Doctors link together to experiment with 'one-stop shopping'

October 17, 2009

As federal lawmakers toil to reform health care, a part of the contentious debate has been playing out successfully in the Indianapolis area for a decade.

At Meridian Health Group practice in Carmel, six physicians and a host of physical therapists, nurse practitioners and physicians’ assistants treat pain as a team.

The intent is to offer one-stop shopping in a specialty—pain—to provide better care at a lower cost. Dr. Dmitry Arbuck founded the model of integration about 10 years ago and thinks it’s the wave of the future.

Democrats and the Obama administration want Medicare to provide more “bundled” payments for groups of doctors who treat long-term patient illnesses.

“In health care, it’s impossible to know it all,” Arbuck said in a Russian accent. “Instead of saying, ‘Go see a doctor,’ we draw advice from each other. One doctor becomes five doctors all at the same time.”

Arbuck explained that his practice treats patients only after other doctors have failed. That means patients often come to him seriously addicted to multiple painkillers—so much so that the painkillers start causing the patients’ pain.

A 42-year-old man, for instance, arrived recently complaining of neuropathic pain in one of his legs despite having received a $68,000 spinal cord simulator.

Arbuck recommended a neurologist on staff perform a nerve-conduction study, followed by the prescribing of medications and a physical therapy program—all undertaken by in-house specialists. Even though the patient has returned to work, Arbuck cautioned that such treatments aren’t successful for everyone.

“We try to wrap around all services,” he said. “Our patients are so sick in so many ways. You have 15 different diagnoses, and those are serious conditions, so you can’t say, ‘Just treat that or that.’”

The benefit, Arbuck argued, is that his patients—20 percent of whom receive Medicare benefits—each have their one medical chart, instead of several, which promotes better care at a lower cost.

While still unusual, the idea of combining practices to treat a specific area could become more prevalent as the escalating cost of health care helps drive the debate on how best to revamp the system.

The Senate Finance Committee so far has suggested bundling only hospital and post-acute payments. But signs are arising that bundled payments also may include physicians who perform procedures and treat chronic conditions.

In a speech to the American Medical Association in June, President Obama specifically mentioned bundling by physicians.

“We need to bundle payments so you aren’t paid for every single treatment you offer a patient with a chronic condition like diabetes, but instead are paid for how you treat the overall disease,” he said. “We need to create incentives for physicians to team up—because we know that when that happens, it results in a healthier patient.”

Bundling Medicare payments would dramatically alter the way St. Vincent Heart Center of Indiana operates, said President and CEO John Stewart, particularly because more than half its patients are elderly and need more care than the larger population.

Also, because most private health insurers, such as Indianapolis-based WellPoint Inc., base their payment to doctors on Medicare rates, they’re likely to follow suit.

St. Vincent Heart Center was founded in 2002 as the Heart Center of Indiana by cardiologists and cardiovascular surgeons from The Care Group and Corvasc. It became part of St. Vincent Health in 2006.

The heart hospital works with several physician specialties at St. Vincent—pulmonologists, endocrinologists, and even obstetricians when an expectant mother develops cardiac complications.

But those partnerships would become even more apparent if the Medicare bundling proposal comes to fruition, Stewart said.

“It would cause our hospital and physicians to work more closely in a lot of areas,” he said. “What it causes you to do is look at your operational processes so you can still provide the highest quality you can at the lowest cost.”

The number of uninsured patients the heart hospital has treated in recent months has surged, and Stewart predicts the amount will only grow as coverage becomes more expensive. So he believes some type of health care reform is necessary.

At OrthoIndy, CEO John Martin is unsure whether bundled Medicare payments would be enough to prompt the local orthopedic practice to add specialties. Besides its 60 musculoskeletal specialists, OrthoIndy also employs physiatrists and anesthesiologists, two providers that treat pain.

“I’m not sure if we would get into dermatology, but we’re like everybody else,” Martin said. “We would look and see what makes sense.”

Factors driving change

Typically in health care, lawmakers don’t legislate system changes. Rather, they legislate reimbursement changes that drive system modifications, said Bill Thompson. He is managing partner at local law firm Hall Render Killian Heath & Lyman, one of the largest health care practices in the nation.

Currently, Medicare and most private insurers pay doctors only for performing procedures and not on how well a doctor maintains a patient’s health.

Medicare reimbursement payments based on patient outcomes, or so-called pay-for-performance, are designed to drive much more coordinated and cost-efficient care, particularly with certain diseases.

Additional measures likely will be introduced into the Medicare system, Thompson said, making it more difficult for physicians to meet the standard of care. Thus, they will receive even lower reimbursements.

Already this year, medical practices face a 21-percent cut in Medicare fees unless federal lawmakers step in and block it.

Lower Medicare reimbursements, combined with the potential for bundled payments and expanding pay-for-performance programs, will drive the trend toward combined medical specialties, Thompson predicted.

“They are not prevalent now because our reimbursement system has not demanded it,” he said. “It awards units of service as opposed to positive outcomes based on coordinated care.”

Coordinated care doesn’t need to be located within one site, though, Thompson argued. It can be spread across several outside specialties needed to treat the ailment, with the primary care doctor acting as the “maestro” and supported by an electronic medical record.

Meanwhile, business is good at Meridian Health Group. The pain practice sees 150 patients a day who are referred by 600 physicians from around the world, Arbuck said.

For him, there’s no debating the health care industry is moving toward the “one-stop shopping” model he’s already adopted.

“This is inevitable,” he said. “It will become the norm.”•



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