Medical Homes

IN THE STATES: San Francisco's Ride on the Health Reform Trolley

Paul Testa — Thu, 03 Jul 2008 16:54:00 -0400

Rice-A-Roni may be the San Francisco treat, but health reform has been the topic du jour of late for the Bay City. As the San Francisco Chronicle noted, yesterday marked the one-year anniversary of Healthy San Francisco—the city’s ambitious plan to make health care accessible and affordable to its uninsured residents.

Like a cable car descending Nob Hill, there have been a few bumps along the way—the growing pains health reform—as well as uncertaintity because of a pending decision from the Ninth Circuit regarding the legality of the city’s efforts. Still, the plan is an innovative effort from one of the cities described in a recent Families USA report as being on the front lines of America’s health care crisis.

The key elements of San Francisco’s plan are laid out nicely here, but we’d like to highlight two points from the initiative:

An emphasis on medical homes in which a participant chooses one of 27 participating clinics to coordinate their care.
Shared and individual responsibility represented by income-based cost-sharing on the part of individuals and an employer contribution for firms with more than 20 employees.

New America health policy program director Len Nichols provided a positive and realistic assessment of the plan for the Chronicle article:

For a city to try to do it at all is pretty amazing. Ultimately, we're going to need federal help to make health care access a reality in this nation, and it's impressive San Francisco is trying to do it in whatever patchwork way they can.

REFORM: Good Grief! Seeking MedPAC's Advice on Primary Care

Paul Testa — Tue, 24 Jun 2008 12:43:00 -0400

Lucy van Pelt used to charge five cents for advice. That's peanuts compared to what some patients will pay today for the services of "health care advocates," according to the Boston Globe. And although the intent is to help people navigate the system, their very existence illustates some of that system's biggest problems.

These firms specialize in coordinating a patient's care and helping them navigate our complex and often overwhelming health care system. What doctors to see, what treatments to seek, where to go with an emergency at 3:00 a.m.—they'll answer all your questions—for a price that can range from $150 an hour to $100,000 a year.

Advice on treatment options, disease management and the coordination of care can take many shapes and forms, but, arguably many of the services provided by these health care advocates, in an ideal world, should be provided by a patient's primary care doctor. Yet, one of the people interviewed for the Globe article said he called his advocate because he didn't want to bother his primary care doctor with routine questions. Having someone to answer your routine questions, to know when there's something bigger at stake, is part of why we need a primary care doctor in the first place! But our current system is set up so that all too often it obstructs rather than encourages such relationships, which are the foundation of health care. These firms, in contrast, are adding another layer of care—and only for people who can afford the fees.

We get what we pay for in health care, and right now we're paying primary care doctors to squeeze in 15 minutes (or less) with as many patients as possible. In its June report to Congress on Reforming the Delivery System, MedPAC made extensive recommendations addressing payment reform, comparative effectiveness, and, yes, primary care.

The report stresses the importance of primary care to the delivery of efficient, high-quality care. The two main recommendations are simple but needed:

Pay primary care physicians smarter. Medicare's reimbursement schedules are more byzantine than Constantine the Great. The basics of evaluation and management—the bread and butter of primary care—are undervalued relative to more intensive procedures like heart surgery because the fee-for-service payment is based on the manual difficulty of completing a medical service. When a heart surgeon becomes more efficient, he or she can perform more operations with fewer complications and is paid more because the volume of cases increases. But this fee-for-service system produces perverse results in primary care. The emphasis should be on education, coordination and management of complex disease—but doctors just aren't paid for putting in the time required to do those tasks right. Instead, they're paid (not much) by the visit. MedPAC proposes adjusting payments in a budget-neutral manner to more accurately reflect the value of primary care. Done correctly, it could allow primary care doctors to spend more time with patients doing the things some are now having contracted out.
Demonstrate the value and viability of a medical home model of care. A medical home coordinates a patient's care, including prevention and chronic disease management. Generally built around primary care doctors, a medical home can also incorporate specialists (like endocrinologists for diabetes). MedPAC also lays out some of the conditions it sees as the foundations of medical home model, including: pay for performance, health IT, and 24/7 access. Framing the proposal in terms of a pilot project—which unlike a Medicare demonstration project does not have to be revenue neutral and can be used to set payment policy—shows how serious the report's authors are about the potential value of a medical home.

We aren't criticizing individuals who go out and purchase something they think their family needs. But it really isn't an answer to the problems in our health care systems; problems which can be addressed by more and better primary care, more integrated delivery systems, and a payment system that rewards coordination instead of fragmentation. More sustainable reform, components of which MedPAC has laid out for us, would change the incentives of our current system so that primary care doctors are paid more for managing their patients' health. And that's something even good ol' Charlie Brown—and maybe even Lucy—could be happy about.

REFORM: MedPAC Says Sustainability and Quality Mean New Approaches

Joanne Kenen — Mon, 16 Jun 2008 17:26:00 -0400

MedPAC's big June report is out, and it's full of big June ideas. Really big ideas. The panel, which advises Congress on Medicare policy, outlines (not all for the first time, but more emphatically and comprehensively) a lot of ideas for changing a lot more than technical fixes to fee scales and payment rates. MedPAC is ready for the whole enchilada (or whatever the geriatric equivalent would be. Chicken dumplings?) in reshaping the system so that it is both higher quality and more cost-effective. The nonpartisan panel of experts wrote:

Fundamental changes are needed in health care delivery in the United States and in Medicare. ... Recent studies show that the U.S. health care system is not buying enough of the recommended care, is buying too much unnecessary care, and is paying prices that are very high, resulting in a system that costs significantly more per capita than in any other country.

