Community health groups, with focus on prevention, fight to be part of new setup for lowering health costs, improving outcomes

The Patient Protection and Affordable Care Act is forcing doctors and hospitals to collaborate on lowering health-care costs while improving health outcomes. Community health groups that focus on preventive care are battling to be included as part of the solution, Laura Ungar reports for The Courier-Journal and USA Today.

One way physicians and hospitals are coming together to "reduce the duplication of services and keep large groups of patients well" is by forming accountable care organizations. Community health groups are having to fight for a "seat at the table" in these "doctor-dominated boards of ACOs," Ungar writes.

Such groups often offer less expensive, non-medical solutions for preventive health, according to a 2014 report by a North Carolina physicians' coalition. Some ACOs are beginning to include them as partners, but Bo Bobbitt, a Raleigh health-care lawyer who was lead author of the report, told Ungar, "The bad news is that the gap between the medical system treating illness and disease and the community health system was larger than we had feared."

Jose Pagan, a health economist who directs the New York Academy of Medicine's Center for Health Innovation, told Ungar that another key challenge is that doctors and hospitals are going to keep working to keep the money flowing their way. "If you go to a surgeon for a solution, they're not going to give you massage therapy," he says. "There's going to be progress, but it's going to be very slow."

Traditionally U.S. health care has focused its attention on "costly medical intervention," Ungar reports, instead of lifestyle changes, with only 3 percent of the $2.6 trillion health-care budget being spent public health and prevention, despite preventable chronic conditions accounting for 75 percent of medical care, according to a 2012 Institute of Medicine report.

"Compared to even the best medical therapy, we can decrease heart attacks, strokes and deaths by between 35 percent and 45 percent by changing lifestyle," Paul Rogers, a Louisville cardiologist at one of KentuckyOne Health System's healthy lifestyle centers, told Ungar.

For example, losing about 10 percent of weight reduces cardiac risks significantly, and losing 15 to 20 percent begins to reverse diabetes, lowers blood pressure, improves sleep and improves cholesterol level, Rogers said.

Another challenge for community-based programs is that little money goes into research on wellness programs, "and without studies, few will invest in their programs," Ungar notes.

Some members of Congress don't see nutrition, physical fitness or stop-smoking campaigns as health funding and gripe about the "nanny factor," Georges Benjamin, a physician who is executive director of the American Public Health Association, told Ungar.

As a result, "annual funding authorized by the ACA for the Prevention and Public Health Fund was supposed to hit $2 billion starting in 2015 but won't reach that level until at least 2022," Ungar reports.

Lifestyle changes are known to help chronic conditions, and Ungar gives many examples in the article. Here is one: Kevin French, 57, a construction contractor in Louisville, told Ungar that he began having chest pain and had to have two stents implanted in his heart in 1993.  And through cardiac rehab, he learned that his previous eating habits, which included lots of fast food, lack of exercise and smoking, played a big part in his heart problems. But with the help of the healthy lifestyle center, he said he  has "basically changed everything" about  his lifestyle and that's "improved not only his health but his family's as well."

Medicare starts to overhaul the way it pays providers, rewarding them for quality, penalizing them for shortcomings

By Molly Burchett
Kentucky Health News

The Obama administration on Monday set a timeline for historic changes in how it pays doctors, hospitals and other health providers under Medicare, shifting away from the program's traditional fee-for-service model and towards a model that rewards care quality.

Rather than give the usual yearly fee increases to Medicare doctors for every procedure or service, the Department of Health and Human Services will tie 30 percent of traditional, fee-for-service payments to models like "accountable care organizations," which base payments (and penalties) on patients' health outcomes. The goal is for half of all Medicare payments to be handled this way by 2018, reports Jason Millman of The Washington Post.

"Today's announcement is about improving the quality of care we receive when we are sick, while at the same time spending our health-care dollars more wisely," said HHS Secretary Sylvia Burwell. "We believe these goals can drive transformative change, help us manage and track progress and create accountability for measurable improvement."

Medicare is the country's largest payer for health-care services, so these payment changes will affect doctors' offices and hospitals across the country. Many experts have viewed this broader shift to rewarding care quality as long overdue, but it's still uncertain how well the approach will work.

"We still know very little about how best to design and implement [value-based payment] programs to achieve stated goals and what constitutes a successful program," concluded a 2014 Rand Corp. study funded by HHS, Millman reports.

Some health-care professionals said Medicare is just aligning with what is already working in the private sector by moving away from fee-for-service, reports Alex Wayne of Bloomberg Businessweek.  “The private sector is further ahead than Medicare right now,” said Justine Handelman, vice president for legislative and regulatory policy at the Blue Cross and Blue Shield Association.

Since Medicare is already limiting payments as part of the 2010 health-reform law, the government must “ensure that only reforms proven to be efficient and effective are put in place,” Chip Kahn, CEO of the Federation of American Hospitals, told Wayne. “Further cuts would undermine our ability to invest in delivery system innovations needed to continue this trend.”

The announcement marks the first time that goals have been set to fundamentally change the way Medicare pays for health care, giving providers incentives to reduce unnecessary services.

Dr. Douglas Henley, CEO of the American Academy of Family Physicians, told CNBC: "We're all partners in this effort focused on a shared goal. Ultimately, this is about improving the health of each person by making the best use of our resources for patient good. We're on board, and we're committed to changing how we pay for and deliver care to achieve better health."