Many Americans believe that medicine is fraught with escalating costs, a variety of quality issues, roadblocks to access, disruptions in coverage and undesired patient outcomes.
Making the parts fit
Business, providers partner to raise quality, cut costs
In Green Bay, Wis., a solution to these issues includes a business, a healthcare provider and an insurance company creating a “philosophical partnership.” Two years of development were needed to overcome inherent business practices that could have limited collaboration and success.
JBS Packerland is a beef processor in Green Bay, Wis. Aurora BayCare Medical Center is the provider, a joint venture of BayCare Clinic, a specialty-care clinic in Green Bay, and Aurora Health Care, a 12-hospital system based in Milwaukee. Humana is an insurance company providing the partnership with the Aurora Direct Network and serves as the third-party administrator. Members of the steering committee include the chief medical officers of JBS Packerland, Aurora Medical Group (primary care) and BayCare Clinic (specialists); the chief financial officer and vice president of human resources from JBS Packerland; directors from the Aurora Health Care regional business development office; and consultants from BeneCo of Wisconsin.
With the steering committee's direction, Humana changed the network and claims processing to establish the partnership's operation. In this model, quality is foremost. Cost is not unimportant but is used as a trailing indicator of success. The team attempted to install things that enhance patient care and quality and discard the ineffective or inefficient.
The following explains their efforts. A concierge phone number provides access to the system; same- or next-day service is ensured by use of this number. Various quality metrics were applied, with JBS first selecting the health system and then both JBS and Aurora BayCare choosing individual preferred providers within the system. Utilization is benchmarked. A nurse devoted exclusively to JBS Packerland members meets face-to-face with patients, building relationships and advocating evidence-based, best-practice guidelines and boosting member compliance and outcomes.
From installation, warranties were applied to all 28 never events set by the National Quality Forum. Two committees provide monthly oversight of medical and administrative concerns. Pre-certifications and pre-authorizations—considered barriers to access—were removed. Aurora BayCare was established as “in network” and other providers became “out of network.”
The partnership is also diligently establishing quality in the second and third components. A nurse condition coach receives data related to the care of targeted conditions. The data establishes trends that guide nurse interventions. The conditions addressed include those of high utilization, risk, intensity of service and cost. While not functioning as a treating nurse, these efforts are invaluable in managing the members' conditions. Finally, patients and providers learn about and are encouraged to use the JBS “best in class, best in cost” preferred drug list. This transparently guides the choice of the right medication offering the right value when making treatment decisions, resulting in improved member compliance, better outcomes and a reduction of the medical complexity and cost.
The outcomes have credibly established the partnership's intent: by addressing quality first and foremost, eventually the bottom line will improve. Quality physicians can provide quality care resulting in greater professional freedom and job satisfaction. Patients can be influenced through education and incentives.
Condition management builds relationships that lead to improved compliance, resulting in favorable outcomes and reduced risk of catastrophic events.
Because of these efforts, the company has not increased copayments, deductibles or out-of-pocket maximums for health benefits since May 2007. The net cost to JBS Packerland decreased 10% for plan year 2008. Aurora BayCare has also increased market share among JBS beneficiaries: to 97% from 40%. Both providers and patients have a health advocate to address condition management properly. Conventional wisdom leads one to believe that these will likely lead to greater stockholder satisfaction, too.
Ernie Vesta is chief medical officer of JBS Packerland, Green Bay, Wis.
Send us a letter
Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.