Home Sweet Medical Home
By Harris Meyer
The Medical Home Model May Attract Primary Care Physicians, Save Money and Boost Quality and Patient Satisfaction
The Medical Home Model May Attract Primary Care Physicians, Save Money and Boost Quality and Patient Satisfaction
It’s 8:15 in the morning and the phone rings in Dr. Harry Shriver’s office. It’s one of his patients, who suffers from congestive heart failure and isn’t feeling well. “Why don’t you come right in?” says Shriver, chief of staff at Group Health Cooperative’s (GHC) clinic in Factoria, Wash. He schedules an appointment for 2 p.m. that day. Within the last few months, Group Health, as part of its two-year primary care “medical home” pilot study, has established a new call management system allowing patients to phone and e-mail their doctors directly.
“The doctors hated it when they first heard about it,” says Shriver, a family physician who’s worked at Group Health for 34 years. “But patients love it, and a lot of the time I can save visits. It’s a 25-second call, and otherwise I wouldn’t have heard about this patient’s problems until noon.” GHC’s preliminary research data show greater patient and staff satisfaction, improved clinical measures, and reduced costs for emergency, urgent care and mental health services—all of which offset the $600,000 up-front investment. On top of that, several veteran family physicians, who were feeling burned out and wanting to retire, including Shriver, have decided to stay on.
“We’re feeling rejuvenated,” says James Bergman, M.D., who’s worked for Group Health for 25 years.
That’s just one part of Group Health’s broader program of creating a comprehensive team approach to providing highly accessible primary care for the clinic’s patients.
The nonprofit staff model HMO hopes to eventually roll out the medical home model to all of its 27 clinics.
Similar efforts to establish a patient-centered medical home approach for primary care and chronic care management have proliferated around the country over the last two years in response to a grim concatenation of crises in U.S. health care. Costs have soared, access to primary care physicians has plummeted, patient and physician satisfaction are low, older primary care doctors are rushing to retire, and young primary care doctors have become a vanishing species.
Home Versus Homeless
There is no simple definition of a medical home. But you know it when you don’t see it.
Even well-insured Americans are painfully familiar with the problems of not having a true medical home—the long wait for an appointment with their primary care doctor, the five-minute visit, the doctor’s lack of access to records, the extreme difficulty of calling to ask a simple follow-up question, the maddening duplication of tests, and the need to go to the ER because the doctor is not available.
In 2004, the American Academy of Family Physicians (AAFP) warned that family medicine wouldn’t exist in 20 years without major changes. Early last year, the AAFP, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association released a set of joint principles describing the patient-centered medical home.
The purpose of a medical home is to facilitate prompt, cost-effective and coordinated access to a comprehensive range of diagnostic, educational, specialty care, out-of-home care and other medical services. The primary care physician, in close collaboration with the patient, leads a team of health care professionals who are responsible for providing or facilitating all the patient’s health care needs.
The goal of the medical home is to improve quality, efficiency and satisfaction for both patients and doctors. Computerized information, including an electronic medical record and decision support tools, help guide evidence-based clinical decision-making, and aggregated data drive continuous quality improvement.
The model features data-based protocols, open scheduling, expanded hours and a variety of ways for patients and providers to work together, including group visits, secure e-mail and interactive Web sites.
“Primary care today is much too complicated to be delivered by a single person,” says Allan H. Goroll, M.D., a Harvard University medical school professor, who is organizing a medical home demonstration involving private insurers and eight primary care practices in Albany, N.Y., and Greater Boston. “There’s no way a lone-ranger doctor can do modern primary care alone.” Last year, four physician groups, several large employers, AARP, and other consumer groups launched the Patient-Centered Primary Care Collaborative to promote the medical home model.
The AAFP funded a two-year, $8 million medical home demonstration project involving 36 practices across the country. It recruited independent researchers at five academic centers to study the project, and they will be publishing results early next year, including data on overall medical costs.
Even though the participating primary care practices did not receive any extra, or different forms of, reimbursement, the practices typically did better financially than before, said Terry McGeeney, M.D., president and CEO of TransforMed, Leawood, Kan., an AAFP subsidiary that the academy established to help practices remake themselves into medical homes.
McGeeney says that it typically took physician practices six months to deal with leadership and cultural issues and reorganize care. But they eventually did better financially because, among other things, patients came in on a more timely basis and the practices started receiving payment for electronic visits. “While large practices already have the resources in place, we found that the smaller the practice, the better position they are in to make changes,” McGeeney says. “Everyone thought this would squeeze small practices out of the market, but I think the opposite will be true.”
