Greater personal responsibility, cost and collaboration in health world

Posted: Sunday, January 4, 2015

After 84-year-old Teresa Ward fell and broke her hip last year, the doctors warned her family they could expect her to live another six — maybe eight — months.

Such major medical setbacks typically accelerate the progression of Alzheimer’s disease, the most common form of dementia, which Ward was diagnosed with at age 72, her daughter, Kathy Gainer, said. As expected, Ward soon stopped talking, slept too much, her weight dropped, and her need for 24-hour supervision was draining her 85-year-old husband.

But Gainer wasn’t ready to place her mother in a nursing home, where she was transferred during rehabilitation.

Last year she entered the LIFE at St. Mary program, a health care model designed to provide a coordinated and collaborative continuum of care for senior citizens that lets them remain in their homes. The individualized care plans can include a personal health aide who dresses and bathes participants, transportation, durable medical equipment, physical and occupational therapy, counseling, and caregiver respite.

Today, Ward is more active, happier and healthier though her Alzheimer’s continues to progress, Gainer said. Her father has more free time for errands, visiting friends, even napping without worrying about his wife.

“She is thriving. She smiles. He is happier because she is happier and she is safe,” Gainer said. “This is the best place to be putting our money for the elderly — for Medicare and Medicaid, this is what they should be doing.”

LIFE at St. Mary is among the health care trends that medical and health care experts anticipate will continue to grow in popularity in 2015, as more Americans experience closer ties with their physical health and financial well-being, and public and private employers continue to grapple with increasing medical costs while maintaining quality care, according to local health and medical experts.

A continued emphasis on disease prevention and management means Americans can expect to assume greater responsibility for the ongoing management of their health care while health services and providers will focus on a more “personalized” and extended approach to medicine.

Programs promoting wellness and healthy behaviors will become increasingly crucial as insurers and employers continue shifting more of the financial burden onto consumers in the form of higher out-of-pocket costs, coinsurance, narrow/tiered provider networks and deductibles. More employer-provided insurance plans will continue to discourage unhealthy behaviors with surcharges, such as for tobacco use, experts said.

The number of American workers with high-deductible insurance plans increased from 4 percent to 20 percent between 2006 and 2013, according to the American Hospital Association’s 2015 Environmental Scan. The average patient deductible has nearly doubled since 2006, and the typical plan deductible now exceeds the typical family’s available savings.

About 320,000 Pennsylvania residents obtained coverage through the federal health insurance marketplace during the first open enrollment period in 2014, said Andy Carter, president and chief executive officer of the Hospital Association of Pennsylvania, which advocates for the state’s hospitals. This year, the number is estimated to rise to 600,000, mostly through the state’s Healthy PA Medicaid expansion.

“More consumers than ever will be enrolled in health plans that have higher levels of out-of-pocket costs," Carter said. “Patients want and deserve to discuss financial obligations upfront, before receiving care. It’s an important part of improving their overall health care experience — another key trend for 2015.”

Population Health

The push to reduce health care spending and improve quality is reflected in a trend known as population health. The concept takes a pre-birth to death care continuum with a collaborative team approach for “treating a whole person in a whole life,” said Dr. Deirdre Donaghy, chief medical officer at St. Mary Medical Center in Middletown.

Population health is an approach that aims at improving health and reducing health inequities in a specific group. The concept revolves around promoting healthy behaviors and lifestyles through regular, basic health care interactions that are free or affordable, such as general health screenings, health coaches, wellness programs, and programs that reward healthy behavior. Typically such programs work with insurers providing one general payout for care.

“Right now, we wait until people fall over and treat for illness,” she said.

LIFE at St. Mary, which started in 2011, is a small model of population health care targeting senior citizens, Donaghy said. The program established under the Balanced Budget Act of 1997 is designed to address needs of long-term care clients, providers and payers. Most participants are Medicare-Medicaid eligible and providers receive a monthly preset payment, which is used to provide services and care.

Participants received comprehensive health and social services overseen by an interdisciplinary team with St. Mary's affiliated providers overseeing all aspects of medical care.

