Health care network goals: Better care at a lower cost

Dr. Michael Pramenko
Dr. Michael Pramenko

Phil Castle, The Business Times

Dr. Michael Pramenko believes a newly formed health care network in Mesa County will achieve its goals of providing better care at a lower cost.

But Pramenko also foresees additional economic benefits when local businesses spend less money on health care and more money on hiring staff  and expanding operations. An area that offers lower health care costs likely will be attractive to new businesses as well.

The operation Pramenko oversees as executive director of Primary Care Partners (PCP) in Grand Junction will be among the first employer groups to receive care under a clinically integrated network named Monument Health.

PCP, the largest physician group in Mesa County with 32 owner physicians and a total of 200 employees, also is a partner in Monument Health along with St. Mary’s Medical Center and Rocky Mountain Health Plans (RMHP).

PCP and St. Mary’s will provide health care services through the network, while RMHP will offer new health insurance plans for the network to employers as well as families and individuals. The new plans also will be available though Connect for Colorado, the state health insurance exchange.

Other Mesa County health care providers that agree to network goals and standards  will be welcomed to join.

An outreach effort for Monument Health will soon begin, followed by enrollment in network coverage later this year, Pramenko said. Employees at St Mary’s also will receive care through the network, he said.

Monument Health represents the culmination of about 18 months of work on setting up a clinically integrated network, Pramenko said. Federal regulations define such a network as a program to evaluate and modify practice patterns to lower costs and raise quality through interdependence and cooperation. While network partners collaborate, they remain independent entities.

Monument Health brings together physicians and the hospital to care for patients. The network works with the insurance company to offer health plans and works with employers and organizations that provide self-funded benefits to employees.

Monument Health constitutes the latest collaboration in Mesa County to provide better health care at a lower cost while also addressing the overall health of the community, Pramenko said.

The network also constitutes a proactive approach to accommodate expected changes in the way health care providers are paid for their services, Pramenko said. “The waters are significantly changing.”

What long has been a fee-for-services model is shifting to paying health care providers based on the quality, rather than quantity, of the services they provide. That includes an expected shift in reimbursements made to providers through the government Medicare program, Pramenko said.

PCP has been working toward that change for about four years, he said. “We’ve been setting ourselves up to take those steps.”

Pramenko said he welcomed the change because the fee-for-services model creates an incentive for health care providers to order additional services for patients even if they’re not needed, which in turn plays a “huge” role in driving up health care costs. Health care providers need to say yes to those services that are needed, but no to those that aren’t, he said.

Under value-based payments, providers that achieve measurable results and lower costs share in some of the money from the savings, he said.

The goal of Monument Health will be to share information, coordinate care, streamline operations, avoid unnecessary treatments and provide services in the least expensive manner possible — such as surgical services in outpatient centers, Pramenko said.

The goal also will be to identify patients at risk of suffering from such chronic conditions as diabetes and high blood pressure and proactively manage their health care to reduce the necessity of far more costly treatments in an emergency room or hospital, he said.

Another factor in driving up health care costs has been spending too many resources on reacting to health care problems and spending too few resources in preventing them, he added.

Patients also have a role to play in becoming more engaged in maintaining good health, Pramenko said. Such benefits as lower insurance premiums and co-payments could help to incentivize that process.

The overall goals of Monument Health are based on what’s become known as the “triple aim,” Pramenko said, of improving the quality of health care and overall health of the community while lowering costs.

But health care also affects the economy at all levels, he said, whether it’s consuming an increasing proportion of gross domestic product at a national level of cutting into the bottom line of an individual business.

Lower health care costs could serve as an economic stimulus, Pramenko said, in freeing up more money for business to expand their staff or operations as well as making Mesa County a more active place in which to do business.