Doctors Medical Center in Modesto, with its 465-bed hospital, is not a small facility -- but it likes to act like one.
It's that small-town, personal approach that has led to some big advances in this Central Valley health care facility, said Matt Coury, CEO of AllCare, the provider group at DMC.
"What's unique in Stanislaus County is the level of intensity by a small group of folks," Coury said. "If you don't have the initiative among the people at the front line or if you have too many people on the front line, it could go wrong. That's the most significant aspect that's driven success here."
That rings true for Mike King, DMC's chief operating officer.
"We've been working together for years," King said. "We see the same people coming to our work meetings all the time. We know each other, we know our patients. Communication is the key."
Communication could be key to the success of the Stanislaus County facility's recent move to an accountable care organization model. The ACO project, which began last year, has surpassed most expectations so far.
The Central Valley ACO was formed by the Doctors Medical Center of Modesto, the AllCare Independent Physician Association and Blue Shield of California.
Admissions, ED Visits Down
In its first year of operation, the Central Valley ACO has posted some impressive numbers.
- Hospital admissions have been reduced by 28.8%.
- The number of days spent in the hospital was cut back by 29.3%.
- Average length of stay in the hospital has dropped slightly (0.6%).
- Visits to the emergency department have declined by 9.3%.
Those numbers are based on comparisons of current-year results with a one-year baseline period from September 2010 to August 2011.
King said success in launching this ACO largely has depended on buy-in from the people involved in it. Doctors Medical Center has had a particularly strong showing, he said, because so many hospital leaders supported it.
"Implementation was a lot of work, but having a dedicated team really works," King said. "Senior leadership has had a hand in [the nuts and bolts of creating the ACO]. Senior leadership has been there and been engaged."
ACOs Forming Across the State
Blue Shield has helped set up 10 ACOs across California. In this early stage, the Central Valley ACO has been its poster child for successful implementation.
"We have 10 different ACOs in 10 different markets, and we're starting to see encouraging results across the board," said Kristen Miranda, vice president of strategic partnerships and innovation at Blue Shield of California. "These particular results are really impressive, and we've spent time thinking about what led to this kind of phenomenal success."
"At the highest level, it's better integration around care issues," Miranda said. "For instance, with a patient who's being discharged, a follow-up appointment is scheduled, and then there's a phone call from a nurse when they arrive home, to make sure they have all their medications, and to answer any questions about those medications, or see if they need any help with transportation to appointments."
The idea is to make sure patients have everything they need away from the hospital, to maximize health and minimize returns to the hospital.
"It's that kind of in-the-trenches coordination that leads to better patient experience," Miranda said. "The idea is, you want to see what's working well and what's breaking down as the patient navigates the system."
Change in Relationship Between Providers, Insurers
The patient-centered approach ends up boosting quality of care and saving money, particularly when applied to high users of the health care system.
That shift in care approach could not happen without another fundamental change in the system, Miranda said -- the way providers, hospital officials and insurers interact.
"We see each other at the negotiating table, and historically that's the extent of the relationship," Miranda said. That us-versus-them dynamic leads to delayed and fractured care, she said.
"But with this [ACO] model, we're now on the same team. The way we're interacting with providers is just so different. Insurers, hospital, providers, we're all part of the resources. This is completely different," Miranda said. "It has been a transformative model."
Miranda, who has now seen that transformation a number of times, said there are a few constants in every ACO startup: "We hear it now from every ACO partnership, people say things like, 'I never even knew who to call when I had a thorny issue.'"
Carolyn Ogden, director of medical management at AllCare, said it's an entirely new world for providers.
"This is different. This is way different," Ogden said. "We had a whole different set of [insurer] contacts before, we had negotiators, we had provider liaisons. But now it's direct access to Blue Shield staff, and that's very helpful."
It's the best result from all the work put into forming the ACO, Ogden said, because the streamlined process gets care to patients in a more timely way.
"I can make a phone call and get results," Ogden said. "We're clinical people, and we do believe in lowering costs, but mostly we like it because it's good logical medical care -- it's good care in a timely fashion. You can actually make a difference with a phone call."
"That's what it's really all about," Coury said. "From a clinician standpoint, with this ACO, you can make a difference."
The biggest change in the relationship between providers, hospitals and insurers, Miranda said, is that the previous time spent in establishing position and forming strategies to handle negotiations is now spent sitting at the same table, talking about patient care.
"It sounds kind of hokey, but I get goose bumps when I sit in these meetings," Miranda said.
Targeting High Users of System
The emphasis on a patient-centered approach yields bigger dividends for chronic users of the health care system, King said, so officials in the Central Valley ACO made a concerted effort to target that high-use population.
"It's the collaborative effort to focus on managing this population that has made the biggest difference," King said. "Just having the focus on a team that can break down barriers in real time is very important."
The organization hired a full-time care coordinator and a hospitalist, and those investments were vital to the turnaround, King said.
The infamous rule of thumb -- that 10% of patients use 90% of hospital services -- encourages ACOs to keep tabs on those high health care users, King said.
"We give them special care. We're making sure they get the appropriate medication and treatment, and get them off that 10% list," King said. "We know who they are, pretty well. It's a small population of patients."
King said the hospitalist and care coordinator probably know most of them by name. "I believe those two people know everyone [in that patient population]," he said. "They're getting a little extra attention, that's for sure."
Miranda pointed out that health care is unlike any other business, in that better patient care actually translates into lower costs.
"We're putting on the lens of what does this look like from the patient's perspective, and who are the others that need to be brought in to care for them," Miranda said.
"The added bonus is, all of that stuff reduces cost," she said. "Doing the right thing turns into the cost-effective thing."