The U.S. health care system has been set up to reward volume, not value. This fee-for-service model has led to a more than 3 trillion dollar industry, according to the Centers for Medicare and Medicaid Services (CMS). The problem is that – despite the steep price tag – health care quality in the United States continues to lag behind other similar countries (Kaiser Family Foundation, 2017). Atrius Health and the legacy organizations that comprise it have long been aware of the flaws of this fee-for-service model and have seized opportunities to manage costs and deliver patient-centered, value-based care.
Managed care roots
Harvard Community Health Plan (HCHP) – which evolved into Harvard Vanguard Medical Associates, an Atrius Health legacy organization – was established in 1969 on the radical idea to replace fee-for-service care with a prepaid group practice. The founders envisioned providing high-quality ambulatory care to the entire community, wealthy and low-income, healthy and sick.
Alternative quality contract
In 2009, Atrius Health became one of the first organizations to sign the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC). The AQC uses a payment system that rewards care coordination, cost control, and high-quality care, as measured by achieving key quality and patient experience goals. So, when a doctor helps a patient manage their diabetes, it’s a win-win-win: the patient feels better and lowers their risk of future health complications, the provider group receives performance incentives, and the overall costs go down.
Accountable care model
With upwards of 59 million Medicare beneficiaries – many high-need and high-cost – the Centers for Medicare & Medicaid Services (CMS) are in a prime position to test novel ways of improving care and saving money. Over the last few years, CMS launched the Pioneer and Next Generation Accountable Care Organization (ACO) Models, which are designed to incentivize value-based care by letting providers share in the cost savings. As a participating organization, Atrius Health has flexibility to test new approaches to delivering the right care beyond what Medicare typically covers.
People who need joint replacements typically face an expensive several-day hospital stay. By partnering with free-standing surgery centers, Atrius Health can now perform a knee replacement on an otherwise healthy patient in the morning and send the patient home in the afternoon, where they can recover with support from a dedicated team of nurses and physical therapists. Patients get the same high-quality care at roughly half the cost, plus the benefit of healing from home.