Better Health Care at Lower Costs

8/7/2019 Better Health Care at Lower Costs

1/26www.americanprogress.o

Better Health Care at Lower CostsWhy Health Care Reorm Will Drive Better Models

o Health Care Delivery

Ellen-Marie Whelan and Lesley Russell March 2010


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Better Health Care atLower CostsWhy Health Care Reorm Will Drive Better Models

o Health Care Delivery

Ellen-Marie Whelan and Lesley Russell March 2010


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Introduction and summary

Doris Jones is a 70-year-old senior ciizen wih muliple healh condiions, including dia-

bees, high blood pressure, hear problems, and arhriis. Doris sruggles o manage hese

chronic condiions, which are exacerbaed by her poor die, immobiliy, and he cos o

her medicaions.

Forunaely Doris receives her care a a very good primary care pracice ha boass a

variey o healh care sysems in place o help coordinae all her healhcare needs. Te

pracice has a specially rained nurse, called a care coordinaor, who makes sure Doris

weigh, blood pressure, blood glucose, and choleserol are rouinely measured, and a

diabees educaor who gives Doris nuriion advice and helped her ge a new monior

o check her blood sugar levels wih a large screen o accommodae her ailing eyesigh.

Doriss medical records are kep elecronically, which means ha all her regular blood

ess and he MRI scan shes had o assess her kidney uncion are shared wih all her doc-

ors, eliminaing he need or each docor o order he same ess.

All o hese poins o coordinaed careregular checkups, healh advice, and care coordi-

naionkeep Doris in conrol o her healh (see box). Bu criical o he naional debae

over healh care reorm, her coordinaed care saves her ime, ravel, and money. Medicare

also saves money because here are no duplicaed or unnecessary services.

A key aim o healh care reorm is o bring beter qualiy and more aordable healh care o

all Americans. Many people ear ha less expensive healh care means ewer services, bu in

healh care more is no always beter and someimes is acually worse.1 Doris belongs o a

healh care sysem ha helps people say healhy hrough beter prevenive services, advice,

and guidance on physical and menal well-being, and regular screenings and checkups. Te

sysem also recognizes he diculy many older, chronically ill paiens may have in manag-

ing heir reamen regimes, and provides assisance wih his. Doriss primary care physi-

cian, her oher docors and care providers, her hospial, and her communiy-based services

are all conneced o ensure seamless care delivery and eecive communicaion.

Te good news is ha Doris doesn live in a ye-o-be-realized ideal world. Remarkably,

hese gold-sandard healh care pracice paterns no only deliver beter paien care and

beter healh oucomes, bu also have he poenial o save he U.S. healh care sysem bil-

lions o dollars every year i hey become he models or healh care reorm naionwide.


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Tere are many ways o decrease he cos o healh care while ensuring qualiy care and here

are many examples o his underway in he Unied Saes righ now. Tese new approaches:

Reduce he wase and duplicaion when every docor a paien sees orders he same ess Limi he chances o medical errors Preven hospial admissions and hospial-acquired inecions.

oo many paiens do no ge all he care hey need because our naions curren healh

care sysem is ragmened and hard o navigae. Ta means hey are increasingly likely o

end up in he emergency deparmen or hospial needing expensive reamen or condi-

ions ha could have been prevened.

Tis paper describes a number o innovaive models o care delivery ha are currenly

delivering he dual goals o providing beter healh care and beter value, and oulines he

key elemens o hese new approaches o healh care delivery and nancing ha should be

par o he reorm o he healh care sysem.

Seventy-year-old Doris learned quickly how dierent coordinated, qual-

ity care would be or her health and nancial well-being when she rst

transerred to a new primary care practice. At one o her rst visits to this

practice, her primary care doctor initiated a review o all the medicinesDoris was taking, prescribed by our dierent doctors. Ater consultation

with all her specialists, it was agreed that some o Doris medications were

unnecessary and another was at the wrong dose, which could possibly

have been dangerous.

The changes in her medication regime improved Doris well-being and

also her budget. Now Doris has better control over her symptoms, less

conusion with dosages, and no longer experiences the dizziness that had

caused her to all several times in the past.

Whats more, both she and her providers are better prepared to pro-

vide quality emergency care. Last year, or example, Doris was taken to

the nearby emergency department with a suspected heart attack. The

hospital could quickly access her electronic medical records, and so knew

her history, which helped determine how to best treat her. Those records

also helped identiy a potential complication that could have occurred

had she been given a new drug that would have interacted badly with

her current medications. On her discharge, the hospital immediate

sent a copy o all her tests to her primary care doctor and her long

cardiologist. Although Doris spent several days in the hospital, she

been back since.

Good primary care and coordinated communications with her card

gist, endocrinologist, and hospital sta ater she was discharged he

to make sure Doris did not end up back in the hospital with anothe

bill. Now, when Doris or her amily are worried, there is a number th

can call 24 hours a day to have their questions answered, and Doris

coordinator even visits her at home i needed, something that kept

out o the hospital when she caught a nasty case o the u last wint

At this point o the report we must note that Doris is not a real pat

Her experience is a compilation o real lie examples rom dierent

innovative models o health care delivery that now exist in the Uni

States. See main report to understand how these experiences add

comprehensive quality health care at lower cost and how they can

implemented in real lie when health care reorm is enacted.

Doris Story


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How health reform can change theway health care is delivered

oday we ge wha we pay or in healh care. When we pay or high-ech services and

procedures, we ge a healh care sysem ha emphasizes volume and inensiy, paying or

more services regardless o he value hey provide. Is a sysem ha doesn always keep

people healhier. I we change he incenives by changing he reimbursemen sysem so

ha we pay or value, no volume, hen we have enormous poenial o slow he growh in

healh care coss and improve paien healh.

Real healh care reorm requires ha we move in precisely his direcion. Tere are many

innovaive iniiaives currenly operaing across he Unied Saes ha can serves as mod-

els or his change in he way healh care services are nanced and delivered. Tese new

models are working eecively despie he ac ha hey have been designed and imple-

mened in a sysem ha does no accuraely reward heir good work. In shor, hey have

succeeded in spie o he curren paymen sysem no because o i.

Healh care reorm promises o change hese upside-down incenives and o reward pro-

viders who deliver beter care a lower cos. Indeed we mus do his i healh coss are o

decrease and Medicare is o be susainable ino he uure. Some o he models ha will be

developed, esed, moniored and evaluaed under he auhoriies provided in he healh

care reorm legislaion include:

Financially rewarding he delivery o primary care hrough approaches such as he med-

ical home and oher care coordinaion programs ha reimburse primary care pracices

o provide and coordinae paiens care

Bundling paymen or episodes o care raher han paying or individual visis or proce-

dures, again o coordinae care and improve oucomes

Linking medical pracices ino inegraed healh delivery organizaions such as

Accounable Care Organizaions by esablishing paymen arrangemens ha move

owards so-called global capiaion, which pays a single price or all he healh care ser-vices needed by paiens in a given ime rame

Invesigaing ways large and small ha will help deliver saer, beter qualiy services in

hospials and in he communiy


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Les now consider examples o each o hese models, how hey have been implemened in

communiies across he naion, and he specic inormaion hey provide abou how qual-

iy, lower cos, coordinaed care can be delivered.

