Improving patient care, plus saving Medicare money, sometimes equals detective work

by Karen Gallagher

“It takes a village to raise old people, too,” says 81-year-old Valura Massey as she sits in her primary care physician’s office in west St. Louis County, her cane close at hand. She’s been dealing with diabetes for many years and recently switched to a new physician, Nathan Moore, MD.

Massey had been good about keeping up with the insulin she needed for her condition but had started buying only enough to last for a short time. She had come to a point where she had reached her coverage gap with Medicare and was having to cover costs herself. “I’m on a fixed income. I asked myself what was I going to do? I thought I might have to go without,” she says.

But Massey found strong support in Lara Kerwin, a clinical pharmacist with BJC Accountable Care Organization (ACO). Massey is part of the BJC ACO through Dr. Moore, gaining access to special programs that provide her help, at no charge, in reaching her health goals. Kerwin got to work researching Massey’s insurance coverage and searching formulary lists for medications that could work.

“Having an ACO allows us to do valuable, innovative things we weren’t able to do previously,” says Dr. Moore. “As in the case of Ms. Massey, we can work one-on-one with patients using staff such as Lara to educate them on their conditions and medical options and any side effects. And Lara can then work with physicians to help take better care of patients with appropriate medications they can afford.”

“The point of BJC ACO is to make sure we’re there to help our patients succeed in their health care journey, and to remove barriers to the care they need,” says Sandra Van Trease, BJC group president. “We have been working with different approaches, mindsets and behaviors to create a care model that will improve health outcomes for our patients.”

In 2012, BJC became the first health care provider in the St. Louis area to form an ACO to better care for seniors. The ACO program was developed by Medicare to help physicians and other care professionals take even better care of people. The Medicare Shared Savings Program rewards ACOs that lower health costs while delivering high quality care based on numerous quality measures relating to care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and the patient and caregiver experience of care.

BJC’s ACO covers about 60,000 seniors in the St. Louis area with both traditional Medicare coverage and with Medicare Advantage plans. The 14 adult hospitals within BJC, as well as BJC Home Care, BJC Medical Group and affiliated providers, form a network to care for seniors in a more coordinated, transparent way.

The program has been working. BJC ACO quality scores are high — an average of 92 percent in 2018 — and the organization has saved Medicare, and taxpayers, $26 million in the past three years.

Doug Pogue, MD, BJC Medical Group president, attributes these savings to some recent changes in how patient care is handled. “We’ve been working to reduce our hospitalization numbers, and we’ve seen a decrease in unnecessary testing, particularly with MRIs. We are providing physicians with monthly reports to help them identify any gaps in care or patients who need follow up. Physicians can then develop plans of care for their patients and share them with every single doctor and clinician involved in the patient’s care.”

Dr. Pogue also points to a team of 26 care partners who follow patients by phone and help with physician orders, medications, education about their health condition and other needs such as transportation to doctor appointments. “Helping patients transition home from the hospital has been particularly successful,” he says. “The care partners make sure the patients don’t bounce right back.”

As a clinical pharmacist, Kerwin also strives to keep patients out of the hospital, especially patients with chronic conditions such as diabetes. Kerwin serves as a bridge between patients, physicians and nurses, working both in person and by phone. She may educate patients on how medicines change over time, help them access  affordable medications and help them reach their health goals.

Thanks to some detective work on behalf of Valura Massey, including looking into Massey’s insurance coverage, Kerwin calculated that switching insulins wouldn’t help her with the price of the drug, but switching from insulin provided in a vial to insulin provided in a pen would. She used a computer database to determine how many units of insulin per day Massey needed, how the pens were packaged and how many were mailed at a time.

But Massey needed some convincing — she had never used pens for insulin and had always had her son pick up her medications at a pharmacy. “I talked with her to explain that it comes priority mail with temperature protocols and is very safe,” Kerwin says.

Working with patients like Massey within BJC ACO, Kerwin has embraced one of the organization’s tenets — better care for patients. She consults with patients to help them reach their goals by finding out how much they’re willing to spend, their preferences, religious beliefs and more. With Kerwin’s help, Massey could get her insulin and, as a result, get her diabetes under control again.

Meeting for the first time in person was meaningful to both Massey and Kerwin. “This is my very best friend now,” Massey says, pointing at Kerwin. “I had thought it was just my time to die when I couldn’t afford my insulin. But thanks to Lara, we have things together now.”

“We are going to have a good long-term relationship,” Kerwin says. “We will keep in touch to talk about all of her concerns, even food choices and other medications. I like stepping out from behind a counter and working in the patient care process to prevent any problems before they happen. I was happy I could help.”

“When you throw a pebble in a pond, the circles continue to expand,” says Van Trease. “The ACO vision is like that. We are taking these opportunities and learnings and applying them to how we care for patients, even outside of the ACO. It is the vision of how care will one day be delivered for all of us.”