Another patient care model that borrows from the population health concept targets specific hard-to-manage chronic diseases, Donaghy said. These high-risk patients are connected with more community services, including telemedicine monitoring, care managers and home care in an effort to reduce hospital readmissions, she said.

St. Mary has such a program in place for patients with congestive heart failure, with plans to expand it to include patients with chronic obstructive pulmonary disease, Donaghy said.

Philadelphia regional health providers are already seeing the effects of greater prevention efforts, said Carter of the hospital association. He attributed the greater use of routine, preventative and outpatient care as driving a downward trend in hospital admissions. Inpatient volumes across the five-county region fell more than 13 percent between 2007 and 2013 — from 708,000 discharges to about 613,000.

“This push toward health and wellness is one of the factors behind the many mergers and partnerships underway in southeastern Pennsylvania,” Carter added.

Mergers and Collaboration

Nationally — and locally — independent health care providers are moving toward mergers to create diverse and financially stable health care systems offering a wide variety of services. The partnerships are particularly beneficial for small hospitals looking to expand in expensive, but high-demand, services such as heart, orthopedics and cancer treatment, experts said.

A local example of such an institutional collaboration is the pending merger announced in October between Abington Health, which has two hospitals and other health care services in Montgomery County, and Jefferson, the Philadelphia medical university and hospital, which would create one the region’s largest health care providers.

The trends collaboration and continuum of care is also happening in the emergency medical services field, according to Dr. Gerald Wydro, regional medical director for the Bucks County Emergency Health Services.

Last year Bucks County EMS joined the Cardiac Arrest Registry to Enhance Survival program through the University of Pennsylvania, a national program designed to improve survival rates for out-of-hospital cardiac arrests. Bucks County rescue squads responded to 334 cardiac arrest calls in 2014, up from 310 the year before, according to Bucks County Emergency Services data.

As part of the program, the county has undertaken a dramatic change in how emergency dispatch operators — the first link in the emergency health care chain — respond to 911 calls involving possible cardiac arrest, Wydro said. They are trained to recognize cardiac arrest signs faster and get callers to start hands-only CPR quicker, actions that can save lives until emergency responders arrive.

Dispatchers now ask fewer, but more targeted questions to determine if a person is in cardiac arrest. They are also trained to recognize specific distressed breathing patterns and even count chest compressions with the caller to keep them focused on continuing CPR until emergency responders arrive, Wydro said.

“We used to ask (callers) if they want to perform CPR,” he added said. “Now we don’t even ask.”

While the hard data isn't expected to be available until next year, anecdotal information suggests that since implementing the new 911 intake call procedures EMS services have seen improvements in cardiac arrest patients arriving at the hospital with a pulse, Wydro said.

As scientists develop a better understanding of the role genetics play in many chronic health problems, health care is continuing to move toward a precision-based model, which has the potential to transform health care and other industries, experts said.

Injecting itself into the personalized medicine trend is the use of mobile information and communication technologies — better known as mHealth. It will be a major tool in the drive toward improving personal health and remotely monitoring chronic illnesses and acute conditions, experts anticipate.

Among ongoing mHealth initiatives are the National Cancer Institutes of Health SmokeFreeTXT program, a smoking cessation service for teens and young adults, and the Health Resources and Services Administration’s TXTTots, a public text messaging library that provides information on nutrition and physical activity to parents and caregivers of children age 5 and younger.

Other technology-driven initiatives in the Philadelphia region are expected to make it easier for doctors and hospitals to share information about patients.

One initiative — the HealthShare Exchange of Southeastern Pennsylvania — is connecting the region’s many hospitals and other health care providers, so they all have access to the latest information about hospitalizations, follow-up care, medications, and other aspects of patients’ care — even when patients are being treated by different doctors at different health systems, said Martin Ciccocioppo, vice present of research for the Hospital Association of Pennsylvania.

“In 2015, look for HealthShare Exchange to lay the groundwork for new, query-based technology that will be even more effective in helping providers prevent errors and avoid unnecessary or duplicative medical tests, lab work, and imaging studies,” he said.

Jo Ciavaglia: 215-949-4181; email: jciavaglia@calkins.com; Twitter: @jociavaglia