Preventable medical errors

Each year in he Unied Saes as many as 98,000 deahs resul rom medical errors.2 From

2004 hrough 2006, paien saey errors resuled in 238,337 poenially prevenable

deahs o Medicare paiens and cos he Medicare program $8.8 billion. Te overall medi-

cal error rae was abou 3 percen or all Medicare paiens, or abou 1.1 million paien

saey incidens, during he hree years included in his analysis. Paiens who experienced

a paien saey inciden had a 20 percen chance o dying as a resul o he inciden.3

Among he causes o prevenable deahs and injury in hospial, medicaion errors and

hospial-acquired inecions rank high. A recen sudy showed ha sepsis and pneumonia

caused by hospial-acquired inecions cos $8.1 billion o rea and killed 48,000 paiens

in 2006.4 Many o hese are inravenous caheer-relaed bloodsream inecions in paiens

in inensive care unis. Abou 250,000 hospial paiens conrac hese inecions annually,

cosing an esimaed $9 billion in exra care.5

Coordinaed qualiy care reduces he chances o medical errors. Checklis-ype iniiaives

such as hose driven by Peer Provonos, an aneshesiologis a Johns Hopkins Hospial,

Harvard pediarician Donald Berwick, and Aul Gawande, a surgeon a Harvard, show

how quickly and cheaply dramaic progress can be made in reducing hospial-acquired

inecions, saving lives and money.6 A healh care checklis is usually nohing more han

a lis o wha every provider knows should be done or a given procedure. Bu jus as a

checklis ensures ha pilos go hrough all he necessary seps when ying a plane, socan a checklis help healh care workers correcly manage a complicaed procedure in an

environmen where ime is criical.

Elecronic prescribing addresses he second serious problemmedicaion and prescrib-

ing errors. Nearly a quarer o all hospial paiens experience medicaion errors, a rae ha

has increased rom 5 percen in 1992.7 Illegible handwriing and ranscripion errors are

responsible or as much as 61 percen o medicaion errors in hospials. A simple misake,

such as puting he decimal poin in he wrong place, can have serious consequences

because a paiens dosage could be 10 imes he recommended amoun. Conusion o

drugs wih similar names is anoher common source o error.

Currenly only abou 9 percen o hospials have compuerized prescripion sysems. I is

esimaed ha eecive use o well-designed compuerized physician prescribing sysems

in every nonrural hospial in he U.S. could preven 522,000 serious medicaion errors and

more han 500 deahs each year.8 Here are some successul examples oday o healh care

providers reducing medical errors hrough coordinaed qualiy care.


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Successful examples

Te Keysone Iniiaive in Michigan, which began in 2004, uses a series o checkliss ocus-

ing specically on prevening inecions in inravenous lines and caheers. Te program,

involving 108 inensive care unis, ocuses on using checkliss o evidence-based inerven-

ions and changing hospial culure, and was unded by he Deparmen o Healh and

Human Services Agency or Healhcare Research and Qualiy. Physicians and nurses ahe paricipaing Michigan inensive care unis implemened he ollowing inervenions:

Rouinely washing hands Using ull serile procedures when caheers are insered ino veins Cleaning he paiens skin wih chlorhexidine, a long-lasing liquid anisepic soap Avoiding he emoral sie (groin area) or caheer inserion, when possible Removing unnecessary caheers

Wihin hree monhs o implemening his simple se o inervenions, Michigan ICUs

slashed heir bloodsream inecion raes by 66 percen. Te median inecion rae

dropped rom 2.3 per 1,000 caheer days (an imporan hospial measure) o near zero.9

From 2004 o 2008, nearly 1,800 lives were saved and 129,000 exra days in he hospial

were avoided due o his paien-saey iniiaive. Each hospial spen abou $120,000 in

sa ime o implemen he saey changes and esimaed savings were over $200 million.

Tese impressive resuls have been susained hrough o he presen.

Anoher sysem ha dramaically reduces medical errors is he use o compuerized physi-

cian order-enry, or CPOE sysems, where physicians order medicaions elecronically.

Firs, CPOE sysems ensure he physicians order is complee, unambiguous, and legible.

Te compuer also assiss he physician a he ime o ordering by suggesing appropri-

ae doses and requencies, suggesing relevan laboraory ess o order, and screening orallergies and possible adverse ineracions beween medicines.

Brigham and Womens Hospial, a large eaching hospial in Boson, developed such a

CPOE sysem and measured he reducion in errors over a ve-year period. Tey ound

ha serious medicaion errors (hose ha acually caused injury or had he poenial o

cause injury) ell by 86 percen.10 Prevenable adverse drug evens such as injury due o

medicaion misakes declined by 62 percen, and poenial adverse drug evens, or near

misses ha reached he paien bu didn cause injury by chance, were reduced 100

percen o zero. And error reducions occurred a all sages o he medicaion use process,

comprised o drug ordering, ranscribing, dispensing, and adminisering.

A cos analysis ound ha he CPOE sysem a Brigham and Womens Hospial realized ne

savings o $16.7 million over 10 years, including ne savings o $9.5 million o he hospials

operaing budge and produced beter oucomes or paiens.11 Because CPOE sysems

Faulty memory and distrac

particular danger in what e

call all-or-none processes:

running to the store to buy

ents or a cake, preparing a

or takeo, or evaluating a

person in the hospital, i yo

just one key thing, you mig

not have made the eort a

Atul Gawande, The Check

festo: How to Get Things Ri

York: Metropolitan Books, 2

http://www.npr.org/templates

php?storyId=122226184


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undamenally change he ordering process, hey can subsanially decrease he overuse,

underuse, and misuse o healh care services, leading o decreased coss, shorened hospial

says, decreased medical errors, and improved compliance wih clinical guidelines.

Medical homes provide better primary care

Te erm medical home is commonly used o describe a primary care pracice ha

enables is healh care providers o ocus on primary care and serves as he ocal poin or

he coordinaion o care. Medical home models provide a paien-based, proacive, and

planned approach o care, where care is coordinaed across various providers o aciliae

he provision o recommended services, eliminae redundancies or unnecessary care, and

engage paiens. Tey are managed by primary care clinicians who receive supplemenal

paymens (on a ee-or-service or per paien-per monh basis) rom healh insurance pay-

ers o suppor heir required coordinaing aciviies.

Since chronic disease accouns or 75 percen o our healh care spending, i is reasonable

o ocus on improving prevenion and managemen o chronic condiions. One o he

bes approaches o accomplish his is hough enhanced primary care, which he medical

home can provide. Sudies nd ha medical homes:

Reduce healh care spending Improve healh saus Suppor disease managemen and prevenion Improve he qualiy o care Reduce medical errors Reduce racial and ehnic healh dispariies12

Te medical home approach o improved primary care is no new. Various payers and

insurers, public and privae, are developing or have implemened medical home pilos.13

Tis growing lis includes 31 saes ha are exploring he medical home concep or heir

Medicaid enrollees.14

Successful examples

Guided Care is one example o a medical home model specically argeing older aduls

wih complex chronic condiions. Te Guided Care model was implemened in 2003 by

a eam o researchers a Johns Hopkins Universiy. 15 I employs an inerdisciplinary eam,headed by a specially rained regisered nurse o plan and coordinae care or he paiens

who enroll in he program. Te nurses work wih paiens on a long-erm basis, provide

ransiional care, develop paiens sel-managemen skills, and educae hem on accessing

necessary communiy-based services such as ransporaion services, Meals on Wheels,

and oher supporive services.


