Lower medical costs, better outcomes, more satisfied Medicare recipients and stronger profits. Sound like an impossible dream of healthcare reform? Turns out it’s all happening now under a new wave of policies embraced by both the Biden and Trump administrations.
After decades of financial incentives that rewarded medical providers for putting people through an expensive parade of procedures, we are now working to shift the focus to wellness, prevention and value.
These advances are taking place under an alphabet soup of Medicare test programs — with names like Accountable Care Organizations (ACO), the Medicare Shared Savings Program (MSSP), Accountable Care Organizations Realizing Equity, Access and Community Health (ACO REACH), and Global and Professional Direct Contracting (GPDC) — but the philosophies are similar. They move care from the traditional fee-for-service model to one tied to health results.
The healthier the patient, or client, the bigger the rewards for providers, rather than the perverse opposite that so often takes place now. Health care providers must put their own skin in the game. We assume more risk in return for the chance of a greater reward. No middle man, no excuses.
I’m not going to pretend this conversion is easy on health care providers, but I am here to attest that it can work, even if the start can be rocky, as it was for us at Lifespark, to be honest.
We’ve been participating in a value-based arrangement in Minnesota for almost four years now between a health system and the largest Medicare Advantage provider in the state. Yes, the first year we lost money and had to write a seven-digit check when we didn’t meet our goals. But we learned — and clients and taxpayers have benefited.
Since then, we’ve seen a 43 percent reduction in hospital admissions for our members in Minnesota and a 24 percent reduction in emergency room visits. Admissions to skilled nursing facilities have been cut almost in half. At the same time, our net promoter score, which measures customer satisfaction, stands at 93 out of 100 — almost three times more than health care overall at 38 and more than double that of Disney’s at 44. Talk about a happy place.
Nationally, The Centers for Medicare and Medicaid Services (CMS) estimates that more than 11 million Medicare recipients will be served by Shared Savings Program ACOs in 2022. Performance data continues to show high satisfaction among seniors as well as savings to the system. In 2020, the most recent figures available, ACOs saved Medicare a collective $4.1 billion, an amount that was a still-impressive $1.9 billion after ACOs were reimbursed for shared savings.
This isn’t to brag. It’s to say this is a game-changer, one that can and does work out for patients and providers. And let’s not forget the taxpayers who fund Medicare, which serves nearly 1 in every 5 Americans and can’t keep operating like some endless money pit. Just because people or consumers don’t always see a bill doesn’t mean that someone isn’t paying it.
Of course, this requires investment: in data analytics, technology, staff and most of all in prevention and wellness. You have to earn the trust of the people you serve by serving them well. Also, and I can’t emphasize this enough, you’ve got to have strong relationships with like-minded people and providers, ones aligned with the idea that the best health care is good health.
It might seem like a numbers game. After all, health care spending accounts for more than 19 percent of U.S. gross domestic product (GDP). That’s a whopping $4.1 trillion, or $12,530 for every man, woman and child.
But what it’s really about is serving people and keeping them healthy and out of hospitals as much as possible.
This new medical philosophy is about looking at the total cost of care, which includes everything a person spends within their medical insurance, plus all out-of-pocket dollars they must use to live their life on their terms, and how that care is delivered and to what end.
It’s about building delivery systems that see patients as whole human beings rather than as a heart bypass or sarcoma or whatever medical condition is being treated. It’s also about keeping people financially afloat — as many as two-thirds of all personal bankruptcies are tied to medical bills and ailments.
We’ve got to stop over-serving patients and under-serving them at the same time. We’ve got to assume the risk of investing in prevention, maintenance and strengthening health, which the Medicare system barely covers today, if at all.
The risk for providers is big, but the opportunity is even bigger. I say be bold. Let’s improve the consumer experience and help patients live magnificent lives. Let’s not even call it health care anymore. Let’s just call it health.
Joel Theisen, BSN, RN, is founder and chief executive of Lifespark, a Minnesota-based complete senior health company. Follow him on Twitter: @Lifespark_CEO.