Coordinated care with doctors and hospitals can improve health and save money

Robin Gladden's most traumatic moments weren't due to her being raised by abusive, drug-addicted parents in a violence-plagued community. Instead, she says it was because of mistakes and neglect by the health care system. 

Gladden, 62, is a thyroid cancer survivor who also has diabetes, bursitis, high blood pressure, acid reflux and sciatica. She’s now a satisfied patient of Kaiser Permanente, a more established form of accountable care organization (ACO) that both treats and insures its patients. 

More typical accountable care organizations are groups of doctors and hospitals that coordinate the care of patients. Kaiser Permanente employs all of Gladden’s doctors and is the insurer she pays her insurance premiums to each month. That means Kaiser loses money if her conditions aren’t managed correctly. 

This financial incentive is supposed to lower the cost and improve the quality of care. 

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ACOs are a big part of the Affordable Care Act's strategy to focus health care more on quality than the quantity of services provided. But it's one that 's far more likely to survive efforts to undermine and replace the law. Although the Trump administration has rolled back or delayed other ACA reforms, such as paying orthopedic surgeons a lump sum for some surgeries, ACOs remain popular with both Republicans and Democrats in Congress.  

“The idea is good: To give the doctors and hospitals a reasonable pot of money and put them, not insurers, in charge of how it is used to help patients,” says physician Adams Dudley, director of the Center for Healthcare Value of the University of California San Francisco. “This has led to some very beneficial interventions, like patient education programs to help people monitor and control their own diabetes, which can save money and improve outcomes.” 

But sometimes, especially for organizations with a short-term view, giving doctors and hospitals a fixed budget has just resulted in them doing what some insurers do: “Deny needed care,” says Dudley, also a professor at UCSF’S medical school.

Kaiser Permanente health plans were top-ranked for controlling high blood pressure, breast cancer screening and 19 other measures for commercial insurance plans, according to quality data out last year by the National Committee for Quality Assurance. 

In September, the National Committee for Quality Assurance’s Health Insurance Plan Ratings for 2017-18 rated Kaiser Permanente health plans as among the nation’s top performers for consumer experience, prevention and treatment.  NCQA’s annual report rates more than 1,000 health plans, including Medicare, Medicaid and Private (commercial), on a 0-to-5 scale, with 5 being the best. 

Only 15 health plans in the country — about 1% — were given a five out of five this year. Kaiser Permanente had six of them, which was more than any other organization. All of Kaiser’s plans scored 4.0 or higher for overall care.

Dudley is more guarded in his take on Kaiser and other ACOs, which he says haven’t been able to “break sharply from the mainstream of American medicine." 

“As a result, the performance of Kaiser and similar organizations (overall) isn’t much different than average," he says.  

Caravan Health, a health care consulting firm that provides services to ACOs, released data recently showing that its clients saved more than $28 million in 2016 while others that weren't Caravan's clients in a Medicare pilot program increased spending by $23 million. 

More similar to the Kaiser model where the insurer is part of the group, nearly 20% of Medicare patients are in ACOs that are either part of a permanent CMS program or in federal pilot projects. says Tim Gronniger, who was chief of staff at the Centers for Medicare and Medicaid Services (CMS) in the Obama administration. 

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Overall, ACOs have “been successful in important ways,” says Gronniger, Caravan’s senior vice president for strategy.

There have been dramatic increases in quality almost uniformly across ACOs, says Gronniger.  That includes an increase in, among other things, preventive services provided, seniors getting their flu shots and the management of chronic diseases like diabetes, he notes. Among quality measures tracked by CMS, the three-year average score increased 15%. 

“If you had expectations that they were going to solve American health care costs in five years,” that hasn’t happened, Gronniger acknowledged. But there’s been progress, including big jumps in the quality of care Medicare patients receive and unprecedented collaboration between health care providers, he says and “that to me counts as successful."  

Gladden has nothing but good things to say about the quality of her Kaiser care. It’s her experiences outside of Kaiser that have turned her into a believer in both Kaiser and wellness. She even hopes to publish a healthy eating cookbook. 

Before she received treatment through Kaiser Permanente, Gladden's care depended on the often-contradictory advice of various doctors, which led her to develop diabetes, she said. She also experienced a very painful medication error in a non-Kaiser hospital when she went to have her thyroid removed because of her thyroid cancer. 

“I know what it feels like to be dying a painful death,” says Gladden. 

But the care provided through the Kaiser treated Gladden's health holistically, not episodically. 

Primary care physician, Sos Mboijana has treated Gladden at Kaiser Permante’s Capitol Hill office for the past 10 years. When she first went to him, Gladden sat down with 10 pages of notes she had taken about her various conditions. After all of her mishaps, she wasn’t taking any chances. 

Now, thanks to his treatment and attention to detail, all of her conditions are under control.

“That’s someone who’s engaged,” she says. “That’s someone who is connected.” 

Wells is a fellow with the Urban Health Media Project, which O'Donnell co-founded. UHMP fellow Louis Steptoe contributed to this report