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Guided Care program resuls improve he qualiy o care and reduce healh care coss

because o less ime spen in hospials and skilled nursing aciliies (nursing homes) and

ewer emergency room visis and home healh episodes.16 Te researchers also nd ha

he Guided Care paiens have beter managemen o heir chronic condiions, especially

due o he improved he communicaion and coordinaion among providers.

Early resuls rom a mulisie, randomized conrol rial indicae ha Guided Care improveshe qualiy o healhcare as measured by paien oucomes, physician and provider saisac-

ion, and coss.17 In addiion o (and in ac because o) he improved oucomes (ewer emer-

gency room visis and hospial says), paiens in he Guided Care program had Medicare

coss ha were 11 o 23 percen lower han paiens no enrolled in his program.18

The Geisinger Medical Home operaes in Pennsylvania and oers round-he-clock access o

primary and specialy care services or 2.5 million paiens who are, on average, poorer, older,

and sicker han paiens naionally.19 Tis medical home model provides nurse care coordi-

naors, care managemen suppor, and home-based monioring. Elecronic healh records

aid physicians and paiens in more ecien delivery o care. o encourage paricipaion in

he program, Geisinger provides monhly paymens o $1,800 per physician and sipends o

$5,000 per 1,000 Medicare paiens o nance addiional sa. An incenive pool is creaed

based on dierences beween he expeced and acual oal cos o care or medical home

enrollees. Incenive paymens are condiional upon meeing cerain qualiy indicaors.

Despie he increased paymens o physicians, preliminary daa show 7 percen savings

in oal medical coss, in par due o a 20 percen reducion in hospial admissions and

29 percen reducion in emergency deparmen visis.20 Paricipans in he case manage-

men program or paiens hospialized or hear ailure had 32 percen ewer readmissions

han hose no in he program and 84 percen o paiens in he program achieve sable or

improved uncional capaciy.

Colorados Medicaid and Childrens Health Insurance program boass a medical home

ha arges low-income children enrolled in Medicaid and CHIP.21 o qualiy as medical

homes, primary care pracices mus have 24/7 access, open-access sysems or similar con-

venien scheduling o appoinmens, and provide care coordinaion. Tis enables pracices

o be eligible or bonus paymens. In March o 2009, his program encompassed 150,000

children who were enrolled in 97 communiy-based pracices wih 310 physicians.

Beter coordinaion and improved availabiliy o primary care providers improved he rae

o well-child checkups o 72 percen o children in medical home pracices compared wih

only 27 percen o children in non-medical home pracices. Despie he increase in well-child visis, he median annual cos or children enrolled in he Colorado Medical Home

was signicanly less han children in oher pracices ($785 compared wih $1000), due o

reducions in emergency room visis and hospializaions. Among children in Denver wih

chronic condiions, median coss were $2,275 or children enrolled in he medical home

compared o $3,404 or hose no involved wih a medical home pracice.

Having a Guided Care nurs

burden o us. Any time we

nurse with questions, she h

the situation proessionally

able to either resolve the p

point us in the correct direc

made our experience with

care system more satisying

and more efcient or the s

overall. Having a Guided Ca

saved us time and energy a

us peace o mind.

Karen Kleiner, about her m

Dolores Smyths participati

Guided Care pilot study

http://www.emaxhealth.com/2


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The North Carolina Medicaid Community Care Model 22 is anoher ype o medical home.

Te Norh Carolina model, rs implemened in 1998, is comprised o 14 communiy

healh neworks ha encompass more han 1,380 pracices and 970,558 Medicaid enroll-

ees across he sae. I is communiy based raher han se wihin a specic docors oce

and he approach is more o a virual medical home raher han a specic primary care

pracice or group o pracices.

Here, individual primary care providers choose o enroll in a larger nework and agree

o serve as paiens physician care managers and help paiens obain access o more

specialized services. Tese neworks are organized and operaed by communiy physi-

cians, hospials, healh deparmens, and deparmens o social services. In reurn, Norh

Carolinas Medicaid program agrees o pay hese healh care providers a modes monhly

ee in addiion o he usual ee or service o ensure ha hey are available around he clock

as a way o decrease unnecessary emergency room visis.

Daa shows ha paiens receiving care in his model have much beter oucomes. For

paiens wih ashma, more han 90 percen receive appropriae prevenive medicaion

wih a subsequen 40 percen reducion in hospializaions or ashma and a 16 percen

reducion in emergency room visis. For paiens wih diabees, nearly everyone now

receives a blood pressure check a each visi o heir clinician (up 8 percen rom beore he

program was implemened) and over hree-quarers are esed or high choleserol

(up rom 11 percen).

oal savings o he Medicaid program are calculaed o be $135 million or low-income

amilies and $400 million or he aged, blind, and disabled populaions.23 A second sudy

esimaed he ashma disease managemen program saved $3.5 million rom ewer hospial

overnigh says and emergency deparmen visis in 2000-2002, and he diabees disease

managemen program saved $2.1 million over he same wo-year period.24

Transitional care for better care when discharged from the hospital

Te healh services a paien receives when hey are discharged rom a hospial say

o eiher home or anoher healh care seting are ofen reerred o as ransiional care.

Tis ype o care coordinaion includes a broad range o ime-limied services designed

o ensure care coninuiy, avoid prevenable hospial readmissions and poorer healh

oucomes, and promoe he sae and imely ranser o paiens rom one level o care o

anoher, or rom one healh care seting o anoher.

Te problem and he cos o poenially prevenable hospial readmissions have garnered

much recen atenion. I is esimaed ha 20 percen o paiens readmited o he hospial

wihin 30 days o discharge could have avoided his addiional hospial say wih beter


11/26


managemen.25 Tis churning coss American axpayers $15 billion annually in Medicare

spending and coss businesses $34 billion each year due o employees need o care or

loved ones who are discharged home wihou needed ransiional care.26

Tere are a ew well-esed models ha demonsrae having a healh proessional (usually

a nurse) mee he paien in he hospial and coordinae care across all setings including

hospial, posacue and rehabiliaive care, and he paiens primary healh care provider,can signicanly decrease avoidable hospial readmission.

Successful examples

Te ransiional Care model a he Universiy o Pennsylvania improves he posdischarge

oucomes or high-risk, high-cos elderly paiens. Advanced pracice nurses, or APNs,

are responsible or providing comprehensive in-hospial planning, coordinaing discharge

planning, and providing appropriae home care ollow-up. Te APN ollows paiens rom

he hospial ino heir homes and provides services designed o sreamline plans o care,

inerrup paterns o requen acue hospial and emergency deparmen use, and preven

healh saus decline. Family caregivers are given help o implemen he paiens care

plan. While he ransiional Care model is nurse led, i is a mulidisciplinary model ha

includes physicians, nurses, social workers, discharge planners, pharmaciss, and oher

members o he healh care eam.

Paiens who paricipaed in he program had ewer hospial readmissions or boh pri-

mary and co-exising healh condiions, improvemens in healh oucomes, and enhance-

men in paien saisacion, which resuled in lower Medicare coss.27 Te mean oal cos

or paiens in a ransiional care model over 12 monhs was 39 percen lower han conrol

paiens ($7,636 compared o $12,481).

