RACINE COUNTY — Not knowing how changing government reimbursement levels and the Affordable Care Act will play out, Wheaton Franciscan-All Saints is adapting its care approach for a new future.
Wheaton executives say the reimbursement picture will change dramatically under the Act, or Obamacare. Current reimbursement models are based on how care has traditionally been delivered, incoming All Saints President Susan Boland said last week.
Wheaton spokeswoman Anne Ballentine said current reimbursement is based on volumes and services. Expensive procedures bring in much more revenue than keeping people healthy.
In contrast, she said, “In the future they’re moving toward a reimbursement model of population health management — meaning, someday there will be more financial incentives to keep people healthy.”
The new law also ties reimbursement in part to patient satisfaction and good or excellent clinical outcomes, Boland and Ballentine explained.
Therefore, to be ready to move into that new era, All Saints is developing new ways of delivering health care, Boland said.
In the past year, she said, All Saints has focused on managing various populations for health — especially in charity care.
“So, we’re trying to shift care away from high-cost practices” and treat people at earlier stages, she said.
In the short term, this new approach sacrifices some government reimbursement, Boland said. For example, All Saints will forego about $2 million in would-be Medicare revenue by starting its new Heart Failure Clinic and catching people before catastrophic heart problems.
“Reimbursement hasn’t caught up with this yet,” Boland said. “Therefore, in the short term, we will continue to provide care that is not reimbursed because these care models are laying the foundation for how health care will need to perform in the future.”
She described three such programs:
• The Asthma Management Program, led by pulmonologist Dr. Steven Johnson at 1320 Wisconsin Ave. A respiratory therapist works with patients with uncontrolled asthma. The 116 patients in the program come in for breathing tests, help with medication management, and if they are experiencing symptoms.
In the 12 months since the program’s inception, All Saints has seen a two-thirds reduction in hospital admissions and a 50 percent decrease in emergency visits from patients in the program.
• The Heart Failure Center, in the Cardiovascular Institute, 3803 Spring St. This pilot program was started last May with 288 patients who’d had heart failure — about 70 percent of them Medicare patients, Boland said.
Those patients visit the center for routine appointments and if they are experiencing symptoms such as fluid build-up, infusion therapy or low or rapid heartbeat. The program also, for example, involved hiring a new pharmacist who goes into the patients’ homes to meet with the family.
In the pilot’s first nine months, All Saints has seen inpatient admissions of those 288 patients drop to one-quarter of what they were in the previous year — an imperfect but compelling comparison. Their emergency-room visits were cut in half.
“We are proving you can keep patients out of the hospital,” Boland said.
• Primary Care Outreach, 1320 Wisconsin Ave. This pilot program, also launched last May, involves 75 low-income people who have been heavy users of the emergency room, Boland said.
Under this initiative, Dr. Jesse DeGroat is the primary care physician for those 75 patients who were not accessing primary care services through a regular physician. Now he and his staff provide regular medical services in the office.
They may identify and help those patients manage chronic conditions such as diabetes, heart failure or respiratory issues, working with specialists as needed.
In the year before the pilot began, those patients totaled 143 emergency room visits. In the nine months since then, they’ve tallied 25.
Similarly, they had 67 inpatient admissions in the previous year and just six since then.
Those results offset almost $500,000 worth of care, Boland said and commented, “This is what innovation in health care looks like.”
“Reimbursement today does not reward this kind of work,” she said, “but we expect that future reimbursement models will. We are preparing for that time of managing the health of populations.”