VOICES OF REFORM: It’s a Beautiful Day in the (Medical) Neighborhood

We quoted Dr. Elliott Fisher in our recent American Prospect piece but naturally the head Dartmouth Atlas researcher had more smart things to share than we could fit in one magazine article. The Dartmouth team has been telling us for years about the unjustifiable and often inexplicable ways that health care differs from one place to another, and how much of our health care spending doesn't make people healthier. What's exciting now is that more people are listening. So we thought we would share  more of what Dr. Fisher told us about how to create a more sustainable high-quality health care system.

One popular concept is the medical home. There isn't yet a consensus on defining a medical home (like obscenity, people know it when they see it.) It's usually described as a practice (large or small) which emphasizes prevention, care coordination and management, and where the payment system promotes those goals. I didn't talk too much to Fisher about what, in his view, does or does not constitute a medical home; but later thinking about our conversation I was intrigued by his idea that "Every medical home needs a medical neighborhood." What would a medical neighborhood (in a livable medical world) look like? Here's one blog-friendly way to map it out.

• Green space or neighborhood gardens is the image that came to mind for Fisher's call for giving more prominence to public health, to keeping the population well. "There's a growing sense of crisis in public health, an understanding that we need to refocus the system on prevention, on health promotion, on the growing burden of chronic disease," Fisher told me.
• A neighborhood "economy." Fisher detects a growing understanding among the public, physicians and large health care organizations that the current "payment system keeps us from doing what we need to do. What we want to do. What we are trained to do. It has us hamstrung." Yet we also now understand what "a high-performance system" should look like. An integrated delivery system, with health IT decision-making support, performance measures. The emphasis should be on results, not volume. On a continuum of care, not just acute episodes. "I think we are starting to see the ingredients required to get there visible on the horizon," Fisher said.
  Medical homes won't meet their potential without payment reform so that hospitals and medical homes can collaborate. As people get more used to the idea that we are wasting billions of dollars in health care, there is a "nascent recognition (that) there is so much money on the table that providers if offered a path out of the current toxic track that the payment system has been in" would be more open to change. "I think if you align the payers and get the incentives for the providers aligned... we could move rapidly."
• People. A medical home, and a medical neighborhood, needs people. People with access to care. People with coverage. So Fisher, although he spends his life figuring out how to fix how we deliver care, views covering people as the "critical first step."
  "Coverage expansion, where we spend a little money up front from the $700 billion we waste (yearly) will facilitate the more effective delivery system. It's much better if everyone's covered. We'll be able to squeeze much harder to get the fat out of the system," Fisher said, adding that all the Dartmouth research about "supply sensitive" health care suggests that covering everyone will cost a lot less than some skeptics maintain.
• Shared Lessons from History. I asked Fisher if he were the health care equivalent of Rip van Winkle waking up now after seeing the beginning of reform 20 years ago, what would surprise him the most about our current sytem. I'm not sure if anyone had ever worded the question in exactly that way, but he responded quickly. "The disintegration of, or discrediting of, what was fundamentally a very good idea—comprehensive managed care the way it was supposed to be." Instead we got the economic incentives and allocation of risk all wrong and "shot managed care in the foot." Now we need to reinvent a form of coordinated, integrated care—like a medical home—without repeating our mistakes. Providers might be more receptive than we might think to shifting to a "more integrated and comprehensive approach to care," instead of the commercially-driven fragmented health care market. "People are starting to be embarrassed by the excesses," he said, adding that we are doing so much radiology that medicine sometimes seems part of the Star Wars series.
• Communication and Community. You can't have a neighborhood if people don't talk to one another. But in medicine today, we've got lots of fragmentation and little communication. Even where primary care is relatively strong, doctors don't tend to coordinate or communicate enough. "Think about it. Our individual encounters with patients—that's the only way we improve health. And that's a pretty broken way of thinking about health care. Think of the chaos if you have 10 different physicians involved in your care, and physicians who don't talk to one another." They may not even know how to talk to each other. They weren't trained to do that, he said. "It's one of the underlying problems with the current professional model."
• Infrastructure. Not just electronic medical records but an electronic medical practice. Lots of routine care can be done by patients themselves, and self-care is increasingly seen as part of chronic disease management. Some routine monitoring can be done by e-mail or telephone (which, economically, becomes more practical for doctors in a medical home model) "Maybe 30 percent, 50 percent, or 70 percent" of office visits could be eliminated—particularly as we know that patients in some parts of the country are told to come in way more often than patients elsewhere. "If you ask patients, ‘Would you rather have been able to check your own blood pressure and email your doctor and have it be less costly or do you want to take a half day off of work and come in?'" Probably the answer would mean fewer than the 900 million ambulatory care office visits we now have a year. Which would also mean it wouldn't be so hard to get our doctors to squeeze us in for an appointment when it is clinically indicated.

In practices that have shifted to this style of practicing medicine, "Everybody is having much more fun. Doctors get to take care of what really matters. And they see their patients long enough to talk to them."

It's sure not what our medical neighborhood looks like right now. But we are hoping for rapid renovations.