Similarly, he Projec RED (or Re-Engineered Discharge) program a Boson Universiy

develops and ess sraegies o improve he hospial discharge process in an eor o

promoe saey and curail readmission raes. I is based on 11 componens ha have

been shown o reduce readmissions and have high raes o paien saisacion. Te 11

componens are:

Educae he paien abou his or her diagnosis hrough he hospial say Make appoinmens or clinician ollow-up and posdischarge esing Discuss wih he paien any ess or sudies ha have been compleed in he hospial

and discuss who will be responsible or ollowing up wih he resuls Organize posdischarge services Conrm medicaion plan Reconcile he discharge plan wih naional guidelines and criical pahways Review he appropriae seps or wha o do i a problem arises

I have allen in love with TC

only do I eel like I have ma

dierence in the lives o my

but TCM has made a diere

my career. Theres a tremen

autonomy in practice and r

rom physicians and other

care providers. In this role, apply the skills and experti

TCM allows me to commun

laborate, and cooperate w

members o the health car

or the benet o my patien

model just makes sense.

Ellen McPartland, MSN, R

Advanced Practice Nurse

http://www.transitionalcare.in

It provides [me with] inorm

on how to deal with the he

system; someone to...speak

When you are sick you don

energy to advocate or you

Patient in Richmond, VA

http://www.transitionalcare.in

PatiWhoB-1798.html


12/26


Expedie ransmission o he discharge resume (summary) o he physicians acceping

responsibiliy or he paiens care afer discharge Assess he degree o undersanding o paiens by asking hem o explain in heir own

words he deails o he plan Give he paien a writen discharge plan a he ime o discharge Provide elephone reinorcemen o he discharge plan and problem solving 2 o 3 days

afer discharge

Paiens in he Projec RED group are one-hird less likely o be readmited o he hospial

or visi he emergency deparmen ollowing discharge. Nearly all he paiens (91 percen)

leave he hospial wih a ollow-up appoinmen wih heir primary care physician com-

pared o jus 35 percen o non-Projec RED paiens. Daa show ha he conrol group

experienced signicanly higher emergency room coss ($21,389 or conrol versus $11,285

or Projec RED paricipans) and readmission coss ($412,544 versus $268,942) wihin

30 days o discharge. Paricipans had overall lower coss o $412 on average per person;

accouning or nursing ime, he esimaed oal cos saving was abou $380 per paien.28

Bundled care means better coordinated care

Te curren healh care delivery sysem is no organized around he care needs o paiens,

which are rarely delivered in an isolaed episode. Exising paymen sysems reward provid-

ers or delivering more individually paid or services raher han beter care. Bundled-

care paymens pay or enire reamen needs or cycles o care, which may span muliple

providers and setings. For insance, he expeced coss o care or a chronic disease such as

diabees could be calculaed and used as he basis or a bundled paymen o he provider

managing he paiens diabees, who would hen apporion hose paymens o ohers

involved in he paiens care. I is a paricularly eecive orm o paymen or he caredelivered around an acue hospial episode and he posacue or rehabiliaion period.

Successful examples

ProvenCare is model o care operaed by Geisinger Healh Sysem in Pennsylvania. Tis

program sared as a bundled paymen srucure or coronary arery bypass grafing, one

o he mos common surgeries perormed and now also covers hip replacemen and caa-

rac surgery. ProvenCare devised wha has been reerred o as a warrany ha involves

a so-called global ee ha covers he surgery and any addiional work relaed o complica-

ions rom he iniial procedure or hree monhs aferwards.29

Care is charged on a per episode basis, which includes work-up, hospial and proes-

sional ees, rouine discharge rae, and managemen o relaed complicaions up o 90 days

afer surgery. By including his 90-day guaranee on surgery, Geisinger rewards providers


13/26


or beter qualiy care. Geisinger relies on elecronic healh records o make hese improve-

mens possible. Tese policies also encourage payer-provider collaboraion and greaer

organizaion o care.

By changing he reimbursemen srucure or he bypass surgery, Geisinger acually changed

he way care was delivered. No only did he coss come down, bu he oucomes improved.

ProvenCare increased he proporion o paiens receiving all 40 required componens orcoronary arery bypass graf surgery and ollow up rom 59 percen o 100 percen. Te

percenage o paiens discharged direcly o home increased o 93 percen rom 81 percen.

In addiion, 30-day hospial readmissions or hese paiens dropped by 44 percen.30

Anoher area o care ha works well wih a bundled paymen sysem is pregnancy, birh,

and anenaal care. One sudy done a a Te Birh Place, a birhing Cener in San Diego,

provided care o pregnan women in a collaboraive care model.31 Te use o a variey o

providers was possible because he pracice was reimbursed or care or he oal episode o

pregnancy rom when he women rs sough prenaal care hrough six weeks posparum.

Mos o he prenaal care was provided by ceried nurse midwives who worked wih

physicians and delivered oucomes ha were as sae as he radiional physician-only

model, bu a a oal cos per pregnancy ha was 16 percen lower. Tis was mosly due o

lower raes o Cesarean-secions and he need or epidural inervenions. Nearly one in ve

women (19.1 percen o women in he radiional pracice) received a C-secion compared

o 10 percen o he women seen a he birhing cener. Ineresingly, during he pregnancy,

he women seen a he birhing cener used 63 percen more services han hose seen a

radiional sies bu his also resuled in 9 percen ewer women seeking care in hospial

emergency deparmens.

Te episode-based reimbursemen allowed a variey o providers o see he women basedon when hey he services were needed raher han being resriced o he radiional ee-

or-service model. Alhough here were more healh services delivered, his ulimaely lead

o less expensive care over he enire period o care.

Accountable care organizations provide more integrated care

An Accounable Care Organizaion is a relaively new concep o healh care delivery ha

is largely driven by changing how care is delivered and paid or. An ACO holds providers

responsible or delivering comprehensive care o a cerain group o paiens, and consid-

ers he qualiy and cos o he care delivered and assumes ull nancial responsibiliy orha care. Te goal is o creae an incenive or he ACO o consrain volume growh while

improving he qualiy o care.

Thats part o the reason th

government is interested. Y

patients doing better, the h

have made more money, th

plan spent less money, and

providersthe nurses, the

physicians assistantshav

pride and reward o knowi

more eective. What were

working better.

Dr. Alfred Casale, Surgica

at Geisinger Wyoming Valle

Medical Center

http://thedailyreview.com/new

geisinger-becomes-national-m

better-health-care-1.160872


14/26


ACOs ha achieve qualiy and cos arges receive a nancial bonus. Financial penalies

may also be incurred i arges are no me.32 A ypical ACO would consis o primary

care clinicians, specialiss, and hospials. An ACO needs o be able o care or paiens

across he coninuum o care in dieren insiuional setings, plan prospecively or is

budges and resource needs, and suppor comprehensive, valid, and reliable measure-

men o is perormance.33

Tis model is well aligned wih many exising reorms, such as he medical home model

and bundled paymens, and also oers addiional suppor (and accounabiliy) o he

provider organizaion o enable hem o deliver more ecien, coordinaed care. While

he medical home model is cenered around a single pracice, ACOs are larger and more

comprehensive, housing many pracices wihin one organizing eniy. ACOs allow grea

exibiliy or providers in boh he ypes o organizaions ha can serve as an ACO and

he mehods by which providers are o be paid. Tis exibiliy allows or he developmen

o ACO organizaional models and paymen approaches ha mach he naure and needs

o he local communiy.

