STORY AND PHOTO BY KAREN BOSSICK

The patient was racking up health care costs, hospitalized three times in a single year for asthma alone.

St. Luke’s representatives figured out that she didn’t always get her inhalers refilled because of the expense so they helped her arrange a low-cost program. They also spent time educating her about the use of inhalers after they learned she didn’t know how to use them correctly to deal with pollution and other triggers.

Since, she’s had no hospitalizations.

Patients like this woman are among those St. Luke’s is targeting as it pilots a new program.

Five percent of the population accounts for the majority of health care costs, Dr. David C. Pate told St. Luke’s staff and community business leaders on Tuesday. They have chronic health problems, are seeing multiple physicians and often do not comply with medications. Half of that 5 percent run up costs that are two to three times that of the other half.

The pilot program utilizes a licensed clinical social worker to educate these patients. Clients working with such workers are doing a better job of keeping doctor appointments and a better job of taking their medications as prescribed.

The hospital is also using data analytics to identify the “rising risk” population so nursing care coordinators can design better programs for their care.

“We’re finding out patients will tell a nurse things they don’t tell physicians, which leads to more ideas about how to impact their care,” Pate said.

The nurses, he said, may learn that patients won’t take them medications because they can’t afford them, because they have side effects that make them feel uncomfortable or because they don’t understand why they need to take them when they feel fine.

A pharmacist may be brought in to figure out whether some of the meds can be deleted or others  substituted that may have fewer side effects.

Pate, president and CEO of St. Luke’s Health System, noted that the average Idahoan spends 17 percent of his or her income on health insurance premiums. The federal government says 8.6 percent is affordable—Idahoans are paying twice that.

“And that’s just for premiums. It doesn’t count co-pays and other out-of-pocket expenses,” said Pate.

St. Luke’s is working with Utah-based SelectHealth to lower costs and premiums while improving patient outcomes. It spent the first few years laying the foundation and just this year made the network fully operational.

“Our bottom line is outcome and cost of care. We figured we can let Washington, D.C. do it or we can do it. And so far it’s not working real well in Washington, D.C.,” said Pate. “The problem with the American health care system is it’s too inconsistent, too inequitable and too expensive. If you’re going to get on top of it, you’ve got to do something like what we’re doing. We’re on the right track, no matter what Washington does, but Washington makes it more difficult. I say: Please don’t make this harder on it. Let us try it and show we can make a difference.”

Thirty-four percent of the patients in St. Luke’s network are in its new value-based system, which covers 170,000 people and includes five insurers. The other two-thirds are in the traditional fee-per service system.

In fee-per-service, patients see a doctor who sends out a bill, which is paid by the insurance company and patient. The more a doctor does, whether necessary or not, the more the doctor earns. But experts generally agree that fee-for-service is wasteful and does not promote high quality care.

St. Luke’s is touting a value-based service that involves a budget or fixed cost instead of open-ended reimbursement. The provider—St. Luke’s—absorbs any losses if the cost of caring for those in the plan exceeds the budget at the end of the year. Conversely, St. Luke’s gets to keep what’s left if costs come in under budget.

The new system rewards not for volume but good patient outcomes, Pate said. There’s no incentive for withholding care as providers must meet 35 measures showing quality outcomes.

The new system addresses a longstanding problem of doctors having too little time to educate patients because they’re on a treadmill where they feel they have to cram as many patients into a day as possible.

Pate recounted seeing a patient with 17 different problems who was taking 54 pills a day and spending $3,000 a month out of pocket on medication. He spent 90 minutes with her instead of the allotted 45, eliminating many of the pills and saving her thousands of dollars. But he was only paid for the allotted 45 minutes.

Given limited time, most physicians would address a few of the woman’s problems and schedule a follow-up to address more, Pate said. Under the value-based system, a nurse coordinator and pharmacist can assist in reviewing everything at once, eliminating the cost of return visits.

The Idaho Statesman ran an article recently noting that the hospital had yet to deliver on its promised savings in insurance premiums. But, Pate said, the system is only in its tenth month. He said the charge is to be profitable in three years.

“My best guess is we’re losing money right now on our value system but we expected that in our first year. The good news is we've lost $10 million less than we'd expected,” he added. “We’re on a journey. This is a marathon, not a sprint.”

Insurers participating in St. Luke’s system are Aetna, Blue Cross of Idaho, Mountain Health CO-OP, PacificSource Health Plans and SelectHealth.

Boise-based Micron is among the companies on board. St. Luke’s is trying to get Wood River Valley companies, such as Sun Valley Company, on board, as well, said Cody Langbehn, CEO of St. Luke’s Wood River.

“We will never settle for compromising quality,” said Pate. “Now we’re asking the community let us improve affordability.”

IN OTHER NEWS:

St. Luke’s has been named a top 15 health care system for quality and safety amongst hospitals that include the Mayo Clinic, UCLA and Johns Hopkins. Its scores, which include 100 for safety and 97 for rate of improvement, means St. Luke’s is the best in the country, said Pate.

• St. Luke’s is building a career center to retrain workers as their roles change.
• It’s using social media to identify and attract potential employees.
• It recently engaged physicians in a leadership program that it hopes to expand in house.
• St. Luke’s is better at attracting a skilled work force than the Idaho as a whole. And partnerships with educational institutions is paying off. Since Idaho State University instituted an accelerated Bachelor of Science in Nursing, Idaho has erased its nursing shortage and become an exporter of nurses.
• Pate said he is most terrified by the epidemic of childhood obesity. “If we don’t do something, that 5 percent I talked about is going to grow.”