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Whitehouse Touts Rhode Island Group Practice as Model for Health Care Redesign

By John Reichard, CQ HealthBeat Editor

May 16, 2012 -- Sen. Sheldon Whitehouse has taken on the role in Congress of showcasing new forms of health care delivery that save money without undermining quality or access, and of touting the role the 2010 health care overhaul plays in incubating that innovation.

But Republican statements at a hearing last week by the Senate Health, Education, Labor, and Pensions Committee challenged the notion that the government can play an effective role in fostering redesign of health care delivery.

The health care law "undermines any serious attempt to reform the delivery of health care in the United States," Sen. Michael B. Enzi, R-Wyo., said in a statement released at the hearing. He did not attend the session.

Whitehouse, D-R.I., who chaired the hearing, emphasized that changes are occurring in the private sector that have produced "real improvements to quality, real improvements in patient outcomes, and real cost savings. The advantage of this approach is that it does not rely on shifting costs or cutting benefits."

His prime example: Coastal Medical, a doctor-run physician group practice that delivers primary care to 105,000 residents of the state, 10 percent of its population. Coastal CEO Alan Kurose testified that electronic medical records and the use of "nurse care managers" have played a key role in making health care more efficient at that practice.

Coastal uses IT to track costs and measure the quality of health care. As part of a shared savings agreement with Blue Cross Blue Shield of Rhode Island, it sets performance goals in areas such as controlling blood sugar in diabetics, keeping blood pressure within normal ranges, screening for depression and immunizing adolescents.

Nurse care managers coordinate treatment services and work with patients to engage them in their own care. They contact patients within two days of a hospital discharge to monitor how they are doing and whether they are keeping up with their post-discharge instructions.

Practice managers also try to ease access to care to better maintain the health of patients. The first thing a patient hears when calling the office is: "Would you like to see a provider today?" The office is open seven days a week to treat children and now has Saturday hours for adults. Starting July 1, Coastal plans to open Sundays and holidays for adult patients.

Practice officials say that costs for its Blues patients grew just 1.5 percent in 2011. Hospital readmission rates for the Medicare Advantage patients it treats fell 27 percent compared to 2010. The number of days Medicare Advantage patients spent in the hospital fell 13 percent compared to 2010.

"We do not intend to bend the cost curve, but rather to break it," Kurose said. "We have committed ourselves to reduce the total cost of care for our populations of patients by 5 percent by the end of 2014," he said.

Kurose said Coastal is an example of how physician practices can build a more efficient form of health care delivery from the ground up. It began with the merger of seven small doctor's offices and since then has added other small practices, now employing some 90 providers.

Much of what it does is consistent with the vision of a "patient-centered medical home" the health care law (PL 111-148, PL 111-152) seeks to help implement as one model for system redesign. Testimony by Kurose was music to the ears of Sen. Barbara A. Mikulski, D-Md. "What you say in your testimony is stunning. It's exactly what we wanted," she said.

Kurose said Coastal has received "crucial support" from federal programs, such as payments for meaningful use of IT—paid for under the economic stimulus law—and regional IT extension centers that help providers adopt IT systems. A Medicare advanced payment program to provide up-front working capital to deliver team-based care through accountable care organizations will benefit Coastal greatly if it is approved for the program, Kurose said.

But Republicans on the HELP Committee argue that money spent under the health care law to test and promote health system redesign is being poorly spent. They've sharply criticized the CMS Center for Medicare and Medicaid Innovation, for example.

Republicans skipped the hearing but made their presence felt in other ways. Enzi's statement said a vital part of fixing the nation's "broken" health care system involves changing the way Medicare pays for services.

James Capretta, a White House health budget official during the President George W. Bush administration, picked up on that point during his testimony. "It will be nearly impossible to move to a high-value, low-cost delivery system if Medicare fee-for-service continues to operate as it does today," he said. He said it has fostered the creation of an "overbuilt" health care system.

"A more reliable approach to higher-quality and lower-cost patient care is strong competition in a functioning marketplace."

Capretta added that the Congressional Budget Office has examined many of the demonstration programs carried out by Medicare officials in the past decade. All of them aimed to promote delivery system changes to control costs and improve care. But he noted CBO's conclusion that the results are "often disappointing."

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