Successful examples

For he pas eigh years, he Camden Coaliion o Healhcare Providers projec has oper-

aed in Camden, New Jersey.34 CCHP is a ciywide organizaion whose aciviies ocus

on communiy oureach, care managemen o high-needs paiens, healh care provider

educaion, pracice managemen capaciy building, daa collecion and evaluaion, and

coaliion-building among key sakeholders. CCHP consiss o a mulidisciplinary oureach

eam o provide care managemen o he highes users o Camden emergency deparmens

and hospials. Tis eam includes a nurse praciioner, a bilingual medical assisan, and

a social work case manager who conduc visis o homes, housing shelers, and even hesrees o coordinae care in a paien-cenered approach.

Te projec provides ransiional primary care, helps paiens apply or Medicaid or oher

governmen sponsored benes programs, coordinaes specialy care, coordinaes ranspor-

aion, helps paiens access medical day programs and oher social services, and provides

emoional suppor. Evaluaion afer one year o operaion indicaed ha paien uilizaion

o ERs and hospials decreased by 40 percen afer enrolling wih he projec and healh

sysems charges or he care o hese high-uilizing paiens was reduced by 56 percen. 35


15/26


How health care reform willfurther innovation

Te new models o healh care highlighed in his paper, and innumerable ohers ha also

exis, will need a concered change in healh care policy and prioriies i hey are o bring

orh he expeced benes o healh care unders, providers, and paiens naionwide.

Key elemens o he healh care reorm bill now under consideraion by Congress would

ensure his happens. Les consider he various elemens in he legislaion.

Center for Innovation

One o he mos imporan provisions included in he curren healh care reorm legisla-

ion is he creaion o a new cener wihin he Deparmen o Healh and Human Services

Ceners or Medicare and Medicaid Services, or CMSa cener ha will ocus on service

delivery and paymen innovaion. Tis is a clear sign ha Congress believes CMS, he

under o boh Medicare and Medicaid ha ogeher consiue almos 50 percen o

naional spending on healh care,36 needs o have he exibiliy o develop, implemen,

evaluae, and expand new paymen models or services ouside he radiional ee-or-ser-

vice model. Currenly, he only way his innovaion can be underaken is hrough legisla-

ion or a waiver process ha would specically allow a new pilo or demonsraion projec.

Te healh care reorm legislaion would give broad auhoriy and unding o he Cener or

Innovaion o deermine wha models will be esed, in wha groups o paiens, and or how

longwih a preerence or models ha reduce program coss while preserving or enhanc-

ing qualiy. o ensure he ocus is no only on cos-cuting measures, here is a requiremen

or providers o repor on paien-oucome measures. Tere is also language ha prioriizes

models ha work wih privae payers in addiion o Medicaid and Medicare.

A provision in he legislaion allows he HHS secreary (in consulaion wih CMS) o

expand he duraion and scope o successul models and o erminae or modiy models

ha do no work eecively. Tis means ha when a hospial or group o healh care pro-

viders changes heir pracice o accommodae a new paymen mehod, and i is demon-sraed o be successul, hey will no need a subsequen congressional voe o coninue or

expand he iniial projec, which also means he mos promising pracices can be scaled up

across he naion.

This is an area where i I sat

with [Senator] Tom Coburn

we could agree on 95 perc

things that have to be don

the things you talk about i

oreducing medical erro

terms o incentivizing doct

ordinate better and work inbetter, in terms o price tra

improving preventionth

all things that not only do

but weve included every s

o those ideas in these bills

President Barack Obama,

health care summit, Februa

http://www.whitehouse.gov/

health-care-meeting/bipartisa


16/26


Te Cener or Innovaion will serve as a place where innovaive ideas are devel-

oped, esed, and ranslaed ino large-scale projecs. I will serve as a communicaions

cener naionally and inernaionally on bes pracice in reorms ha help healh care pro-

viders o deliver care in a cos-eecive manner while mainaining heir paiens healh,

and i will enable policymakers and lawmakers assess he reurns made on he axpayers

dollars invesed in healh care.

Hospital-acquired conditions

Te healh care reorm legislaion includes provisions o limi paymen or services ha

resul in a condiion acquired while hospialized and include a penaly or cerain high-

cos and common condiions ha are acquired as a resul o he hospializaions. Tere

is also language ha would explore he same penalies or oher providers paricipaing

in Medicare, including nursing homes, inpaien rehabiliaion aciliies, long-erm care

hospials, oupaien hospial deparmens, ambulaory surgical ceners, and healh clinics.

Tese provisions will encourage hospials and healh care providers o implemen he kind

o checklised-based sysems o preven medical errors and inroduce elecronic-based

drug prescripion sysems o preven prescripion errors.

Medical homes and primary care

Tere are numerous provisions in he healh care legislaion moving hrough Congress ha

will oser he developmen, implemenaion, and coninuaion o medical homes, especially

or he chronically ill. For example, he legislaion provides increased reimbursemen or

primary care providers and some addiional unds o sar and expand new medical homes.

In his way, he legislaion will help jumpsar he expansion o medical homes o delivercoordinaed qualiy healh care a lower coss o more and more Americans naionwide.

Transition care

Te healh care reorm legislaion includes provisions ha ocus on improved qualiy o

care and paien oucomes around a hospial admission. I includes proposals o reimburse

care managemen aciviies perormed by nurse-care managers or paiens wih chronic

diseases as hey are discharged rom he hospial in an atemp o diminish poenially

prevenable readmissions.

Bundling

Te healh care reorm legislaion provides or a number o pilo programs. For insance,

bundled paymens would be made o a Medicare provider or anoher eniy composed


17/26


o muliple providers o cover he coss o acue-care inpaien and oupaien hospial

services, physician services, and posacue care over a dened period o ime or a range o

dened condiions.

Accountable Care Organizations

Te healh care reorm legislaion includes provisions o promoe he developmen o

ACOs. By design, here are ew deails beyond general requiremens writen ino he legisla-

ion. Medical pracices mus agree o be accounable or he overall care o heir Medicare

beneciaries, have adequae paricipaion o primary care providers, dene processes o

promoe evidence-based medicine, repor on qualiy and coss, and coordinae care.

By allowing his exibiliy wihou sringen requiremens, here is hope ha dieren

ypes o healh pracices can paricipae and should encourage he inegraion o larger

healh ceners wih smaller healh care pracices. In addiion o exibiliy in srucure,

here is also exibiliy in paymen o encourage muliple paymen approaches ha pro-

moe coordinaion so ha healh care pracices wih dieren levels o capabiliy could

begin acceping as much accounabiliy as possible.

Electronic health records

Improved use o elecronic healh records is an inegral elemen in almos all hese models.

For example, eecive coordinaion requires improved communicaion and shared inor-

maion. Te daa required o measure paien oucomes and ulimaely evaluae he suc-

cess o hese models will also oser he developmen o beter and more inegraed healh

inormaion echnology sysems. Congress and he Obama adminisraion realized heimporance o his and made an early invesmen in healh I by commiting $20 billion in

he American Reinvesmen and Recovery Ac o 2009.


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Necessary elements in new modelsof health care delivery

Ulimaely, each o hese models o care will work because hey use ried and rue ele-

mens o care ha have demonsraed beter healh oucomes a lower coss. Te ollow-

ing elemens o care have been examined, implemened, and esed or years bu, in many

cases, have been dicul o pu ino pracice because o exising paymen srucures or

oher disincenives ha have no rewarded a ocus on prevenion, primary care, and coor-

dinaion beween providers. Heres wha would change i we enac healh care reorm o

ensure hese qualiy care models o healh care spread across he counry.

