The Free Press, Mankato, MN

March 31, 2014

Health providers holding down costs while better coordinating care

Health providers holding down costs while better coordinating care

By Tim Krohn
tkrohn@mankatofreepress.com

---- — Among all of the clamor over the rocky start to health insurance reform and the long-held perception of out-of-control health care spending, something unique happened without a lot of fanfare.

“Health care costs went up less than inflation the past two years nationally,” said Dr. Greg Kutcher, president and CEO of Mayo Clinic Health System in Mankato.

“And that’s not by accident. There’s a lot of focus on doing things differently and being more efficient.”

But it’s not simply looking for areas to cut expenses as the push in health care is also to provide better outcomes for patients. The idea is that if someone with a chronic health condition – such as diabetes – has more coordinated care that keeps them healthier longer, the patient not only reaps obvious benefits but costs are held down because more intense treatment can be avoided.

At the Mankato Clinic, they call the approach Health Care Homes.

“We’re working more in teams to proactively reach out to patients, especially those with chronic disease conditions,” said CEO Randy Farrow.

“We make sure they come in for regular care. We see what their health care goals are and how we can help them meet those goals. You use clinically based research to reach those goals.”

At Orthopaedic & Fracture Clinic, the health care providers aren’t managing people’s chronic conditions.

“Our care is episodic. You blow out your knee and we take care of it, and maybe down the road you dislocate your shoulder and come in,” said Andrew Meyers, CEO of OFC.

Still, they too are focused much more on developing the best outcomes as insurers are more and more interested in comparing the outcomes of different physicians and health provider groups.

Meyers said such comparisons can be very tricky. “They all talk about quality outcomes but they never really define what that is.” And he said it is impossible to compare the success of an orthopedic surgeon who specializes in very complex cases and those who do more routine cases.

Baby boomers, sports keep OFC busy

OFC is the only provider of orthopedic services in south-central Minnesota with offices in Mankato, Faribault, Hutchinson and Northfield, as well as doing work at many hospitals in smaller communities in the area. They have 15 orthopods and 125 employees.

Meyers said the number of total joint replacements continues to grow at a rapid pace. “When the last of the baby boomers retire, 50 percent of the population will be baby boomers. And we baby boomers are at the age where the number of total joint replacements keeps going up.”

Sports medicine also has grown to be a big part of OFC’s business. While all the providers do some sports-related work, OFC now has three sports-trained orthopods on staff. After doing any needed surgery, OFC offers physical therapy.

While there has always been about the same number of kids playing sports, Meyers said there are more injuries and at younger ages now.

“We start kids in sports so early now. By the time they’re in high school, they have 10 years of experience and they are performing at levels we used to see in college. Years ago kids weren’t blowing ACLs or dislocating shoulders.”

OFC does much of its surgery in the surgery center on the Wickersham campus – a center owned equally by the Mankato Clinic and OFC. They have a new open MRI and a new 3.0 MRI, both of which are the largest available.

But the OFC doctors also perform surgeries at the hospital in Mankato and in other communities. If, for example, someone is brought to the Emergency Department in Mankato, OFC doctors would handle any orthopedic surgery that is needed.

“It might be something we do right away, or with something like a twisted knee, we want it to calm down for a while and may wait until later (to do surgery).”

Meyers said a big push for them in the coming year is to expand alternative ways to allow people to recover from joint replacement surgeries.

“We’re doing total joint replacements in our surgery center and then recoup them at a hotel or an Ecumen or Thro community,” Meyers said.

He said patients are put up in hotels, such as the Hilton Garden Inn, and a nurse is stationed in another room, providing 24/7 care to one, two or three patients recovering from surgery.

“It saves the patient a lot of money compared to staying in the hospital. They like it because they have nice rooms, can order the food they want, and they save a bundle.”

Meyers said the only thing holding back on an expansion of the hotel recuperation concept is that some insurance companies – for reasons he said he can’t fully understand – are still balking at allowing it even though it saves the insurance company a lot of money.

He said candidates for such recuperation must meet certain health criteria. Someone of advanced age suffering from diabetes, for example, would still recover in a hospital.

Like everything in health care, OFC has seen staggering technological advances, said Meyers, who remembers when a knee orthoscopy meant pushing a tube into someone’s knee and literally looking into the knee with the naked eye. Today, tiny video probes do the job.

“All rotator cuffs (surgery) used to be a big incision down the front of your shoulder. Now we do them through three little button holes.

“The technology is just off the charts.”

Meyers said cases of bad medical parts being implanted in people’s joints aren’t a medical liability for OFC, but it puts them in a bad position. The OFC did use the Stryker hip replacement parts in several patients – parts later found to be defective. Stryker has already agreed to some settlements stemming from lawsuits and will likely pay billions of dollars.

“We just make sure we work with our patients to follow up with them and do another procedure if that’s what they choose. It’s a bad situation, but most people understand we don’t make the parts. We just do the surgery.”

Mayo seeing a ‘culture change’

Better coordinating care for chronic disease isn’t just a matter of better treatment for diabetes or heart disease, Kutcher said.

