Before Ohio expanded Medicaid in 2014, 28,000 uninsured, low-income patients in Cleveland relied on a program called MetroHealth Care Plus for access to healthcare. Launched by Cleveland-based MetroHealth System, the success of this program helped pave the way for Medicaid in Ohio.
We checked in with Akram Boutros, MD, president and CEO of MetroHealth and an internist, to talk about the success of the program. Here, Dr. Boutros discusses how MetroHealth's status as the safety-net health system in a consolidated, mature market affects its strategy, how Care Plus affected Ohio residents across the state and how he expects today's healthcare trends to play out over the next 15 years.
Note: Responses have been edited lightly for length and style.
Question: What is special about your market, and what do you have to work into your strategy that maybe you would not elsewhere in the country?
Dr. Akram Boutros: We have a fairly consolidated market with two nationally and internationally renowned health systems — Cleveland Clinic and University Hospitals — that are the dominant forces regionally. The MetroHealth System is the third largest, with the Sisters of Charity Health System trailing behind in size. It is also a fairly consolidated market on the physician level. Close to 90 percent of the physicians in the city of Cleveland are employed by one of the health systems.
As a result of the maturity of the market, we have had to find new ways to embrace the retail revolution and have done so through smaller, more dispersed clinics. These are express care, school-based clinics, physician practices and drug store-based clinics.
This market has a very high poverty rate and since MetroHealth’s mission is to lead the way to a healthier community, we have to focus on primary care delivery in a very deliberate, effective way. Nearly 52 percent of our patients are Medicaid or uninsured.
Q: A recent study showed costs of care for patients in the MetroHealth Care Plus program were almost 28.9 percent lower than the Medicaid spending cap allowed by the government and that it was successful in improving the quality of care for patients with diabetes. Can you tell me a little bit more about what that program does and its significance or impact?
AB: There has been much discussion on whether Medicaid expansion works or not. There has been research that shows Medicaid expansion increases the utilization of emergency services and may not be able to provide enhanced outcomes. The MetroHealth Care Plus program demonstrated that an established, mature and focused patient-centered medical-home program can achieve Institute for Healthcare Improvement's triple aim for Medicaid expansion by providing appropriate access, improved outcomes and lowered costs by reducing unnecessary emergency room visits and inpatient admissions.
Our study showed we saved $41 million a year for 28,000 patients. That's approximately $2,000 per patient per year, which is also significantly more than other shared-savings and total cost-of-care programs have achieved. We think our success helped, in large measure, to expand Medicaid in Ohio, or at least overcome opposition to its expansion in Ohio.
Q: If you could fix one thing about healthcare tomorrow, what would it be?
AB: Payment reform. I would align payment much more toward improving social determinants of care (access to care, housing, food, transportation, social support, health literacy and environment). Health systems today are not providing care early enough because we have both legal impediments and financial disincentives to deal with the aforementioned social determinants of health.
Q: What is your vision for healthcare delivery in 2030?
AB: I believe technology is going to continue to accelerate and miniaturize by 2030. I expect each person to use anywhere from 10 to 20 embedded intelligent processors related to their health. The advent of FitBit and other devices that have shown quick adoption will lead the way to anything from processors that test for levels like blood sugar and subsequently dispense medications, to things such as Google Glass and other tools for patients.
In addition, I believe we will move from regional health information networks to a national health information network that will make EHRs available anywhere in the U.S., giving patients a good snapshot of their healthcare wherever they need it.
Most of the primary care will be moved to self-care and guided-care. Self-care is how you normally take care of yourself when you have a cold: There will be incentives for you not to utilize healthcare services unless you actually need them. Guided-care is what most people in this country experience in the first 10 years of life when their moms take care of them. Moms are guided by a pediatrician but once they understand how the child reacts to certain things, they are able to provide most of the care. That will also translate to many more interactions than happen today. These interactions will be prompted by members of the care team, rather than the patient. Now, patients call a physician to make an appointment. That will be replaced by medical paraprofessionals, health coaches, navigators, coordinators, social workers and pharmacists reaching out to the patient through email, texts, prompts, visits and videoconferencing, and their goal will be to help the patient maintain health rather than ameliorate illness.
Finally, regenerative medicine will improve so patients will be able to have organs grown for them and prosthesis will achieve near-equivalency, meaning someone who loses their arm may have a prosthetic arm that is close to equivalency.
Q: What other major trends are you seeing in healthcare?
AB: There will be more consolidation of insurance companies. We will start to see more employer-sponsored clinics, many more apps for self and guided care, and I think we will see retail medicine and telemedicine become more available. Patients will be able to get care on their terms when they want it, how they want and where they want it. We're going to move from saying, "The doctor will see you now," to "Doctor, the patient will see you now."
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