An increased focus on prevention

Te U.S. healh care sysem is in ac primarily an illness-care sysem, wih 95 percen o

healh care coss going o rea healh problems afer hey have occurred. Seveny-ve

percen o healh care coss in America are atribuable o chronic condiions, many o

which are prevenable. Ye only 2 percen o 3 percen o he U.S. governmens healh care

budge is invesed in prevenion, a percenage unchanged since 1934.37

Prevenable risk acors or chronic disease include smoking, poor die, lack o physical

aciviy, and alcohol use. ogeher, hese accoun or approximaely 38 percen o all deahsin he Unied Saes ye one in ve Americans coninue o smoke and nearly wo ou o hree

American aduls are obese or overweigh. Prevenive measures can deliver subsanial healh

benes relaive o heir ne coss some are cos saving and ohers are cos eecive. 38

Te ailure o adequaely address chronic disease risk acors no only limis progress oward

achieving healh or all Americans, bu also jeopardizes he naions economic securiy.

Improved quality

A recen analysis rom he Urban Insiue looked a how he qualiy o U.S. healh carecompares inernaionally o answer he quesion:39 Does America really have he bes

healh care in he world? For some aspecs o care we do. I someone becomes very sick

and needs he laes, cuting-edge reamens, he Unied Saes is probably he bes place

o receive care.

We are not in a business w

should have to be acceptin

choice that were either go

have to cut the care we giv

going to have to accept hig

Theres a third way o doing

is: redesigning the care wh

do the things people wanteective and which cost le

doing it wrong.

Dr. Stephen Jencks, Senior

at the Institute for Healthca

Improvement, Cambridge M

http://www.npr.org/templates

php?storyId=111098800


19/26


Ye his is no he kind o care mos o us will ever need. Te researchers nd ha U.S.

healh care is no pre-eminen in qualiy. Tey argue ha reorm, specically srenghen-

ing incenives o apply knowledge and mee qualiy sandards, employing echnology o

reduce errors and ensure appropriae care, and helping consumers and paiens o demand

beter qualiy, is needed o improve he healh care sysems relaive perormance. Te

qualiy deci in healh care is cosly in erms o lives and dollars:

Only abou hal o paiens receive he recommended care,40 and one-hird or more o

all reamens and procedures perormed have no proven benes.41 Unnecessary care

accouns or $250 billion o $325 billion in annual healh coss.42

Only 40 percen o docors wash heir hands afer paien conac, a key acor in hospial-

relaed inecions ha kill 90,000 paiens each year.43

From 2004 hrough 2006, paien saey errors resuled in 238,337 poenially prevenable

deahs o Medicare paiens and cos he Medicare program $8.8 billion.44

Research has documened remendous variaion in hospial inpaien lenghs o say, visis

o specialiss, procedures and esing, and cossno only by dieren geographic areas o

he counry bu also rom hospial o hospial in he same own. Spending more does no

ensure beter healh care; hose areas o he counry wih he highes coss and highes vol-

ume o services generally have he poores healh oucomes and lower-paien saisacion.45

Sraegies o reduce hese decis in care are an essenial par o healh care reorm.

Better coordination of care

Coordinaion o care reers o policies ha help creae care ha is more organized boh

wihin and across care setings and over ime. Broadly speaking, i means making healh

care sysems more atenive o he needs o individual paiens and ensuring hey ge he

appropriae care or acue episodes as well as care aimed a sabilizing heir healh over

long periods. Tis helps keep hem ou o he hospial. Tese issues are paricularly bene-

cial paiens wih chronic condiions and he elderly who may nd i dicul o navigae

ragmened healh care sysems.

Beter care coordinaion can improve paien saisacion wih heir care, and resul in

beter paien oucomes. Where care coordinaion leads o more appropriae care (or

example, hrough ewer medical errors, more appropriae medicaion and less rehospial-izaion); cos eciency and cos eeciveness will also be enhanced.

Lack of care coordinationsuch as inecien communicaion beween providers and

lack o access o medical records when specialiss inerveneleads o duplicaion o ess

and inappropriae reamens ha cos $25 billion o $50 billion annually. Te Naional


20/26


Academy o Sciences Insiue o Medicine explicily saes ha care coordinaion is

needed o improve he qualiy o healh care in he Unied Saes.46

Multidisciplinary care teams

Mulidisciplinary care is a eam approach o he provision o healh care by all relevanmedical and allied healh disciplines. I recognizes ha increasingly he care people wih

chronic condiions need does no jus involve docors and nurses bu menal healh pro-

essionals and a broader range o allied healh proessionals.47

Tis approach is abou delivering holisic healh care ha is ar beyond merely disease and

reamen. Wih a diverse group o healhcare proessionals, such as physicians, nurses,

pharmaciss, dieicians, and healh educaors, social service and menal healh providers,

here is more cerainy ha all o he needs o he paien will be me. Te mos imporan

member o he mulidisciplinary eam is he paien who is a he cener o he eam.

Mulidisciplinary eams convey many benes o boh paiens and he healh proes-

sionals working on he eam, benes such as improved healh oucomes and enhanced

saisacion or paiens, he more ecien use o resources, and enhanced job saisacion

or eam members.

Electronic health records

A survey las year ound ha only 1.5 percen o U.S. hospials have comprehensive elec-

ronic records sysems,48 only 8 percen have basic sysems ha cover a leas one clinical

uni, and only 17 percen o docors currenly use compuerized record-keeping sysems.While almos every imporan nancial ransacion we do is recorded online, our medical

records are suck in he 19h cenury.

Elecronic healh records have he poenial o ransorm healh care, improving qualiy

and reducing coss by reducing duplicaion and wase ha coss hundreds o billions o

dollars and he medical errors ha cos ens o housands o lives each year. o achieve

hese goals, healh I will need o move o ensure meaningul use o elecronic healh

records in areas such as elecronic prescribing, elecronic exchange o healh inormaion,

and reporing o clinical qualiy measures. oal savings could range up o $100 billion

over he nex 10 years,49 and early governmen esimaes show abou 212,000 skilled jobs

could be creaed rom his program.


21/26


Rewarding better patient outcomes, not more services

Insead o paying he same amoun every ime a hospial or physician does a procedurea

pracice ha encourages more proceduresunders should pay or value wih an agreed

measure ha would combine paien oucomes, qualiy and saey, service, and oal coss

over ime. Research shows ha even afer aking ino accoun race, povery, and healh

acors, more han 70 percen o he dierences in spending beween high-spending placesand low-spending places could no be explained away by he claim ha paiens were

poorer and sicker. Insead, i came down o more hospializaions, more docor visis, and

more diagnosic ess.50

Healh care providers wan o provide high-qualiy, cos-eecive paien care, bu he

ee-or-service paymen sysem discourages hospials and healh proessionals rom

working ogeher o enhance prevenive care, beter manage chronic diseases, reduce

readmissions, and improve eciency. We need a paymen sysem ocused around beter

healh, no jus more care.

The patient as partner in their health care

Consumers and paiens ace considerable challenges in becoming acively involved in

heir healh care. Tey are expeced o underake a sweeping array o healh care asks,

rom comparing coverage opions when selecing healh plans o nding compeen

docors and sae hospials o choosing eecive reamens and managing heir chronic

condiions. When aced wih he need o make an imporan decision, consumers may

no know where o urn or help or may nd misinormaion, raher han useul guidance.

