Like many healthcare systems around the country, ours is moving towards team-based primary care. The notion behind team-based care is that the interaction between one physician and one patient is no longer sufficient or even ideal in an era of increased patient complexity, further demands on physicians such as more documentation requirements, and consistent variance in reimbursement. While team-based care can mean different things, at its core, it includes different healthcare specialties , usually operating at the top of their license, providing multi-disciplinary care, often to complex patients. Components may encompass integrated behavioral health, pharmacist management of chronic disease medications, nurse-led visits to manage depression, hypertension, or diabetes per algorithm, and social worker or nurse case management.
A couple of articles in a recent Journal of the American Medical Association ("Association of integrated team-based care with health care quality, utilization, and cost" and "The high cost of prescription drugs in the United States: origins and prospects for reform") unpeel the complex layers of team-based care in an era of healthcare delivery and payment reform, with an imbalance of costs and savings in care. Not surprisingly, team-based care is associated with better outcomes and decreased healthcare utilization for medically-complex patients. The challenge arises in how the cost benefit is allocated. It takes resources to start and maintain a team-based care program. While the article by Reiss-Brennan and colleagues showed that more money was saved than was spent, the money was spent by the healthcare system but was saved by the payer (which could be government or insurers). The health care system "lost" twice in this model —first by assuming a greater cost to provide ambulatory care to these patients and second by experiencing reduced reimbursement on these same patients.
Similarly, the article on prescription drug costs by Kesselheim and colleagues highlights many faulty aspects of the current medication management method in the US. Some very expensive medications actually do have a positive cost-benefit ratio when examined over the lifetime of the patient. However, similar to the study above, the costs are realized by one entity (the payer), while the benefit may be realized by an entirely different entity as payers and insurers change. For example, a five- digit price tag for 12 weeks of hepatitis C treatment is sustained by the patient's current insurer. If that treatment is effective and forestalls future high –cost treatment for end-stage liver disease, it is a financially beneficial equation (plus it is better for the patient) — unless one payer foots the bill and another reaps the reward.
The good news in all this is that we are discovering ways to reduce healthcare spending and doing it in a way that benefits patients through enhanced relationships with their care team, provision of care that is sustainable for those providing it, reduced emergency room visits, reduced hospitalizations, improved outcomes, and longer, healthier lives. The bad news is that the costs are born by one group and the financial benefit realized by another. It is time for health care payment to jump the curve and catch up with the improvements in care delivery.