Focus health care on prevention

In health care, pounds of cure come with ever-increasing price tags. Costs are driven upward by better drugs, better machines and our inclination to extend our lives for as long as we can — regardless of cost, regardless of the quality of life medicine delivers in our final days. Among industrialized countries, we pay the most for health care but rank poorly in health outcomes. Cuba outperforms us in infant mortality.

The rate of increase in health care costs has slowed in recent years, but most believe the upward pressure on costs is only taking a breather. In response, the whole health care system is focusing on ounces of prevention. Private insurers like Humana and Florida Blue are investing lots of money and time trying to induce their customers to avoid behaviors that lead to chronic conditions and big medical expenses later.

Public and non-profit groups involved in providing health care in Florida don't get as much attention, but they also understand how smart care now saves money later.

In many Florida communities, for example, grass-roots groups of community health workers try to facilitate better primary care in low-income areas. These lay health workers, who come from and live in the communities they serve, have helped control costs by integrating social support into health care — arranging transportation for medical appointments, for example, or visiting homes to check whether someone's taking medication, or conducting informal education and counseling sessions on diet and blood pressure. The state, to its credit, funded a certification program for community health workers that produced its first graduates earlier this year.

Meanwhile, in Naples, an innovative non-profit that provides health care services to Medicaid patients and others has structured itself to align payer, provider and patient toward better health and lower cost.

The Healthcare Network of Southwest Florida dates to 1977, when it was established to provide health care to migrant workers and poor people in Collier County's rural areas. Today, the organization operates facilities throughout the county that provide medical and dental care to about 40,000 people, including 30,000 children (60% of the children in the county).

About 70% of the network's patients are children on Medicaid, but its clinics also attract Medicare recipients and private-pay patients. "We have quality physicians and quality facilities," says CEO Mike Ellis. Last year, the network had $35 million in revenue.

The Health Network is unique in two ways. One, it provides mental health care to all its patients. More significant, the Health Network owns its own insurance company, Integral, based in Tampa. Integral is a "provider service network," an alternative kind of HMO that the state authorized as it moved Medicaid recipients into regional managed care networks.

Typically, an HMO or provider service network receives a fixed sum for each Medicaid recipient; it then negotiates rates for office visits and other medical services with provider groups like the Health Network. Usually, the interests of payer and provider diverge — "like Venus and Mars," Ellis says. An HMO's main interest is making sure it spends less than it receives; providers, meanwhile, just want to get paid fairly for whatever services they render.

The business relationship with Integral, however, focuses the Health Network on primary care — on trying to head off chronic diseases and, ultimately, the expensive medical interventions that would cut into Integral's bottom line. Any operating profits generated by Integral go right back into the Health Network — building a virtuous cycle in which better health produces more resources for better health.

For the first time, the Health Network has an incentive to try to make its patients healthier rather than simply treat disease — it can abandon the "repair shop" approach to medicine that has dominated health care in the U.S., he says.

Last year, Integral generated a small surplus that Ellis expects to increase over time. "A lot of people are watching how payers and providers work together because it makes a lot of sense."
It's worth noting that this innovation occurred in the context of the Medicaid system, which some in the Legislature said shouldn't be expanded because it is "broken." The fact is that Medicaid probably isn't any more broken than the rest of our health care system.

And consider: The decision not to expand Medicaid left about 670,000 low-income Floridians uninsured — individuals and families making too much for Medicaid but too little for subsidized insurance under the Affordable Care Act. According to the Kaiser Family Foundation, 80% of those in that gap are adults with no dependent children. Deadbeats? Two out of three work at least part time. Half work in agricultural or service jobs in firms with fewer than 50 workers.

The Legislature may not want to expand the Medicaid system to pay for these Floridians' health care, but ignoring them doesn't mean they won't get care if they get sick enough or injured. It just means they'll end up in an emergency room, with the charges picked up by Medicaid Low Income Pool funds or by the hospital shifting the costs to its paying customers.

Meanwhile, these uninsured Floridians will be the least likely to get the primary, avoid-chronic-disease care and social supports that are becoming hallmarks of both the public and private payer systems.

They will suffer for not being insured. And we all, one way or the other, will pay.

Tags: Editor's column