Someimes he choices are simply oo complex or hem o make on heir own.

oo ofen, paiens are placed a risk or unsae care or herapeuic goals ha canno be real-

ized because imporan healh care inormaion is communicaed using medical jargon and

unclear language. Te communicaions gap beween paiens and care providers involves

lieracy, language, and culure. Muliple seps need o be aken o close his gap. Failure o

provide paiens wih inormaion abou heir care in ways ha hey can undersand will

coninue o undermine oher eor o improve paien saey.51 Paiens also need subsan-

ial and ongoing help wih changing behaviors ha pu hem a increased risk or illness.


22/26


Conclusion

Te enacmen o healh care reorm will mean he coordinaed, qualiy healh care

services ha are so benecial o Doris are aordable and available o many Americans. I

will mean ha Doriss daugher, a single moher who is a breas cancer survivor, will nally

be able o ge healh insurance coverage. And Doriss son, who has avoided he docor or

years because o he cos, will nally ge he healh checkup he needs and advice abou a

healhier liesyle ha means he won develop diabees like Doris.

Te real legacy o healh care reorm, however, is or Doriss grandchildren and he grand-

kids o all Americans. When he progressive healh care delivery sysems examined in his

paper are widely available across our naion, our grandchildren will have he opporuniy

o grow up healhy and secure in he knowledge ha hey and all Americans have

equiable and aordable access o he qualiy healh care hey need a a lower cos o hem

and American axpayers in he 21s cenury.


23/26


Endnotes

1 Ellen-Marie Whelan and Sonia Sekhar, Costly and Dangerous Treatments WeighDown Health Care (Washington: Center or American Progress, 2009), availableat http://www.americanprogress.org/issues/2009/07/costly_and_dangerous.html.

2 Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, To Err is Human:Building a Saer Health System, (Washington: National Academies Press andInstitute o Medicine, 2000), available at http://books.nap.edu/openbook.php?record_id=9728&page=R1.

3 Health Grades, The Fith Annual Healthgrades Patient Saety in American Hospi-tals Study (2008), available at http://www.healthgrades.com/media/dms/pd/patientsaetyinamericanhospitalsstudy2008.pd.

4 Michael Eber and others, clinial and enmi o utms Attributablt halt carAssiatd Spsis and Pnumnia, Archives o Internal

Medicine 170(4)(2010):347-353, available at http://archinte.ama-assn.org/cgi/content/abstract/170/4/347.

5 Health Grades, The Fith Annual Healthgrades Patient Saety in American Hospi-tals Study.

6 Peter Pronovost and others, An Intervention to Decrease Catheter-RelatedBloodstream Inections in the ICU, The New England Journal o Medicine355 (26) (2006): 2725-2732, available at http://content.nejm.org/cgi/content/ull/355/26/2725.

7 Immediate Care Business, Computerized Doctors Orders Reduce MedicationErrors, July 30, 2007, available at http://www.immediatecarebusiness.com/articles/77h3012133821356.html.

8 The Commonwealth Fund, Preventing Medication Mistakes and Adverse DrugEvents in the Hospital, available at http://www.commonwealthund.org/Con-tent/Perormance-Snapshots/Improving-Patient-Saety/Preventing-Medication-Mistakes-and-Adverse-Drug-Events-in-the-Hospital.aspx.

9 Atul Gawande, The Checklist, The New Yorker, December 10, 2007, p. 8,available at http://www.newyorker.com/reporting/2007/12/10/071210a_act_gawande?currentPage=8.

10 David Bates and others, The Impact o Computerized Physician Order Entry onMedication Error Prevention, Journal o the American Medical Association 6(4)(1999):313-321, available at http://jamia.bmj.com/content/6/4/313.abstract.

11 Rainu Kaushal and others, Return on Investment or a Computerized PhysicianOrder Entry System, Journal o the American Medical Association 13(3) (2006):261-266, available at http://jamia.bmj.com/content/13/3/261.short.

12 12 Anne C. Beal and others, Closing the Divide: How Medical Homes PromoteEquity in Health Care: Results From The Commonwealth Fund 2006 Health CareQuality Survey (New York: The Commonwealth Fund, 2007), available at http://mobile.commonwealthund.org/Content/Publications/Fund-Reports/2007/Jun/Closing-the-Divide--How-Medical-Homes-Promote-Equity-in-Health-Care--Results-From-The-Commonwealth-F.aspx.

13 Melinda Abrams, Karen Davis, and Christine Haran, Can Patient-Centered Medi-cal Homes Transorm Health Care Delivery? (New York: The Commonwealth

Fund, 2009), available at http://www.commonwealthund.org/Content/From-the-President/2009/Can-Patient-Centered-Medical-Homes-Transorm-Health-Care-Delivery.aspx.

14 Neva Kaye and Mary Takach, Building Medical Homes in State Medicaid andCHIP Programs (Washington: National Academy or State Health Policy, 2009),available at http://www.medicalhomeino.org/NASHPmedicalhomesnal.pd.

15 Agency or Healthcare Research and Quality, Onsite Nurses Work With PrimaryCare Physicians to Manage Care Across Settings, Resulting in Improved PatientSatisaction and Lower Utilization and Costs or Chronically Ill Seniors (2008),available at http://www.innovations.ahrq.gov/content.aspx?id=1752.

16 S.L. Aliotta and others, Guided Care: A New Frontier or Adults with ChronicConditions, Proessional Care Management13(3) (2008): 151-158, available athttp://www.ncbi.nlm.nih.gov/pubmed/18562909; Carol OShaughnessy, Prom-ising Models o Care Coordination or Adults with Multiple Chronic Conditions:Getting Closer to the Holy Grail? (Washington: National Health Policy Forum,2009).

17 S.L. Aliotta and others, Guided Care: A New Frontier or Adults with ChronicConditions.

18 Modern Medicine, Geriatrics, Guided Care medical home model costs less than

usual care (2009), available at http://geriatrics.modernmedicine.com/geriatrics/NEWS/Guided-Care-medical-home-model-costs-less-than-usu/ArticleStandard/Article/detail/618816.

19 Ronald Paulus, Karen Davis, and Glenn Steele, Continuous Innovation In HealthCare: Implications O The Geisinger Experience,Health Afairs 27(5) (2008):1235-1245, available at http://content.healthaairs.org/cgi/content/abstract/27/5/1235?ijkey=xGyM8BnoFl/q2&keytype=re&siteid=healtha.

20 Ibid.

21 Kevin Grumbach, Thomas Bodenheimer, and Paul Grundy, The Outcomes oImplementing Patient-Centered Medical Home Interventions: A Review o theEvidence on Quality, Access and Costs rom Recent Prospective Evaluation Stud-ies (San Francisco: USCF Center or Excellence in Primary Care, 2009), availableat http://amilymedicine.medschool.ucs.edu/cepc/pd/outcomes%20o%20pcmh%20or%20White%20House%20Aug%202009.pd.

22 Community Care o North Carolina, Community Care at a Glance (2009), avail-able at http://www.communitycarenc.com/PDFDocs/CCNC%20AT%20A%20GLANCE.pd.

23 The Henry J. Kaiser Family Foundation, Community Care o North Carolina:Putting Health Reorm Ideas into Practice in Medicaid (Washington: KaiserCommission on Medicaid and the Uninsured, 2009), available at http://www.k.org/medicaid/upload/7899.pd.

