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New BlueCross BlueShield Chief Wants to Make Health-Care Delivery Systematic


BlueCross BlueShield Chief Dr. Ken Phenow Has a Plan

Considering that BlueCross BlueShield of Louisiana is the state’s largest health insurer with more than 1.4 million members, Chief Medical Officer Dr. Ken Phenow finds himself well positioned to work toward his goal to improve the state’s health-care system. Or more accurately, his goal is to make the health-care system a system in the first place.

?“I wouldn’t really say we have a health-care system. It lacks ‘systemness,’” says Phenow, who joined BCBSLA as a senior vice president some six months ago. “There’s a lot of fragmentation and reduplication, and patients often get lost along the way. On the other hand, a good system is integrated and organized. We just don’t have that in our current health-care delivery model.”

?One source of waste, Phenow says, is patients’ use of expensive health-care resources instead of first being channeled through primary-care providers, even though primary-care providers are trained to take care of 85 percent of medical issues. For example, suppose someone strains his back moving furniture. A primary-care provider is likely to prescribe an inexpensive anti-inflammatory medicine and perhaps send the patient for physical therapy. If the patient visits an emergency room or an orthopaedic surgeon instead, the costs of X-rays and other specialized tests can quickly add up, both for the insurer and the patient, who covers 20 percent of the cost.

?To help make health-care delivery more systematic, Phenow has been spearheading a rollout in the state of “patient-centered medical homes.” In these medical homes (which is a concept and doesn’t necessarily involve a single physical building), the focus is on teamwork. Doctors direct patient care and maintain one-on-one relationships with patients, but they are supported by nurse practitioners and other medical professionals. The home is meant to be the first place patients turn to, whether they need acute care, chronic care, preventative care or behavioral care.

?In the current health-care model, doctors often find themselves on what Phenow calls “the hamster wheel,” a situation in which they need to race through back-to-back appointments in loaded schedules to cover costs. The medical home model will give doctors more breathing room and time to spend with patients.

?An additional benefit for patients is that the medical home model unifies their care and coordinates it across different providers, thereby reducing fragmentation and reduplication and reducing the likelihood that something important is overlooked. In addition, this medical home system will improve patients’ access to doctors by including open-access scheduling, after-hours appointments, online visits and telephone visits. Improving access will mean patients will be more likely to obtain care before medical issues become serious and less likely to seek expensive treatment at 24-hour emergency rooms.

?“Under this model, doctors will be providing extra services. The question is, how are we going to reimburse them?” says Phenow. “There will still be the standard fee-for-service, which is how doctors are compensated now. But we’re also developing two other types of reimbursement.”

?One is a care management fee. Doctors will be paid a sum upfront based on the number of patients they have on their roster. Each patient’s risk will be taken into account, too. For example, a 70-year-old with chronic conditions carries a higher risk than a healthy, young college student who infrequently needs medical services. Doctors will also receive a pay-for-performance bonus, which Phenow believes will better incentivize preventative medicine and improve the quality of care.

?“The key concept is that instead of taking care of an individual patient, doctors are taking care of a population. It’s about holding the physician accountable for good outcomes across their patient base,” says Phenow. BCBSLA will measure over time the overall trend of a patient population in a medical group. Then the medical trends of that group will be compared to trends in the overall market. If the medical group saves the insurer money then the doctors can share in those savings.

?People in the New Orleans area may have also noticed an advertising campaign encouraging them to take a Personal Health Assessment, another initiative of Phenow’s. This assessment is a computer questionnaire currently open to anyone, not just BCBSLA members. It allows individuals to get a snapshot of their health, and depending on what each person needs, the website will display recommendations, videos and resources.

?“The purpose of the assessment is to help patients become much more aware about their health,” says Phenow. “As a society, we’ve become apathetic. We eat too much, eat the wrong thing and don’t exercise. People need to learn that you can’t get away with this forever. We’re seeing more chronic disease than ever before, and about 70 percent of chronic disease can be prevented by lifestyle changes.”

?Although Phenow no longer has a roster of patients himself, he used to work as a primary-care doctor. A Navy scholarship paid for his medical training, and he subsequently spent several years working as a family doctor at Naval bases. Before becoming a doctor, Phenow had graduated from the UCLA School of Public Health, and his career has straddled the line between practicing medicine and medical administration.

?“I really want to make an impact on health in Louisiana,” he says. “My goal is to help BlueCross BlueShield develop medical homes to improve care and slow down the progression of chronic disease in this state.”