Bill Mendenhall sat in an armchair at his house in Anchorage and strapped a blood pressure cuff to his arm.
“Lately, it's been all over the place,” he said, the monitor buzzing. He clocked his blood-pressure reading and said, “So, that’s a little high.”
Mendenhall’s working with his primary care doctor to bring down his blood pressure. People can lower their blood pressure through diet or medication, and if they don’t, it can lead to serious health problems.
“It's insidious what high blood pressure can do to your kidneys and so forth,” he said. “We call it the silent killer, because you don't really feel it.”
Preventative health care like this, which is typically more cost-effective than typical health care, is one focus of the new program that Mendenhall is a part of. Mendenhall is on Medicare, federal health insurance that mostly serves people aged 65 and up, and the program he’s a part of is re-tooling how some Alaska health care providers work with Medicare patients.
It’s called Envoy Integrated Health and Mendenhall is the patient representative on their board. It’s a coalition of different types of providers in Anchorage and Mat-su that includes multiple clinics.
Dr. Gene Quinn, their Chief Executive Officer, said typically health care in the US follows a ‘fee-for-service’ model.
“If I do a procedure x, I get paid y,” he said. “(If the) patient does well, I get paid y. (If the) patient does poorly, I get paid y. It doesn't matter about the quality or the outcome of what I do. I still get paid just for doing it.”
Their model turns that payment system on its head and providers get paid for how healthy their patients are, not how many times they have an appointment or procedure. It’s called a value-based care model.
Envoy worked with the Centers for Medicare and Medicaid Services, CMS, to set up a program similar to those already in place in many other states.
“That model is one of the most tried and true models that exists in value based care,” Quinn said. “It's been around for over a decade. It saves CMS and Medicare billions of dollars every year.”
SImply put, Quinn said, the Centers for Medicare and Medicaid Services set a benchmark for how much the entire group of Medicare patients should cost per year.
“And if you maintain their good care, but also do it in a way that saves costs to the system, then you get to split part of that savings,” he said.
It’s a way to financially incentivize efficient, effective care. That’s especially important in Alaska, a state with some of the highest health care costs in the world.
Envoy’s program has saved the Centers for Medicare and Medicaid Services a lot of money – more than $7.6 million on around 6,000 patients over the first year, Quinn said, which is higher than is typical for this type of program. A portion of that was paid to Envoy.
It’s just one model of value-based care and Alaskans may start seeing more, because the state is getting over a billion dollars over the next few years from the federal government through the Rural Health Transformation Program. The program prioritizes several aims for health care in the state, including moving toward value-based care.
Anne Zink, former head physician for the state, said on a population-level the premise of value-based care is simple.
“How am I paying for the things that are actually going to create the best outcomes?” she said.
She said typically rural health care costs are higher and the health outcomes are worse than in urban areas.
“So, that's part of the reason why the Rural Health Transformation (Program) is saying, ‘How can we spend our money more wisely so that we get better outcomes and can potentially spend a lot less?’” she said.
She said it incentivizes health care systems to look beyond just ‘sick care’ to wider impacts on health, like access to nutritious food.
“Some insurance companies have built grocery stores in community because then the grocery store can help provide healthier foods,” Zink said. “And they saw that saved them insurance dollars.”
In another example, Zink said a county reduced emergency room visits for kids with asthma by working with the housing authority to get rid of mold and pests. Social determinants of health, like education, employment and housing quality, impact 80% of health outcomes.
Envoy has also started focusing on those wider influences on health. Dr Quinn said they started a system to connect their patients to social services–like a food bank or organizations that help people find stable housing.
Quinn said value-based care is good for both patients and health care providers.
“Physicians want to take good care of patients,” Quinn said. “They don’t want to worry about finances. They don’t want to think, ‘Is this patient Medicare or Medicaid or commercial pay and can I afford to see them?’ Value-based care really flips that.”
He said it’s a win-win – value-based care can prevent provider burnout and make for healthier, happier communities.