24 Ibid

25 Stephen F. Jencks, Mark V. Williams, and Eric A. Coleman, Rehospitalizationsamong Patients in the M edicare Fee-or-Service Program,. N EJMThe NewEngland Journal o Medicine 14 (360) (2009): 1418-1428, av Available at http://content.nejm.org/cgi/content/short/360/14/1418.

26 Mary D. Naylor, What is Transitional Care and Why Does it Matter to theNational? (Washington: Center to Champion Nursing in America (, 2009),Aavailable at http://championnursing.org/blog/2009-07/what-transitional-care-and-why-does-it-matter-nation.

27 University o Pennsylvania, Transitional Care Model, Aavailable at http://www.nursing.upenn.edu/media/transitionalcare/Documents/Inormation%20on%20

the%20Model.pd; M. D. Naylor and others, Transitional Care o Older AdultsHospitalized with Heart Failure: A Randomized, Controlled Trial, Journal o theAmerican Geriatrics Society52(5) (2004): 675-684; M. D. Naylor, Health CareNeeds o Chronically Ill Older Americans: The Challenge (U.S. Senate FinanceCommittee, 2009).

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29 Geisinger, Provencare: Frequently Asked Questions, available at http://www.geisinger.org/provencare/aq.html(last accessed March 2010).

30 Karen Davis and Kristo Stremikis, Ensuring Accountability: How a Global FeeCould Improve Hospital Care and Generate Savings (New York: The Common-wealth Fund, 2009), available at http://www.commonwealthund.org/Content/From-the-President/2009/Ensuring-Accountability.aspx.

31 Jackson, D, Lang and others, Outcomes, Saety, and Resource Utilization in aCollaborative Care Birth Center Program Compared With Traditional Physician-Based Perinatal Care, American Journal o Public Health 93(6) (2003): 999-1006.

32 MedPac Report to the Congress: Improving Incentives in the Medicare Program(June 2009).

33 Kelly Devers and Robert Berenson, Can Accountable Care OrganizationsImprove the Value o Health Care by Solving the Cost and Quality Quandaries?(Washington: The Urban Institute, 2009), available at http://www.rwj.org/les/research/acobriefnal.pd.

34 Jerey Brenner, Building an Accountable Care Organization in Camden, NJ.Working Paper (University o Medicine and Dentistry o New Jersey, RobertWood Johnson Medical School, 2010).

35 Agency or Healthcare Research and Quality, Provider Team Oers Services andReerrals to Frequent Emergency Department Users in Inner City, Leading toAnecdotal Reports o Lower Utilization (2008), available at http://www.innova-tions.ahrq.gov/content.aspx?id=2265.

36 Chris Fleming, 2009 U.S. Health Spending Estimated at $2.5 Trillion,Health Aairs Blog, February 4, 2010, available at http://healthaairs.org/blog/2010/02/04/2009-u-s-health-spending-estimated-at-2-5-trillion/.

37 Susan Blumenthal and others, PuttingPutting Prevention into Practicein Health Care Reorm The Hufngton Post, (July 18, 2009,). Aavailable athttp://www.hufngtonpost.com/susan-blumenthal/putting-prevention-into-p_b_239260.html.

38 Joshua T. Cohen, Peter J. Neumann, and Milton C. Weinstein, Does PreventiveCare Save Money? Health Economics and the Presidential Candidates, TheNew England Journal o Medicine 358 (7) (2008): 661-663, available at http://content.nejm.org/cgi/content/ull/358/7/661.

39 Elizabeth Docteur and Robert A. Berenson, How Does the Quality o the U.S.Health Care Compare Internationally? (Washington: The Urban Institute, 2009),available at http://www.urban.org/UploadedPDF/411947_ushealthcare_quality.pd

40 Elizabeth A. McGlynn and others, The Quality o Health Care Delivered toAdults in the United States,The New England Journal o Medicine 348(26) (2003): 2635-2645, available at http://content.nejm.org/cgi/content/short/348/26/2635.

41 Ibid.

42 Thomson Reuters, WASTE IN THE U.S. HEALTHCARE SYSTEM PEGGED AT $700BILLION IN REPORT FROM THOMSON REUTERS, Press release, October 26, 2009,available at http://thomsonreuters.com/content/press_room/tsh/waste_US_healthcare_system.

43 Centers or Disease Control, Hand Hygiene in Healthcare Settings-Core (2002),

available at http://www.cdc.gov/HANDHYGIENE/download/hand_hygiene_core.pd.

44 Health Grades, The Fith Annual Healthgrades Patient Saety in American Hospi-tals Study.

45 Elliot S. Fisher, Julie Bynum, and Jonathan Skinner, The Policy Implicationso Variations in Medicare Spending Growth (Hanover, NH: The DartmouthInstitute or Health Policy and Clinical Practice, 2009), available at http://www.dartmouthatlas.org/atlases/Policy_Implications_Brie_022709.pd.

46 Karen Adams and Janet M.Corrigan, Transorming Health Care Quality (Wash-ington: National Academies Press and Institute o Medicine, 2003), available athttp://www.nap.edu/openbook.php?isbn=0309085438.

47 G.K. Mitchell, J.J.Tieman, and T.M. Shelby-James, Multidisciplinary care planningand teamwork in primar y care,Medical Journal o Australia 188 (8) (2008): S63.

48 Ashish K. Jha and others, Use o Electronic Health Records in U.S. Hospitals,The New England Journal o Medicine 360 (16) (2009): 1628-1638, available at

http://content.nejm.org/cgi/content/ull/NEJMsa0900592.

49 David Goldman, Obamas big idea or saving $100 billion, CNNMoney.com,August 21, 2009, available at http://money.cnn.com/2009/08/21/technology/electronic_health_record_cost_savings/index.htm.

50 Jason M. Sutherland, Elliott S. Fisher, and Jonathan S. Skinner, Getting PastDenial The High Cost o Health Care in the United States, The New EnglandJournal o Medicine (2009), available at http://healthcarereorm.nejm.org/?p=1739&query=home.

51 The Joint Commission, What Did the Doctor Say?: Improving Health Literacy toProtect Patient Saety (2007). available at http://www.jointcommission.org/NR/rdonlyres/D5248B2E-E7E6-4121-8874-99C7B4888301/0/improving_health_lit-eracy.pd.
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About the authors

Ellen-Marie Whelan, NP, Ph.D. is a Senior Healh Policy Analys and Associae Direcor

o Healh Policy a he Cener or American Progress.

Lesley Russell, BSc (Hons); BA, Ph.D. is a Visiing Fellow a he Cener or American

Progress and a visiing proessor in he Deparmen o Healh Policy a GeorgeWashingon Universiy. She is he Menzies Foundaion Fellow a he Menzies Cenre or

Healh Policy, Universiy o Sydney-Ausralian Naional Universiy and a research associ-

ae a he U.S. Sudies Cenre a he Universiy o Sydney.

Acknowledgements

We are graeul or excellen research assisance rom Jusin Henderson and or Sonia

Sekhars help wih he reerences.


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The Center or American Progress is a nonpartisan research and educational institute

dedicated to promoting a strong, just and ree America that ensures opportunity

or all. We believe that Americans are bound together by a common commitment to

these values and we aspire to ensure that our national policies relect these values.

We work to ind progressive and pragmatic solutions to signiicant domestic and

international problems and develop policy proposals that oster a government that

is o the people, by the people, and or the people.

Better Health Care at Lower Costs

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