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Behind The Scenes, This Obamacare Program Is Lowering Costs In Kentucky

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Rande Swann had a very, very bad October.

That's when her 80-year-old husband Don started getting sick for the first time in his life. First, it was cataract surgery. Then it was a partial knee replacement surgery. And then, as the kicker, a little more than a week after returning home from the hospital, her husband tried to climb the stairs by himself and fell.

“I was frantic because at the same time he’d taken the fall, that was the day I’d been in the ER with my 92-year-old mother all day long because she had blockages in the bowel ducts," said Swann. "I finally get her settled and come home to check on him and he’s lying splayed out in the first floor foyer in pain.”

At 64, Swann talks hurriedly, still works part-time and she teaches a broadcast journalism class. She’s got places to go. But her role as a caregiver for two and the stress that comes with it sent her to a dark place.

“It was like, I have this sizable life insurance policy on me," said Swann, "and if they can’t get him in a nursing home, at least if I die, then he’s well cared for. There’s plenty of money to take care of that. There will be enough funds to take care of mother.”

Thankfully, Swann did not take her own life. Her husband and mother both got the care they needed, and she didn’t have to pay for all of it.

And for that, Swann credits a woman named Misty Stallard.

Stallard works for KentuckyOne Health Partners. A former nurse, she spends most of her day inside a cubicle talking on the telephone. Stallard is part of a huge effort by the federal government to curb the cost of health care spending in the U.S. through the creation of accountable care organizations, or ACOs. They are groups of health care providers who work together to coordinate all aspects of a patient’s care.

“I help them make appointments to see their surgeon, post-opp appointments," Stallard said. "I help get home health in the home if they need rehab. If they need to go to the ER, I will try to get them into see their physician and prevent that."

When the Affordable Care Act — or Obamacare — was passed by Congress in 2010, it didn’t just create the health insurance exchanges or the expansion of Medicaid in states like Kentucky. These ACOs first started on a big scale because of Obamacare.

The law is almost 2,000 pages long, so there’s a lot more that could go away when the ACA is likely repealed by GOP lawmakers in Congress. But most of its provisions fly under the radar, provisions like ACOs.

A Low Profile

ACOs were designed to reduce medical errors, avoid duplicating care and save money. In the time KentuckyOne has been running its ACO, key metrics like “hospital length of stays” and “readmissions within 30 days of hospital discharge” have been reduced by half. Quality scores have gone up. And KentuckyOne said last year, the company saved $18 million for its Medicare patients alone.

But ACOs are still pretty low-profile. Most people don’t realize they’re part of one, let alone that these programs were created through Obamacare. Even Swann, who spoke with Stallard daily about her husband’s care, had no idea.

“Even having gone through all this, I didn’t realize it was tied to the ACA," Swann said. "In fact, my husband said 'does this have anything to do with Obamacare,' and I said no.”

KentuckyOne Health Partners CEO Don Lovasz said people aren't told about the connection to Obamacare on purpose because ACOs are difficult to explain.

As an example, Lovasz describes a situation where an elderly patient — "Don" — gets a hip replacement. Often, many patients have more than one illness going on at once, so in addition, the elderly patient might have a diabetes flare-up or high blood pressure during recovery at home.

“You’d call orthopedics, and because there were two or more things going on at once, the individual docs would say, ‘well why don’t you go back to the hospital,’" Lovasz said. "So patients would get readmitted unnecessarily. With the care coordination model, we’re able to look ahead and if it looks like 'Don' is developing pneumonia, we get some care as quickly as possible.”

So, what happens if the Affordable Care Act is repealed? President Donald Trump has promised as much, and Congressional GOP lawmakers are still trying to iron out what a replacement will look like.

Whatever happens, Lovasz doesn’t think the ACOs are going away. That’s because despite some hiccups, ACOs are saving money. Harvard Medical School professor Michael Chernew said the way ACOs are structured gives both providers and insurers incentives to coordinate care.

“In the old system, providers that were efficient — all that flowed back to the insurer," Chernew said. "In this new system, the providers get top share in some of that, and that incents them to create more efficiencies."

And that’s why insurers are interested in and, in some cases, expanding ACOs. Lovasz said even though KentuckyOne Health started the ACO because of Medicare, the company is now contracting with commercial insurers and is coordinating care for about 115,000 people.

Lovasz said KentuckyOne Health is also in talks with four Medicaid insurers in Kentucky to take on patients who are poorer, younger and generally in worse health.

When Rande Swann found out that the reason she was able to talk to KentuckyOne Health’s Mindy Stallard was a program created by the Affordable Care Act, she got a bit worried. But it saved her life and her sanity, all the while getting her husband better care than he normally would have under a traditional system.

And when Stallard got Swann’s husband into a nursing home to recover from his fall, KentuckyOne Health went a step further, getting him into the same nursing home where Swann’s mother was living.

“They arranged to put them next to each other so I could sit in the middle of their rooms and see about their care at all times,” Swann said.

Lisa Gillespie is WFPL's Health and Innovation Reporter.

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