By Steven Yahn
There aren't many Ambulatory Intensive Care Units in the United States, but those that are in place are reducing costs and increasing quality of care for the chronically ill.
The goal of an AICU is to provide high-quality care at lower costs for individuals with complex health conditions such as diabetes, cardiac disease, pulmonary disease and renal disease plus varying degrees of depression, or often a combination thereof.
Mercer runs an AICU in Dallas called CareConnect, which deviates from traditional physician-only care, instead providing a team approach to caring for people with chronic illnesses. The treatment is expensive upfront because patients are cared for by multiple specialists.
With the right talent in place, though, the concept can provide good care and reduce costs.
"What makes this model so effective is that it is driven by physicians and nurses chosen specifically for their ability to deliver better care and to work closely with patients to address their concerns in a highly caring manner," said Dr. Neil Smithline, a Mercer physician consultant who helped develop the Dallas program.
But it remains to be seen whether the concept will work on a broad scale.
"I think the jury is still out on AICUs," said Dr. Jaan Sidorov, chair of the San Francisco-based NORCAL Group, a medical professional liability insurance company. He said the concept shows promise, but getting a number of organizations to commit to the upfront costs could be challenging.
Even with multiple physicians and nurses attending them, patients can still end up in an emergency room or in a hospital on a frequent basis, said Dr. Sidorov.
AICU teams may also contain dieticians, nutritionists, pharmacists, pulmonary experts and other medical specialists. First-year results for CareConnect have been dramatic, Mercer said, with a 20 percent reduction in cost (net of plan expenses), improvements of 15 percent or greater in physical and mental functioning and a 45 percent reduction in absenteeism. The success in Dallas has led Mercer to plan for two additional CareConnect units in Richmond, Va., and Seattle by the end of 2013.
With the AICU team approach to care, patients with the most complex and chronic conditions are provided around-the-clock care. "This extra caring means being accessible to the patient -- through extended evening and weekend hours and 'virtually' via online access," said Dr. Christopher Crow, founder of Village Health Partners, a family medical practice company affiliated with Mercer. "It means using a physician-led team of health care providers to coordinate the care of patients to achieve high-quality outcomes at reasonable costs."
CareConnect and other AICUs also dramatically change physician compensation. Physicians are rewarded for excellent results and for spending additional time with their patients. They are paid an additional fee for the extra care coordination required. They also have the opportunity to receive additional compensation for demonstrated improvement in patient health outcomes.
"Providing new resources and new incentives to mature primary-care practices allows them to better serve the most at-risk patients while creating the value we need from our health care system," said Dr. Cliff Fullerton, chief quality officer for Health Texas Provider Network, which is also involved in the CareConnect project.
Eric Bassett, senior partner at Mercer, said that using an AICU is a quality improvement play. "The resulting fallout of that in a positive way are cost savings," said Bassett. "So everything within the AICU concept is focused on giving the sickest patients, the ones who have the toughest issues, who are very fragile, the best possible physicians and their teams the best possible care."
Bassett cited a program in which nurses walked patients to their cars after physician visits. That gave nurses a chance to ask questions about their office visits and determine whether they were taking the right medications.
Patients in the Mercer program also are guaranteed a 30-minute call-back time. "Remember, these patients are very fragile," said Bassett, noting that if they go hours or days without a call-back, they could end up in an emergency room.
Running a successful program also means finding the right doctors. "There are good physicians out there, but some of those physicians are not set up for taking care of the chronically ill," he said.
Dr. Sidorov, from the NORCAL Group, agreed. "I haven't seen any literature on this, but I personally believe that the average primary-care physician really has to be professionally called to do this kind of work. While it can be rewarding, it's also a very, very different type of practice setting than doctors like me are typically acculturated to in the course of our training. In short, I don't believe that doctors who do this kind of AICU work grow on trees."
However, Dr. Sidorov noted, "depending on the reimbursement, depending on the salaries, physicians working in this field may be helped by the prospect of better payment."
When it comes to primary care, traditional insurance typically covers physician services and the principal payment mechanism has been to provide a payment (or fee) for each patient encounter, or service. Until recently, health insurers generally have been reluctant to adequately cover health services that occur outside the narrow confines of a doctor-patient encounter.
"That's why providing additional payment for non-physicians providing services, such as counseling and coordination of care, is so revolutionary," said Dr. Sidorov. "The other wrinkle is that instead of reimbursing each encounter, each phone call or referral, insurers prefer to provide a global fee, usually on a monthly rolling basis for each patient who is requiring that level of service.Once insurers pay for it, primary physicians can provide it."
The AICU concept was jump-started in 2005 when the Oakland-based nonprofit health care philanthropy California Healthcare Foundation provided the first of several grants to Dr. Arnold Milstein, then Mercer's chief medical officer. It was nicknamed the "Bug Project," a reference to the Volkswagen Beetle, which had reduced the total annual cost of new car ownership, just as this project hoped to reduce the total annual cost of health care.
To design innovative care delivery models that would greatly reduce medical spending while also improving quality, Dr. Milstein recruited a "Mission Impossible" project team of clinicians, managers and systems engineers. The first innovation to emerge was a new form of primary care designed to exclusively serve patients with complex, unstable chronic illness. Such patients were at high risk for emergency room use and unplanned hospitalizations -- both costly endeavors.
The team named it an Ambulatory Intensive Care Unit, or AICU. "Our strategy for lowering costs was to provide much better quality to the segment of health care enrollees who are at the highest risk -- that is the 20 percent of enrollees who generate approximately 70 percent of a health plan's spending in a given year," said Dr. Milstein.
"The AICU team also intensively managed discretionary specialty care and ER care."
Dr. Milstein estimated that an AICU could reduce annual per capita spending by 15 percent to 30 percent net of its operating costs and substantially improve clinical outcomes and experience of care for high-risk patients who consume almost 50 percent of total spending for populations under 65 and more than 70 percent for populations over 70.
In addition, Dr. Milstein noted that implementation of the bug project testing sparked further organizational innovations. "It showed that collaboration among clinicians and engineers can create new care models that generate much greater value per dollar for their patients," he said.
In what have become standard guidelines for AICUs to follow, Dr. Milstein and his team created three "floors" for their project.
The first floor was care provided by well-trained community health workers. These "health coaches" were supervised by AICU nurses and/or physicians. They helped manage primary hospitalization risk factors on a 24/7 basis.
The second floor consisted of physicians supported by a team of medical assistants and nurses. The team used electronic health records, on-the-spot telephone consultations with specialists and selective onsite specialist services to reduce costs and increase the health impact of primary-care visits.
The third floor care was careful management of specialized consultations including hospital care. Using data from a cooperating insurer, the AICU team selected a narrow referral roster of cost-effective and high-quality specialists with whom to coordinate activity.
Margaret Laws, director of innovations for the underserved program at the California HealthCare Foundation and one of the members of the original group, said that Dr. Milstein and his team initially focused on dramatically lowering the cost of care, "but that moved very quickly to the realization that the only way you're going to dramatically lower the cost of care was if you can identify and work to treat the high-cost people."
Dr. Sophia Chang, another member of the original Mercer team, said the program's emphasis on patients and families managing their own conditions sets the AICU approach apart.
"Part of the original project model was a lot of support for what we call self-management and essentially using peer coaches, and not necessarily professional staff," said Dr. Chang.
She added that a lot of the AICU activity is based in the United States "because of our higher prevalence of specialists and because primary care is lacking in so many environments overseas."
Steven Yahn is a former editor with Advertising Age. He can be reached at email@example.com.
June 1, 2013
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