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LSU and CNNs
A Good Fit
OP-ED by Michael Kaiser, MD
PUBLISHED: November/December 2011
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Having delivered over a quarter of a
million outpatient encounters and
72,000 inpatient days of care to the
state’s Medicaid population in State
Fiscal Year 2011, the LSU Health Care Services Division
(HCSD) has significant influence on the health
care outcomes of Louisiana residents who rely on this
public coverage program. The Department of Health
and Hospitals is attempting to transform healthcare
for the state’s Medicaid population by establishing Coordinated
Care Networks (CCN). LSU HCSD is ready to
be a major player in “effectively coordinating enrollees’
health care” as the CCN model aspires.
The rationale for this transformation in care is to eliminate
the State’s current fee-for-service model, while
replacing this model with care that is coordinated to:
1) enhance access, 2) give patients more choice for
care, and 3) improve health outcomes for patients. As the State
embraces the advent of CCNs, one may wonder what LSU, as a
healthcare leader, brings to the table in terms of value.
LSU HCSD, a subdivision of the LSU Health System, has an
integrated healthcare network that links patients to care. The
patient-centered medical home serves as the core of this network,
providing a culturally-sensitive approach to care management
and the education of patients and families as they assume
responsibility for their own health and disease. Patients needing
specialty and subspecialty medical care are linked to LSU
and community providers for medical management and then
returned to their medical home for continuity. LSU HCSD was
the first health system in the country to have National Committee
for Quality Assurance accreditation for its medical
homes at all seven hospitals.
In addition to its strength in the medical home model, clinicians
within the LSU Health System use evidence-based practice
guidelines and strategies for managing disease and preventing
disease progress. This comprehensive approach to care
has been nationally recognized for both the quality of care and
for decreasing the need for costly hospitalizations and emergency
room visits. Value is inherent in this approach to care.
The Medical Home, coupled with the well developed Disease
Management programs, yields an opportunity that will only
end with higher quality care for the patient and lower costs for
the state. The CCN partnership will only strengthen this opportunity
through process and resource integration.
LSU HCSD stands ready to successfully partner with DHH in
their efforts to provide the state’s Medicaid population with “a
health care delivery system that provides a continuum of evidence-
based, quality-driven health care services in a cost effective
manner.” To illustrate this readiness, simply look at one of
the main goals that DHH has tasked the CCNs with: Improved
outcomes through management of chronic disease, early detection,
and treatment. LSU HCSD has several years of data to
demonstrate performance in these areas.
For example, the percentage of Diabetic patients with a hemoglobin
A1c < 7.0 increased from 45% to 55% during the period of
op-ed
2001 to 2008 (Butler, Kaiser, Johnson, Besse, Horswell, 2010).
This dramatic increase translates into less need for acute hospitalization,
and more importantly, decreased complications from
uncontrolled disease. Achievement of this type would be difficult
to accomplish with single providers or even multiple provider
groups that are not linked and coordinated in their effort.
Our disease management guidelines and research are also making
a difference in the lives of Heart Failure patients by improving clinical
decision-making and life expectancy. Although much of the
peer-reviewed literature supports the link between race and gender
with poor health outcomes in Systolic Heart Failure, through
research LSU HCSD has found that disease management programs
break this link for indigent patients and no disparities can
be found. When using disease management guidelines, the risk
of mortality according to race and gender is not apparent in our
HCSD data and dispels the myth that negative health outcomes
can not only be expected, but predicted in this population (Arcement,
Horswell, Singh, Key, Butler, & Hebert, 2007; Hebert, Lopez,
Horswell, Tamariz, Palacio, Li, & Arcement, 2010). Additionally,
our research supports that disease management can decrease
mortality in indigent patient populations (i.e., African American)
with an ejection fraction of < or = 25% (73.1% vs 36%, P < .001)
(Hebert, Horswell, Key, Butler, Cerise, & Arcement, 2006).
Another major goal of the CCN model is a reduction of emergency
room costs. For patients who have traditionally gone to
the emergency room for non-emergent care, LSU Health has alternatives.
Over the past year, an urgent care clinic has opened
adjacent to the Interim LSU Public Hospital in New Orleans.
Another urgent care site is set to open in Baton Rouge within
the next year. At these locations, physicians address the immediate
healthcare needs of the patient. Additionally, as part of
an integrated healthcare system, they can also refer the patient
to one of LSU’s primary care or specialty clinics for follow-up
or ongoing care, engaging patients in the medical-home model
and the resources that then become available.
LSU’s focus on disease management programs such as Diabetes
care has created a more efficient use of Emergency Room resources.
Emergency Room use by patients for only true emergencies
equates to dollars saved. Diabetic patients who participate
in evidence-based disease management programs and continue
long term are less likely to use the emergency room for urgent
care than patients who are insured, but not followed in disease
management programs (greater odds, up to 1.70). Patients with
better-managed glycated hemoglobin (Hb1c) levels achieved
through specific disease management strategies are 82 times
less likely to use the emergency room for urgent care visits (Chiou,
Campbell, Horswell, Myers, and Culbertson, 2009).
LSU’s multi-layered and cohesive healthcare organization remains
constant in its availability and flexes when necessary. It
can provide for patients who are mostly healthy but occasionally
face bouts of minor illness, patients recovering their health
or living with disability or chronic illness, or patients coping
with the end of life. The LSU medical home and coordinated
network of care are well suited for all of these circumstances.
The goal of CCNs in Louisiana meshes nicely with the goal LSU
pursues and consistently achieves in improving the health of its
patients while also reducing healthcare costs.
REFERENCES
Arcement, L., Horswell, R., Singh, M., Key, I., Butler, M., & Hebert, K. (2007). Disease
management reduces racial and gender differences in survival among indigent patients
with systolic heart failure. CHEST 2007 – Poster Presentation.
Butler, Kaiser, Johnson, Besse, Horswell (2010). Diabetes Mellitus disease management
in a safety net hospital system: translating evidence into practice. Population
Health Management, 13, 319-324.
Chiou, S., Campbell, C., Horswell, R., Myers, L., and Culbertson, R. (2009). Use of
the emergency department for less-urgent care among type 2 diabetics under a
disease management program. BMC Health Services Research, 9, 223.
Hebert, K., Lopez, B., Horswell, R., Tamariz, L., Palacio, A., Li, H. & Arcement, L.
(2010). The impact of a standardized disease management program on race/ethnicity
and gender disparities in care and mortality. Journal of Health Care for the
Poor and Underserved. 21.
Hebert, K., Horswell, R., Key, J., Butler, M., Cerise, F., & Arcement, L., (2006). Mortality
benefit of a comprehensive heart failure disease management program in indigent
patients. American Heart Journal. 151, 478-83.
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