Updated January 30 at 10:30am
HEALTH services

Blue Cross, Coastal contract rewards health outcomes

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PROVIDENCE – A new, two-year contract was announced today between Coastal Medical – the largest primary care provider in Rhode Island – and Blue Cross & Blue Shield of Rhode Island – the state’s largest health insurer.

Dr. G. Al Kurose, president and CEO of Coastal, called the contract, which moves away from the fee-for-service business model, a pivotal milestone in local health care reform.

Under the agreement, Coastal Medical becomes eligible for additional financial compensation if it achieves the best-in-class health care quality metrics established by the National Committee for Quality Assurance and manages total cost of care better than Blue Cross’s remaining primary care physician network.

If the contract requirements are satisfied, Coastal will be eligible to share a percentage of any meaningful medical cost savings experienced by its group of patients.

Up to one-third of all U.S. health care spending is waste, according to Peter Andruszkiewicz, Blue Cross’s president and CEO. “It is spent on things that don’t improve people’s health, such as unnecessary hospitalizations or redundant testing.”

“Here in Rhode Island, where our members’ medical costs totaled more than $1.3 billion last year, that’s well over $100 million annually in unnecessary medical spend,” he added. “We’re thrilled that Coastal Medical has partnered with us to help redirect some of those dollars to improving our members’ health and making health care more affordable.”

From Blue Cross’s perspective, the new contract “changes the ball game significantly for health insurance, for the patient and their health care. It puts more skin in the game for primary health care doctors,” Andruszkiewicz told Providence Business News.

With 101 health care providers located in a total of 18 offices in Cranston, East Greenwich, East Providence, Lincoln, Newport, Pawtucket, Providence, Smithfield, Wakefield, Warwick and Wickford, Coastal Medical provides care to more than 105,000 patients, 35 percent of whom are Blue Cross members.

Kurose told PBN that the new contract has a triple aim – “improve the patient care services, improve cost efficiencies, and improve the health of the population.”

Through the patient-centered medical home, he continued, “we are shifting our focus from a reactive to a proactive approach.”

“Excellence in patient care must always come first and is our primary goal at Coastal Medical,” Kurose said. “One of the biggest frustrations physicians have had under the old fee-for-service model is that they simply can’t spend as much time caring for complex patients as they would like to. This agreement realigns the financial incentives to allow our physicians to spend more time caring for our most chronically ill patients.”

Early detection of illness, better access to care and closer attention to the needs of chronically ill patients improves their health and creates savings for the system, according to Kurose. “Patient care then improves, doctors are rewarded for doing the right thing and care becomes more affordable.”

Kurose cited emergency room visits as an example of a place where the new approach will help cut. In Rhode Island, in 2010, emergency department use of 17.4 percent higher than the rest of the Northeast region, he said.

“On the weekends, we don’t want our patients to go to the emergency room unless it’s really an emergency,” Kurose said. “For instance, if you or someone you love is having chest pains, we want you to go immediately to the nearest emergency room, no matter what the day. On the other hand, if you think you may have pneumonia or maybe just a very bad cold, we are now able to offer Coastal Medical patients convenient and more affordable weekend office hours. When a patient does require hospital attention, we will ensure that follow-up care is coordinated by the primary care office and is seamless for the patient.”

Blue Cross & Blue Shield, Coastal Medical, Health care, insurance, hospital,

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