Paul Grundy, M.D., IBM’s director for health care transformation and chair of the medical home collaborative project, says “patients just love it.” From a buyer’s perspective, though, the key point is to change the current, dangerous system of uncoordinated care. “It’s morally wrong for someone to touch you without knowing every medication you’re on, when they know it can kill you,” he says.
Moreover, studies have shown that quality of care in the U.S. on a wide range of measures is poorer and costs are higher than in other advanced countries that offer greater primary care access and quality. Poor primary care also has been tied to growing disparities in the health of Americans associated with income, race and ethnicity.
Primary care specialty groups, large employers, state and federal policymakers, and some insurers are pushing to transform the delivery of and reimbursement for primary care using the medical home model.
Medical home proponents recognize that inappropriate and inadequate payment is a big part of the problem with the current primary care system. Thus, they are trying to convince payers to experiment with ways to reimburse providers for delivering services in more patient-centered ways, rather than only paying for face-to-face office visits. They need data, however, to persuade employers and insurers that this will save them money overall.
In July, Congress approved $100 million for 12 three-year Medicare demonstrations of the medical home concept in eight states, starting in 2009 or 2010, and giving the Secretary of Health & Human Services more authority to implement it for all of Medicare. Medicare’s Relative Value Scale Update Committee has issued several recommendations for how to pay practices participating in the pilots, which could mean an extra $50 per patient a month. In addition, 34 states have approved or are considering funding for medical home pilots for their Medicaid populations.
Large private health insurers in Pennsylvania and New York, including Independence Blue Cross and Aetna, have agreed to pay for comprehensive care management as part of medical home pilots. Some payers are requiring that providers receive medical home certification from the National Committee for Quality Assurance, which offers three levels of recognition.
“At the end of the day, there has to be the same or higher quality at lower cost,” says Bruce Nash, M.D., senior vice president and chief medical officer at the 400,000-member Capital District Physicians’ Health Plan in Albany, N.Y. “That’s the only way we can appropriately pay doctors more. Then we can make it more attractive for medical students to choose primary care.” Nash’s doctor-governed, nonprofit insurance plan has agreed, as of Jan. 1, 2009, to pay three primary care practices extra for providing comprehensive care to all their patients as part of a 30-month medical home demonstration.
Reengineering Isn’t Simple
But reengineering primary care and convincing public and private payers to make it financially worthwhile for providers are no simple tasks, and those involved in trying to bring about this massive transformation admit they have a huge amount of work to do. It’s a bit of a chicken-and-egg issue.
“The question is, do you wait for insurers or the government to say this is what we want, or do you create it?” says Joseph Bianco, M.D., a family physician and member of the board of SMDC, a nonprofit four-hospital system with a 400-doctor multispecialty clinic that serves northern Minnesota and Wisconsin. “We just decided to do it because it’s the right thing to do, and it meets a lot of the needs for the future.”
SMDC’s Phoenix Project pilot—so named because the current primary care model has crashed and burned—created a new practice model focusing on primary care team management of chronic disease, screenings and immunizations at four clinics. A key component is pre-care planning: staffers contact patients prior to a scheduled office visit to make sure all necessary lab tests have been done and the patient’s medication list is up to date. The project started in March, and it’s too early to say whether the approach has reduced overall costs. But Bianco has seen progress in doctors’ willingness to work as a team, letting non-physician staff handle such key tasks as ordering evidence-based labs prior to office visits.
SMDC accepts that keeping people well through better primary care may reduce revenues on the procedural and hospital sides. “We’re hoping to present an outstanding product to a lot of payers that will meet the demand of lower costs for high quality,” Bianco says. “The bottom line is that the patient comes first, and we’ll just have to adapt to a healthier population.” Then he laughs at the irony.
While there’s wide agreement that the medical home model can improve quality and satisfaction, skeptics say it’s more important in the short term to simply boost reimbursement for primary care doctors and encourage them to do their jobs well in the traditional way.
“It’s a great concept that needs five to 10 years of work,” says Robert Berenson, M.D., a senior fellow at the Urban Institute in Washington, D.C., who co-wrote a critical article on medical home efforts in the September issue of Health Affairs. “In that period, we could head into a real crisis. You need to directly address inadequate payment.”
Hospital System Jumps In
Since hospitals employ a large percentage of primary care physicians and provide technology and staffing support, advocates say it makes good business and political sense for hospitals to become champions of medical homes.
