that's spread across all caregivers dealing with a patient. In its model, Baylor, with a powerful hold on much of the North Texas hospital industry, will decide how patients should be treated and how the payment pie is sliced. Doctors, hospitals and insurers in North Texas have a hard time trusting each other. And medical professionals don't like being told how to do their jobs.
Patients may not like it either. The last overhaul of patient care and payments on this scale took place in the 1990s, when HMOs, or health maintenance organizations, were introduced on a wide scale. Patients rebelled against insurers getting between them and their doctors on decisions about care, and they may not see much difference if it's a hospital rather than an insurance company making the calls under accountable-care.
In 2000, 3 million Texans were enrolled in HMOs. Last year, it was 852,000.
In that decade, however, Dallas changed from an average spender for health care to one of the biggest spenders in America on a per-patient basis.
Congressional Democrats have struggled for months to write legislation that will extend coverage to more Americans, including many in Dallas who lack health insurance. Insurance might persuade some of those people to seek preventive treatments they now skip because of cost. The legislation also encourages communities to try models such as accountable-care organizations, under the theory that doing so will lead to better care at lower cost.
"I don't think we can really afford to wait for what might happen with national health care legislation," said health economist Mark McClellan, keynote speaker for Monday's summit.
"It's very clear we need to move to more preventive care, and more coordinated care. While legislation can help address that, there are certainly a lot of steps that can be taken in the meanwhile, ahead of health care reform."
Wooing employers
Roberts said Baylor will not wait for Congress to pass a health care overhaul bill. Instead, he has been going directly to large North Texas employers with a pitch that Baylor can improve quality while lowering costs with an accountable-care model.
"I might go to a Texas Instruments and say, 'I know you've been struggling with your health care costs. Can we help you bend the cost curve?' " Roberts said.
Early next year, Baylor will meet with the Texas Employees Retirement System and Blue Cross Blue Shield of Texas to see if it can help slow the growth of the system's health care costs.
Those costs for the 528,000 participants are projected to be $2.1 billion by year's end, according to the system's records.
"We will be looking at a number of innovations in plan design and reimbursement structure, including patient-centered medical homes, clinical integration and an accountable-care organization structure," Roberts said.
In Baylor's accountable-care plan, Baylor would be held responsible for organizing its hospitals and physicians to lower costs. In a contract, the employer would have to agree to a number of terms, possibly changing health insurance plans, which could set up fights between Baylor and health insurers. The contract might also require the employer to hire an outside wellness program developer to get workers in shape, Roberts said.
What's less clear, and more controversial, is whether employers would instruct workers to visit only Baylor doctors and hospitals.
Roberts said he's unsure what employers will do. If employees are given the freedom to choose their doctors and decide not to participate in Baylor's accountable-care system, then Baylor has limited power in controlling costs.
If workers are limited to Baylor services, the hospital system secures a steady revenue stream and leverage over regional hospital competitors.
One difficulty facing health providers that are considering accountable-care models is how to sell the idea to patients without their feeling it's just another cost-control measure.
"The challenge with evidence-based treatment is that sometimes we don't like what the evidence shows," said Eduardo Sanchez, chief medical officer of Blue Cross Blue Shield of Texas. Sanchez pointed to the uproar over a federal advisory panel's recommendations that women younger than 50 don't need routine annual mammograms screening for breast cancer. The panel warned that early testing causes many more false diagnoses and needless procedures than life-saving cancer detections.
"Does preventive medicine have to save money to be worthwhile?" Sanchez asked. "The response has been that, clearly, it shouldn't be driven by the idea of saving money."
Prevention as cure
Much of Roberts' work in transitioning Baylor into an accountable-care company will involve reshuffling programs that are already working to keep patients out of the emergency room, where costs are inflated.
Kellie Kahveci, an advanced nurse practitioner at Baylor, may have saved the company thousands of dollars through a routine home visit this month to Elvira Tippett, 71, of Garland.
"I haven't been doing too good the past couple of days," said Tippett, who has hypertension, diabetes, heart failure and high cholesterol. She was on Baylor's list of patients warranting extra attention, and the first of four whom Kahveci would see that day.
"I thought about going into the emergency room because I feel I have cancer," Tippett said with her right arm extended for a blood-pressure reading, while sitting on the edge of her bed next to a TV tray holding seven medicine bottles.
Kahveci listened to her concerns and reminded Tippett of all the tests disproving her cancer notion. After some prodding, Kahveci discovered the root of the problem.
Tippett said she cries often. She feels lonely, even though four generations live in the house with her and the extended family comes over every Sunday for dinner. She is depressed, even though she goes to church and the Bible next to the TV lay open to Proverbs 31, which describes a virtuous woman.
"My kids love me to death, and I don't want to leave them yet," Tippett told Kahveci.
"Ms. Tippett, I think you're borrowing trouble, my friend," Kahveci said, her hand on Tippett's shoulder. "I want you to call me when you start having anxiety. If you're feeling anxious, it might be something I can help you with over the phone."
To be sure, all North Texas hospital systems are involved in some sort of organized program to cut costs and improve quality.
Texas Health Resources, the largest hospital system in North Texas and Baylor's chief competitor, is less aggressive in creating accountable-care organizations.
Barclay Berdan, senior executive vice president at THR, said the Arlington-based hospital system is more focused on developing an electronic health records system to give doctors a better presentation of patient data. With easy access to that information, doctors can group patients with similar medical conditions and create a more targeted care plan.
Berdan said such quality care improvements will lead to cost savings.
Both hospital systems are trying to influence the decision making of the U.S. Centers for Medicare & Medicaid Services. The federal agency will have the power to determine how the anticipated health care overhaul bill is implemented in regional hospital communities.
"We've been doing this a lot longer than anyone else has in the marketplace, and we've probably had more influence than anybody has in the marketplace," Berdan said when asked to compare THR's influence with Baylor's influence over CMS's decisions.
Doctors vs. hospitals
An accountable-care organization requires physicians, hospitals, therapists and home care workers to be accountable to each other for what they spend and for the results they achieve – a powerful inducement to coordinate.
North Texas physicians say they, not the hospital systems, should run accountable-care organizations. But the challenge in North Texas is that those health providers are not as integrated as the providers in other Texas cities, said Michael Darrouzet, chief executive of the Dallas County Medical Society, which represents interests of doctors.
Doctors in the Dallas-Fort Worth area tend to operate in smaller, disconnected practices, Darrouzet said.
Even if physicians and hospitals reach an agreement to work together, they'll need a private health insurer to help bear the risk, said Darren Rodgers, president of Blue Cross Blue Shield of Texas, the state's largest insurer. In some cases, the insurer will be expected to partner with the same hospital systems that routinely fight for better reimbursements.
As offers to back an accountable-care system begin to appear on Rodgers' desk, he'll ponder a different question.
"Should I be spending my resources with the most expensive hospital system in town, or a more reasonable one?" Rodgers asked. "If we're trying to save money, it matters."
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