Can pharmacists and EMS teams bend the cost curve, improve care?

Health care spending in the United States may be still on the rise, but the rate of increase has slowed. According to 2012 data, health spending grew 3.7 percent to $2.8 trillion, or about $8,900 a person.

In other words, the plane is still taking off but not climbing at quite so steep an angle. The big question is why. The Great Recession? Early dividends from the Affordable Care Act’s reforms?

“It’s unclear,” said Dr. Anish Mahajan, director of system planning, improvement and data analytics for L.A. County’s Dept. of Health Services. “We’re still studying it.”

Mahajan, who worked in the White House Office of Management and Budget for former director Peter Orszag as the ACA was taking shape, told this week’s 2014 National Health Journalism fellows that he wouldn’t pin the spending slow-down on the ACA.

“I would argue it’s way too early for the ACA to show any reductions in cost,” Mahajan said. “And I say that because it only just started January 1. I say that because half the states aren’t doing Medicaid expansion. I say that because the delivery system transformation needed to reduce costs hasn’t happened.”

Millions of patients may be newly insured, but many of them are still seeking out primary care providers and specialists. It’s too early to see major cost savings from patients still struggling to access care, Mahajan said.

While that may be, the ACA is actively providing grants and incentives to fund experiments across the country in an attempt to figure out what types of interventions and payment systems can best reduce costs in the field.

This week’s National Fellows got an in-depth look at two very different innovations – one of which relies on an Obamacare grant – to better manage patients’ care, lower costs and curb unnecessary E.R. visits.

“Those are the bright spots, the experiments that if they work we hope would be scaled,” Mahajan said.

Program makes better use of pharmacists

The first such experiment fellows heard from this week aims to enlarge the role of pharmacists in managing the care of complex patients, especially diabetics.

“We are struggling to care for more and more complex patients with chronic illnesses all the time,” said Dr. Michael Hochman, medical director for innovation at AltaMed Health Services, a large network of clinics in Los Angeles that is partnering with USC Pharmacy for the three-year pilot program.

Clinics such as AltaMed’s are finding the supply of primary care docs can’t meet demand. “We don’t see a huge pipeline in the years ahead based on medical students career choices,” Hochman said. “I think the answer is really going to be team-based care.”

That could mean expanded roles for nurse practitioners, physician assistants, or in the case of the AltaMed-USC collaboration, clinical pharmacists. The joint program, funded by a $12 million grant from The Center for Medicare and Medicaid Innovation, places a pharmacist on collaborative teams with a doctor and pharmacy technician at 10 of AltaMed’s 45 sites.

“We want to see the person who gives you headaches,” program founder Steven W. Chen, associate professor at USC’s School of Pharmacy, tells doctors. Those complex patients typically benefit the most from the attention of a pharmacist who can identify drug interactions and dosage problems, remove or add drugs, make home visits and follow-up calls, and generally keep patients and their drug regimen on track. Chen recalled one challenging diabetic patient in Watts who was storing his insulin in a broken refrigerator in an empty lot, a detail only revealed by a home visit.

According to numbers cited by Chen, the program has identified nearly 20,000 medication problems in nearly 2,000 patients in its first year. Emergency room visits dropped 38 percent one year after patients were enrolled in the program, while inpatient visits declined 13 percent. Those decreases can free up space in crowded safety net systems.

But does the program save enough money to pay for itself by keeping patients out of hospital? “I personally think that’s an extremely high barrier to hit,” said Hochman, who suggested the program’s real value lies in improved care for chronically ill patients. And that could potentially justify carving out funds in AltaMed’s nearly $500 million annual budget to pay for pharmacists after the grant funding expires in 2015.

Hochman endorsed descriptions of pharmacists as the most over-trained and under-utilized members of the health care team. “I really think there’s a lot more we could be doing with pharmacists,” he said.

A new approach to 911’s frequent fliers

Pharmacists who make home visits and keep tabs on diabetics offer one option for keeping chronically ill patients out of the E.R. But can EMS techs – normally charged with transporting patients to the hospital – actually be tasked with keeping “frequent fliers” out of their ambulances and local E.R.s?

Fort Worth, Texas and its MedStar ambulance service have found a way to do so and have the data to back it up. MedStar began enrolling patients who called 911 frequently in a program designed to address their underlying issues. EMS workers now do home visits and find creative ways to solve such patients’ health-related problems. An on-staff nurse triages 911 calls and helps less urgent callers resolve their situation without a trip to the E.R.

“If you talk to any paramedic who has been a paramedic more than a week, they will tell you that the vast majority of the patients that they respond to and take to the hospital don’t need to be there,” said Matt Zavadsky, a former paramedic who is now director of public affairs for MedStar. “And that’s a conundrum we’ve had in our system for 30 years.”

Zavadsky told fellows the story of a patient named Michael, who called 911 daily. Crews eventually figured out that if they gave Michael a hamburger, they could convince him not to go the hospital (his medical needs weren’t urgent). At other times, Michael would call 911 in order to see the hospital nurses. Crews began giving him erotic magazines. “What did we teach Michael?” asked Zavadsky. “If you’re hungry or horny, call 911. We’ve created a lot of these patients. We have to un-create them.” 

MedStar’s initiative to “un-create” such callers has proved an early success. Out of 94 patients who completed MedStar’s “EMS loyalty program,” there has been an 82 percent reduction in 911 calls requiring transport to the emergency department, according to MedStar data.

A dozen paramedics and one nurse carry out the program. Local hospitals, increasingly working under capitated payment models and facing early readmission penalties, have praised the system and its cost savings. Medicaid and Medicare stand to benefit as well. As The New York Times’ Elisabeth Rosenthal reported last year, Medicare “has become alarmed at its fast-rising expenditures for ambulance rides: nearly $6 billion a year, up from just $2 billion in 2002.”

In Michael’s case, a MedStar consultation revealed that he was simply afraid of taking the bus, so he routinely called for the ambulance. Upon enrolling him in the frequent-flier program, EMS staff spent several visits teaching him how to safely ride the bus. As a result, MedStar says it hasn’t had to respond to a call from him in over a year.

Said Zavadsky, “We help get them connected to the health resources they didn’t even know they had.”