“It’s good for patients, good for market share, and good for retaining doctors,” McGeeney says. “But they’ve been slow to get on the bandwagon.”
While hospitals generally have not been leaders in this movement, a few hospital systems are in the vanguard. Those that have established or are considering medical home demonstrations include SMDC in Duluth, Minn.; Park Nicollet Health Services in Minneapolis; Geisinger Health System based in College Station, Pa.; Middlesex Hospital in Middletown, Conn.; Spectrum Health System in Grand Rapids, Mich.; and Massachusetts General Hospital in Boston.
Park Nicollet is trying the medical home model at two sites for children with chronic diseases such as asthma, and also for adult congestive heart failure patients. The system, which features a 440-bed hospital and a 600-physician multispecialty clinic, thought the medical home approach would create a competitive advantage in the market.
Another motivation was that the system was getting a growing number of very sick patients, and providers were feeling exhausted, says Barbara Benjamin, M.D., a family physician who serves on Park Nicollet’s community board of directors.
“Burnout is our big issue in family medicine,” she says. “More people are wanting to go part-time, and the primary care doctor pipeline is just drying up.”
For the adult congestive heart patients, a nurse talks on the phone every day with each patient to monitor five indicators, such as weight. While the program is expensive, Park Nicollet has found that it’s averted at least 50 hospital admissions per month for these patients.
The problem is that Park Nicollet is losing hospital revenue, and insurers so far haven’t paid extra for the comprehensive patient management to offset those losses.
“We aren’t abandoning it, but we aren’t expanding it because we don’t want to lose even more,” Benjamin explains. She’s desperate for insurers to compensate for the better and more comprehensive care Park Nicollet has designed for these patients. “Patients with multisystem diseases need a total team,” she says. “The doctors have been trying to do all these things as well as deal with more paperwork, new regulations, etc. That’s just not sustainable.”
Saving Family Practice
Group Health Cooperative had built-in advantages in adopting the medical home model. It’s a nonprofit staff model HMO that employs 400 physicians, so the provider and insurer incentives are aligned. It already had implemented a sophisticated electronic medical record system, with pop-up alerts for doctors on preventive care. And it offers many other resources to support its doctors. Michael Soman, M.D., president and chief medical officer of Group Health Permanente, says he chose the Factoria clinic for the demonstration because it was already one of the best-performing clinics, but its physicians were feeling burned out and considering retirement. He met with the doctors and staff and went through a joint process of designing changes to implement the medical home principles.
A major expressed need was to reduce the doctors’ panel size, i.e., the number of patients assigned to and under the care of each doctor. Group Health budgeted $600,000 a year for two years to add staff, including 1.5 doctors, reducing panel size from 2,500 to 1,800 patients. That enabled the doctors and staff to spend significantly more time on visits with patients, as well as communicating with them by phone and secured e-mail.
In addition, the clinic assigned a registered nurse to share each family physician’s office and work closely with the doctor on patient follow-ups, including calling patients discharged from the hospital to go over their care plans. Plus, the clinic shifted two pharmacists from working mostly on cost control to consulting directly with patients and doctors on drug regimens.
The key, Soman says, is focusing on each team member’s role in supporting the patient. “The secret sauce is clinicians seeing themselves as the patient’s trusted colleague in disease management and decision-making. That comes from the clinician’s heart, not the smaller panel size,” he says.
Group Health’s preliminary survey results indicate that patients are pleased with the changes. Archie Cress, 78, of Mercer Island, Wash., a patient of GHC’s Shriver, suffers from severe diabetes and heart disease. He says that now the nurse calls him frequently to get his blood sugar readings.
“It surprised me when they started calling me,” he said. “It made me feel like they really cared.” He thinks the extra attention has kept him out of the hospital.
Shriver says he used to see 24 patients a day and now sees 12 to 14. He can spend 30 minutes with each patient and accomplish a lot more than before. While he still has a long day, starting at 7:30 a.m. and leaving at 6 p.m., he feels he accomplishes more, has better closure with patients, and enjoys his work more.
Soon, his daughter, Lisa Baker, a family practice resident, will join him at the Factoria clinic. When she entered her residency, he was apprehensive that she would regret her choice. But when Soman introduced the medical home model and Shriver saw that it made life better for patients and doctors, he felt relief.
“It meant a lot that I was setting the stage for my daughter’s career,” he says.
Harris Meyer is a freelance writer based in Yakima, Wash.
This article 1st appeared in the November 2008 issue of Trustee Magazine.
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