In health care circles, the notion of value-based medicine has been around for some time. Rather than a “sick care” model, the thinking goes, we should move to a “well care” one, where value and outcomes are the priority. The vision is tantalizing, but realizing it has been slow.
Joon S. Lee, the Chief Medical Officer of UPMC’s Insurance Services Division, which administers the nation’s second largest provider-owned health plan, is challenging that status quo. “Our health plan is transitioning from traditional fee-for-service payments to a system where getting paid depends on the outcome, such as lowering hospital readmissions or optimally managing co-morbidities like hypertension,” he says.
The centerpiece of this transition is a “shared savings” physician reimbursement formula that allows each practice to keep a percentage of the money saved from observing treatment guidelines to lower the total cost of care. “More than half of UPMC Health Plan patients are now under a shared savings contract,” Lee says. “We expect that number to rise as we move it from primary care to the specialty side.”
Lee is also looking at new ways to leverage UPMC’s connection to patients to improve preventive health measures. He cites his experience in directing UPMC’s Heart and Vascular Institute, one of the largest integrated cardiovascular delivery programs. “A decade ago we began to see that, despite all the new technology, deaths from heart disease were inching up again,” Lee says. “We were failing to control for risk factors linked to unhealthy lifestyle behaviors like obesity and smoking.”
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In response, the Institute worked with the UPMC Health Plan to create a patient-centered coaching program called Prescription for Wellness, utilizing UPMC’s vast community outreach capabilities in managing heart care from a whole person perspective.
Though there is much yet to be done, Lee says that in the end, integrated care is a puzzle where the pieces fit. “Through the coordinated approach we minimize expensive hospital care. But when it’s necessary, UPMC offers the best there is. We meet the patient in the community to seed healthy behaviors, improve outcomes, and keep our insurance rates down. It’s a trifecta win, for the payer, the provider, and the member.”
Scientific American asked four UPMC leaders about how technology, science, and adjusted incentives are transforming the patient experience, and the future of medicine. This article is one of four interviews.
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Headquartered in Pittsburgh, UPMC is a world-renowned health care provider and insurer. We operate 40 hospitals and 700 doctors’ offices and outpatient centers, with locations in central and western Pennsylvania, Maryland, New York, and internationally. We employ 4,900 physicians, and we are leaders in clinical care, groundbreaking research, and treatment breakthroughs. U.S. News & World Report consistently ranks UPMC Presbyterian Shadyside as one of the nation’s best hospitals in many specialties and ranks UPMC Children’s Hospital of Pittsburgh on its Honor Roll of America’s Best Children’s Hospitals.