Test shows how hospitals battle to balance care, cost

Results from an experimental Medicare program launched as part of health care reform efforts show that three Twin Cities health care systems all took good care of their patients, but couldn't always cut costs at the same time.

Park Nicollet, Allina Health and Fairview Health Services all agreed to act as "accountable care organizations" under the Pioneer program — overseeing the care of elderly Medicare patients, and gambling that the hospitals could profit by keeping patients healthy while lowering medical costs below expected levels.

Park Nicollet received a $2.1 million reward because its patients were cheaper than the federal Medicare program expected in 2013, but Allina Health of Minneapolis didn't save enough on patient care to receive any bonus. And Fairview's patients ended up costing more than Medicare expected, meaning the health system might have to pay the federal government back some of the money it received for their care.

Whether the three hospitals learn from their results and achieve savings without sacrificing quality in the next three years of the Pioneer experiment has implications beyond their own bottom lines. Persuading hospitals to become accountable care organizations — to share in the financial risks and rewards of their own efficiency — is an underlying but unproven tenet of U.S. health care reforms.

Medicare officials are encouraged by the 2013 results. Between 23 U.S. hospital systems in the second year of the Pioneer program, and another 220 in the first year of a similar Shared Savings Program, the federal agency announced $372 million in savings beyond what they would expect to pay for elderly patients in their traditional fee-for-service benefits program.

But even the successful hospitals are finding success to be a grind. Ten of the original 33 health systems in the Pioneer study dropped out. Park Nicollet needed to make substantial upfront investments in additional staff to achieve its reduction in spending per Medicare patient, and it is ultimately reducing the number of billable services it provides to patients in the process.

One of its most successful innovations has been hiring geriatric nurse practitioners to staff a night hot line and advise nursing homes on alternatives they can try for residents having medical problems before sending them to hospital emergency rooms.

The effort is noticeable at St. Gertrude's nursing home in Shakopee, where most nighttime consultations with doctors about residents having problems would result in residents going to the ER.

"[The doctors] were sending them to the hospital in huge numbers, because they didn't want to talk about it in the middle of the night and they didn't know these people," said Annette Lundy, the nursing home's director of case management.

But earlier this year, a sweet 80-something who plays in the bell choir at the home awoke in the middle of the night and couldn't find the bathroom or remember her name. Instead of sending her to the hospital, a Park Nicollet nurse practitioner advised the woman's caregivers to collect a urine sample and administer antibiotics for what was almost assuredly a urinary tract infection that was underlying her confusion. She never went to the hospital.

"It saves a ton of money for everybody involved," Lundy said, "and a ton of time for everybody involved."

Most elderly patients don't want to go to the hospital anyway, and nursing home residents often fare worse when they are transferred because they aren't participating in their usual exercises or activities, said Chad Sharkey, one of Park Nicollet's geriatric nurse practitioners who fields nighttime calls. "They become weaker yet and then discharged to the nursing homes in worse shape than on day one when the problem started."

The good news in the Medicare Pioneer results is that all three Minnesota health systems ranked high for quality of care for their Medicare patients. Park Nicollet was one of the top providers in the program for making sure its elderly patients had timely vaccinations and colon cancer screenings, and that its diabetic patients were in optimal health — though it ranked worse than others in timely screenings for depression.

Fairview overall ranked above average for quality of care as well. And a closer analysis of Fairview's costs showed that some doctors were slower to offer palliative and comfort care to dying patients, which helps avoid costly procedures that ultimately don't help them, said Patrick Herson, system executive for Fairview Medical Group. "There are physicians who are uncomfortable with it. They still see death as the enemy." He said the study provided a learning opportunity for Fairview doctors and administrators.

The health system is using data from the Pioneer project to identify patients most at risk for hospital admissions and targeting them for at-home care services to keep them healthy and safe.

"If we can identify those patients earlier," Herson said, "there are things we can be doing further upstream for them."