At Mayo, a program called COMPASS is aimed at identifying patients with diabetes and heart disease to make sure those people are getting any mental health care they need.

“Many of them have overlapping depression issues,” Kutcher said. “If people don’t deal with that, they often don’t take care of the heart disease or diabetes.

“We’ve seen some real improvement in care in that population.”

Mayo has also been gaining efficiencies and easier patient experiences by beefing up a nurse call line.

“Call line doesn’t really do it justice. If you call for an appointment for certain problems, you’ll be transferred to a nurse and a lot of times they can help you deal with it right on the spot, rather than people having to go to a doctor or the ER,” Kutcher said.

“Things like refilling nasal prescriptions – nurses have been trained to help you with things like that. It’s a change in culture for patients and in health care. We call it ‘doing the right care at the right time at the right place.’ ”

Occupational medicine is another area seeing growth and new approaches and the need for more specialized knowledge.

“The rules on Department of Transportation truck-driver certification are very tough now. It used to be a family physician could do it, but not now,” Kutcher said.

He said occupational medicine now works more closely with employers to create workplace safety programs and deliver care on site.

“If we see common injuries in certain settings, we can help businesses put things in place to prevent them. Or if you have employees who have to leave for several hours once or twice a week for diabetes checks, with bigger companies we might be able to do something on site for them.”

Another big efficiency change that isn’t directly noticed by patients is something called Care Traffic Control, a coordinated internal system that allows hospital and clinic staff from across south-central Minnesota to decide quickly where a patient would best be treated.

“Say a provider from St. James wants to admit a patient to Mankato or somewhere else. These are complex situation where you have to make sure everyone has the available nurses, social workers, medical specialists ready,” Kutcher said.

“This system makes it much easier. Sometimes they maybe don’t even need to be transferred from their facility to another one if the other facility can get the help they need.”

It also makes things less complicated for patients, he said. “You’d often heard complaints from patients about why wasn’t this all in place or why are they doing the same tests again? This helps with that.”

Mayo is also relying on a variety of technology to help providers deliver better care to patients.

The local Mayo system is a certified telestroke center in which a wide variety of test results and data from someone who just suffered a stroke can be relayed instantly to a team of Mayo neurologists, who may be in Arizona.

“When someone has a stroke, it’s very time sensitive. Some people should be given a clot-busting drug early on, but it’s risky to do and it’s not given at small hospitals. It’s a very complex decision to see who gets it and sometimes people who should have gotten it didn’t,” Kutcher said. “Now they can get a neurologist online immediately to help them make the diagnosis and if they need (the clot-busting drug) they can be sent to Mankato or wherever.”

Clinic’s expansion underway

The biggest project since Mankato Clinic built its Wickersham Campus several years ago is under way as a $9 million pediatric center is going up there with an opening set for late fall.

Part of the pediatric clinic will include space for Gillette Children’s Health Center as part of an expanded partnership between Mankato Clinic and Gillette Children’s Specialty Healthcare in St. Paul.

“We’ll be able to offer not only general care but sub-specialized pediatric care through Gillette,” Farrow said. “They will offer things like pediatric cardiology, urology, endocrinology.

“Kids have special needs because their organs aren’t fully developed and these physicians have the specialization. It will be a significant expansion of what we can do.”

He said things such as having specialists on hand to adjust braces for special needs kids will be a big help for parents. “A lot of times the braces need to be adjusted once or twice a month, and they won’t have to go to the Cities or somewhere else.”

Farrow said that as part of their effort to improve care, the clinic brings in focus groups, including one that was made up of parents of pediatric patients.

“A lot of the comments were that it’s not easy to come in from 8 to 5, so we’re offering evening hours now in pediatrics, Monday through Thursday,” he said.

“We’re putting a lot of emphasis on how we deliver care."

Another new approach is a return to house calls – sort of.

“We’re starting something we call Blue Stone, a program to provide primary care services on site for people who live in assisted-living facilities. Some of these folks are frail and it’s hard for them to be transported and some may have cognitive issues,” Farrow said.

Teams consisting of a physician, nurse practitioner and a support person go out regularly to sites that have contracted with the clinic.

“They get to know the people, which helps with their care. We have four (sites) signed up already, and we think it will be very popular and we expect a lot more to sign up.”

The clinic also started a new dialysis center, in partnership with DaVita Dialysis, at Madison East Center. Farrow said it is popular with patients.

“It’s really exceeded our expectations. We just saw a growing need for that service, unfortunately. People have to come in at least three times a week and spend several hours, so we want to make it a nice place for them. We’ve gotten a lot of good feedback.”

The clinic also spent last year beefing up the psychology and psychiatric departments.

“We’ve really expanded there. We added two or three more providers that focus on children’s behavioral health. That was a big need we couldn’t meet before.”

All told, the clinic added 17 new physicians and advance-service providers last year.

“We continue to grow. The future of health care is obviously uncertain with all the reforms. But we think if we stay focused on trying to provide the best care possible and creating excellent patient experiences, we’ll be successful,” Farrow said.