Frequent visitors to the emergency room tend to get the blame for the soaring cost of health care. In effect, everyone's monthly insurance premiums cover the most expensive patients. So BlueCross BlueShield of Tennessee — like many insurers — has begun devoting more energy to its priciest patients in a long-term effort to control overall costs.
These are patients like Charles Henderson of Nashville, who has had a pretty rough 12 months. First his mother died. Then he was diagnosed with prostate cancer.
"When you hear cancer, you think it’s going to be the end," he says.
Since he’d been homeless and uninsured until recently, his trip to the doctor also discovered a case of Hepatitis C. That’s now under control. And radiation seems to be working on the tumor.
"It will be 44 treatments, 44 different days," Henderson says. But quite literally, he never would have made it to all those appointments without Kelly Hutchison, his care coordinator. She arranged a free ride to hospitals all over town.
"It’s been real rough, but I dump everything in her hands," he says. "I know she hates me for that — but I couldn’t have ever done it myself."
Hutchison is a nurse who works for BlueCross. Aside from lining up rides, she also calls Henderson to make sure he’s taking his medicine and eating healthy. She brought him cupcakes and kitchen supplies to celebrate his final radiation session.
But just as he neared the end of his cancer treatments, his urologist stopped taking his insurance. So Hutchison started calling around.
“Right now we’re currently finding him another physician to carry over his urology care,” she says, with Henderson chiming in that, left to him, he probably would have "given up" before finding a new doctor.
In Tennessee, BlueCross has hired 55 nurses like Hutchison to handle patient coordination for 323,000 people — or approximately 10 percent of its 3.1 million patients across the state. For those who have chronic conditions like congestive heart failure and hypertension, the insurer has found it can save money by holding their hands now, because it can prevent patients from needing more expensive treatment later. Blue Cross reports cutting inpatient admissions by 4.7 percent and ER visits by 0.6 percent among these patients.
Coordinators each have thousands of people they're responsible for and target those who regularly land in the hospital. They reach out to those who haven't made a primary care visit in more than a year and try to schedule one. When these patients are in the hospital, coordinators follow them through the discharge process and make sure prescriptions are filled. For the latest year for which the numbers were calculated, BlueCross estimates it saved $1.6 million, even after accounting for the staffing cost to run the program.
Increasingly, hospitals have become more interested in joining forces with insurance companies because of new bonuses for making people healthier and penalties for folks showing up with the same problem over and over. Vanderbilt Medical Center is one of BlueCross's newest partners. Saint Thomas was an early adopter.
The strategy is nationally recognized as a patient-centered medical home, though the name can be misleading.
"It's an experience, not a place," says Ann Greiner, CEO of the Patient-Centered Primary Care Collaborative, which advocates for this approach as a way to help simplify the increasingly-complex health care system.
Greiner likes to think of the concept as providing a "general contractor" for a patient’s health — coordinating rather than performing the care. The idea was standardized in 2007 but has continued to evolve. And still, most people do not have a medical home.
"Ideally, everyone has the benefit of a patient-centered medical home, and then there are more intense services for those patients that really need them," she says.
While the incentives are changing, physicians are still mostly paid for procedures and tests, not counseling and coordinating. So for now — in Tennessee and elsewhere — insurance companies and Medicaid programs are the major force behind patient-centered medical homes. And they primarily help the sickest — where insurers see the biggest potential savings. Blue Cross Blue Shield of Michigan has one of the oldest programs in the country and has decreased adult ER visits by 15 percent.
But aside from cutting costs, BlueCross argues that it’s creating a better experience for chronically ill people, like Charles Henderson. However, the insurer acknowledges it needs to find a balance between hand-holding and sending patients out on their own.
Nancy Muldowney, who manages the company’s care coordinators in Middle Tennessee, says she doesn't want patients like Henderson to grow overly dependent on the additional help.
"He has to own part of that health. A lot of our program is we want to empower patients, and we partner with patients so that they can own their health," Muldowney says. "It’s a very long process. It doesn’t happen overnight."
The goal is for Henderson to take initiative himself, and he’s starting to. He recently needed glasses, and instead of throwing up his hands, he scheduled an eye appointment. His care coordinator hopes he does the same when it’s time for his cancer checkups.