Road Map for Reform
Our population health model for providing care deserves duplication.
| Illustration by Sherrill Cooper
This past June, I delivered a speech at the National Press Club about Hopkins’ strategy for handling millions of newly insured Americans who soon will be seeking medical care.
I began with a personal story. In 1971, I was asked to be "the" anesthesiologist on Martha’s Vineyard before starting a Harvard fellowship. Shortly after I arrived, a young woman with no insurance needed a surgical procedure. She could pay the medical bills herself but couldn’t afford the normal three-day hospital stay. She begged me to give her minimal medication to facilitate her discharge that day. What sticks in my mind is helping her as she struggled to her car so she could recover at home.
Today, outpatient surgery avoids costly hospital stays. Thanks to a revolution in anesthesia, Hopkins facilities perform 2,400 outpatient procedures monthly. This is the promise of medicine: ongoing research and discovery that will transform the delivery of care.
Under the new health law, we will have to devise comparable care-delivery transformations as 32 million people become eligible for health insurance by 2019. Half of them will be covered under Medicaid. Can we give so many people quality care that also is affordable?
The approach we’ve put in place at Hopkins involves cost-efficient use of our entire integrated health system, particularly Priority Partners, our managed care organization (MCO) that serves 175,000 Medicaid patients. Hopkins established Priority Partners in 1997. Soon, it attracted 25 percent of Maryland’s Medicaid beneficiaries. What happened next is a cautionary tale for policymakers: A flood of patients sought health services. Many hadn’t seen a doctor in ages or had multiple chronic conditions. This is the population now poised to enter the nation’s health system.
Over its first nine years, Priority Partners lost $57 million. It made us wonder if Hopkins could continue its mission to the poor. At that point, we turned to the tried-and-true scientific method. Using facts, data, and experimentation, we designed and put in place a "population health model," which examines coverage through the lens of cost data and identifies quality health outcomes.
Here’s how Priority Partners’ population health strategy works:
Each month, we compile a risk score for each member, taking into account age, gender, frailty, medication patterns, lab results, claims history, clinical events, secondary medical conditions, and hospital-dominant conditions.
We determine who needs what kind of help. Then we focus on self-management, behavior modification, and, if necessary, intervention.
We work in teams—caregivers, family members, social workers, nurses, and nurse practitioners—with the primary care physician as quarterback. We’ve found that giving an informed, motivated patient an action plan, supported by a proactive medical team, electronic health records, and transitional care, improves outcomes.
We stratify the population. The bulk of Priority Partners’ patients (70 to 80 percent) have low-severity problems. More challenging patients (15 to 20 percent) receive specific interventions including technology-assisted home monitoring, health coaching, and care coordination. The remaining 5 to 7 percent are patients with high-severity, costly conditions. They receive intensive care management, including tele-monitoring and nurse case-worker visits.
Clearly, our strategy is working. We’ve seen great improvements in the costs associated with prenatal and high risk infant care, for example. Low or very low birth weight babies account for half of annual spending on births. They remain in the hospital 15 times longer and cost $84,000 per birth. Our "Partners with Mom" program improves maternal fetal wellness through face-to-face assessments, follow-ups, care-management plans, monitoring, intervention, and postpartum-care management.
The result? Today, the very-low birth weight rates for Priority Partners nearly match the national average. Neonatal intensive care admission rates and length-of-stay linked to maternal risk factors are lower than those of the national Medicaid population. And prenatal care compliance exceeds the national Medicaid average.
All of this comes without any loss in quality: Satisfaction rates among Medicaid patients in this category equal those for private plans in Maryland and nationwide.
Such positive results come at a time when 30,000 individuals joined Priority Partners in 2009—people who consume enormous resources when first admitted. Despite this surge, our MCO is showing a small profit this year—a sharp reversal of fortune.
This population health model isn’t just theoretical; it is working in the real world.
Hopkins’ approach provides a proven, high-quality, data-driven road map that can inform the federal government, states, and health care systems as they prepare for Medicaid expansion.