By Sarah Glenn
For the Journal
POCATELLO – Concerns over cost and efforts to bump up quality have prompted more than 700 area healthcare providers to join a new alliance.
Born in 2013, the Portneuf Quality Alliance (PQA) is a group of doctors offices, hospitals, and private companies who, together, aim to improve health outcomes and bring a little more muscle to the cost negotiating table.
Their collaboration means two things: better controlled costs and higher quality care.
“We are aiming to improve the quality of care and provide a better experience,” said Dani Jones, Executive Director of the Portneuf Quality Alliance. “Then also we are aiming to reduce the overall cost of care.”
The core idea is simple: share information, decrease expensive redundancies and use all that data to figure out what works and what doesn’t.
“We have excellent providers in our area, but sometimes they practice in silos,” Jones explained. “They don’t know what happens once patients leave their practice.”
For example, if someone has COPD, it is hard for their pulmonologist to know if they were admitted to the emergency room, what tests have already been done or what medications they talked about with their primary care doctor.
As long as all these different providers partner with the Portneuf Quality Alliance, they can log into a secure patient portal and see the whole scope of what’s going on with that patient.
“What we are doing is trying to bridge that gap,” Jones said. “We can better facilitate that transition from place to place and for those with chronic conditions, we can really get in there and help.”
Jones estimates that the alliance currently helps about 6,000 patients across Bannock and Bingham counties.
The alliance also partners with payers, including Blue Cross of Idaho, Regents, Pacific Source’s Medicare Advantage plan and the Portneuf Medical Center Employee Health plan.
According to PMC spokesperson Todd Blackinton, the alliance is the main reason why Portneuf employees won’t see their healthcare costs increase this year.
In order to get the full cost and quality benefits the alliance can offer, both a patent’s doctor and insurance company should be involved in the PQA.
“There are a lot of patients out there who are seeing a PQA provider but not necessarily on one of these insurance plans,” Jones said. “In that case, the best consolation is that you know your provider is working to provide excellent coordinated care.”
For example, a medicaid or medicare patient won’t see many cost benefits and won’t be able to have a PQA care manager step in and help with coordinating where to go. But Jones says these patients can take comfort in knowing their PQA-affiliated doctor has their eye on quality.
How will this lower costs?
One major benefit to the payer (often an insurance company) as well as providers is that people are generally healthier – meaning fewer visits, redundant tests and claims.
Another cost benefit to forming a clinically integrated network comes in the form of collective bargaining abilities.
If a network meets the FTC compliance requirements to be considered a clinically integrated network, the government will provide a safe harbor for it to perform collective bargaining. Collective bargaining by physicians that compete with each other is considered anticompetitive and is prohibited except when physician networks are financially or clinically integrated. In essence, more providers equals more bargaining muscle.
The Portneuf Quality Alliance, among other health care alliances, are paying attention to rising costs and hope to do something about it.
“Better care at a lower cost is really what this is all about,” Jones said. “Patents need to feel that they are getting the best bang for their buck.”
More than 10 percent of total spending for married couple only households went to healthcare in 2015, almost twice as large a share as reported by one parent households (5.2 percent), the Bureau of Labor Statistics (BLS) said. Healthcare expenditures rose 1.2 percent in 2015. Translating that to dollars, the average household spent $4,290 on medical expenses in 2014. In 2015, the average household spent $4,342 on medical expenses.
Health insurance rates climbed too. The BLS reported that average health insurance costs for Americans climbed 3.8 percent between 2014 and 2015. In dollars, that’s an average of $2,868 (2014) versus $2,977 (2015).
Privacy and the PQA
While better sharing patient data might seem like a way to improve quality care, it can also raise red flags for privacy watchdogs.
The Health Insurance Portability and Accountability Act (HIPAA) allows those in the medical profession to share patient information with other medical professionals if it’s a matter of coordinating care or arranging payments. While completely within the law, the PQA has gone a step further to address privacy concerns.
“In our case, we have created an internal data usage policy that governs all of this,” Jones said. “People in management (at the PQA) really don’t need to know names or personal information.”
However, in a model that relies on large amounts of patient data to see how they can improve outcomes and use evidence-based approaches to care, information is going to be shared.
“When we crunch the data as management, it is at the aggregate level so there’s no personal information shared,” Jones said. “Nobody’s name is showing up in these reports.”
According to HIPAA rules, once identifying information is removed from the patient’s record, it can be used and shared. The U.S. Department of Health and Human Services says there are two ways to de-identify information; “either: (1) a formal determination by a qualified statistician; or (2) the removal of specified identifiers of the individual and of the individual’s relatives, household members, and employers is required, and is adequate only if the covered entity has no actual knowledge that the remaining information could be used to identify the individual.”
A growing trend
The concept of clinically integrated networks is becoming widely-used and increasingly popular the health care arena. In Idaho, four clinically integrated networks exist. They are the Saint Alphonsus Health Alliance, St. Luke’s Health Partners, Portneuf Quality Alliance and the Kootenai Care Network.
When the Health Care Advisory Board, a private research organization, first began studying clinical integration strategy in 2008, researchers were able to identify only five networks widely known to exist, primarily affiliated with either large independent practice associations or health systems. Although no hard data is available to show the total number of clinical integration programs that exist today, Advisory Board research has identified more than 500 organizations that are currently pursuing this strategy, including health systems and physician groups of all shapes and sizes.
The urge to collaborate in order to stop skyrocketing healthcare costs isn’t limited to health care providers. In February 2016, 20 major companies—including American Express Co., Macy’s Inc. and Verizon Communications Inc.—banded together to use their collective data and market power in a bid to hold down the cost of providing workers with health-care benefits. That alliance covers about 4 million people.
The growing trend towards alliances is also being fueled by changes in healthcare law and philosophy – mostly brought about by Affordable Care Act regulations.
The ACA, or Obamacare, aims to shift the focus from a pay-for-service business model to a pay-for-outcomes model. Doctors now have to show that their interventions are making their patients healthier. But that’s hard to do when their access to patient data stops at the end of the doctor’s door.
The American Hospital Association has eight “advocacy issues” it champions on its website. According to AHA:
“Clinical integration is needed to facilitate the coordination of patient care across conditions, providers, settings, and time in order to achieve care that is safe, timely, effective, efficient, equitable, and patient-focused. To achieve clinical integration we need to promote changes in provider culture, redesign payment methods and incentives, and modernize federal laws.”
The PQA now tracks many quality measures that help quantify the quality of health care services provided by health care professionals, clinics and hospitals within the PQA health care network. These measures use data associated with providers’ ability to deliver high-quality care or relate to long term goals for quality health care. A full list of these quality measures is available at http://portneufqualityalliance.org/quality-measures/
“There’s still a lot of work to be done,” Jones said. “But it is a nice trend and the patient is at the heart of it.”
For more information on the Portneuf Quality Alliance, visit http://portneufqualityalliance.org/.