Medicare does more than take care of the elderly and disabled. It sets patterns and models for much of the U.S. medical system, affecting how hospitals function and doctors practice. It also costs a lot. The commissioners stated further:

Without change, the Medicare program is fiscally unsustainable over the long term. Moderating projected spending trends requires fundamental reforms in payment and delivery systems to improve quality, coordinate care, and reduce cost growth.

In the coming days, we'll delve more deeply into aspects of the report. But here are five points that struck us as particularly integral to getting away from a system that has evolved so that it too often rewards the quantity of care, rather than the quality.

1) Comparative effectiveness. MedPAC last year urged Congress to create an independent entity to figure out which drugs, procedures, devices, surgeries, etc. work best, and which don't work so well—or at all. MedPAC goes into more detail this year on the pros and cons of various models, but it stresses that that oversight should be independent and funding should be broad-based, "from federal and private sources because the research findings will benefit all users—patients, providers, private health plans, and federal health programs."

2) Medical home pilot project. A medical home coordinates a patient's care, including prevention and chronic disease management. It is centered around primary care doctors, but specialists can be part of it— notably, endocrinologists for diabetes. It's accessible when the patient needs it (not just 9:00 to 5:00, or else head to the nearest emergency room). Payments would be based on how well overall care is managed, not just how many services or procedures a patient gets. Requirements for the pilot program include using health information technology for clinical decision making, as well as up-to-date records of advanced directives.

3) Bundling and readmissions. We hear a lot of talk about shocking medical errors, but we pay less attention to all the things that can go wrong when patients transition from one setting to another, ie. a frail elderly person who has been severely ill in the hospital returning home, or transitioning between a nursing home and a hospital. One step MedPAC recommends (and it would be phased in during several years after hospitals are given the necessary data and feedback) is reducing what Medicare pays to hospitals with high readmission rates for certain conditions. Another is to "bundle" payments. That is going to require a lot of experimentation to get right, but the idea is instead of paying the hospital one chunk of money for inpatient care, and then paying for a lot of other doctors and tests and procedures in and out of the hospital related to the same illness, there would be one comprehensive payment (pilot projects and experimentation will be necessary to determine exactly how that will be divvied up).

4) More primary care. As MedPAC notes, raising payments for primary care won't address all the reasons (including lifestyle and status) that young docs choose high-paying, high-volume specialties instead of internal medicine, family medicine, geriatrics, and the like. But money can help. MedPAC also looks at how to draw on the cost-effective primary care expertise of advanced practice nurses and physicians assistants.

5 ) Disclosure. Hardly a day goes by (see this recent Boston Globe story about a Harvard psychiatrist) when we don't hear of another doctor or research team that was getting more money than we realized from a drug or device manufacturer. MedPAC wants more disclosure and public reporting. (Hmm. Do you think they can figure out a way of getting them to donate those payments to finance comparative effectiveness??? ) MedPAC outlines several mechanisms for greater transparency but notes, "payers, plans, patients, and the general public are often not aware of these potential conflicts of interest." They should be—sunlight is the best disinfectant.

QUALITY: What Patients Think of Patient-Centered Health Care

Joanne Kenen — Mon, 19 May 2008 13:30:00 -0400

"Patient-centered medicine" is one of the buzzwords in health these days, so it was refreshing to hear from patients who actually had a voice in finding that center. Four spoke at a panel this spring sponsored by the Institute for Healthcare Improvement. Four patients. Four very different experiences. All had some success in creating a more responsive health care system. And when we at New America talk about reforming health care, we don't just mean insuring people. We want everyone to be covered so they can be part of a system that delivers high-quality, cost-effective, patient-responsive care.

(If you are interested in the difference between "patient-centered health care" which involves how we deliver care that patients need, and "consumer-directed medicine" which is a market-oriented approach to financing health care, read this Healthbeat pos t . They are not necessarily mutually exclusive, but they aren't synonymous.)

* * *

Twenty years ago, when Richard Scholtz, was not quite 40, he needed surgery to replace a defective heart valve. Grateful for excellent care, he showed his appreciation by coming in every Friday to play music in the doctors' waiting room. Twenty minutes into his first "performance," one of the physicians came out and declared: "Everybody's blood pressure is lower!" It became a steady gig. They offered him a job, but he declined payment, although he later accepted a barter arrangement. He serenaded. They kept his heart ticking.

The experience did propel Scholtz, who is from Bellingham, Washington, into more activism about patients and health care, and he was able to help his aging mom learn to take care of her heart disease in a community that was part of a Robert Wood Johnson Foundation-funded "Pursuing Perfection" initiative. Among other things, the program helped patients create secure electronic medical records that they controlled. They could monitor their own chronic diseases, and share information at their own discretion with doctors, pharmacists and other practitioners, as well as family or friends who were part of their care team.

At the time his mother was already a bit confused—not suffering from dementia but having trouble dealing with a complicated medical condition. "Self-managing for congestive heart failure was tricky," he recalled. "But the care specialist spent time listening to her, understanding how she learned. So she was able to self-manage." The personal health record "has become a place where the patient has to make sense of their own situation," he said. The record contains both treatment instructions as well as the patient's own goals, how he or she stays well. Now that his mother is well into her 90s, he is less of a health-sidekick for her, and more her health navigator. He has also gotten deeper into "health mapping," which is both a literal map and a metaphor for understanding the context of good health in the life of an individual or a community (More on that later this week).

* * *

Patient two was Ashley Peterson of Minnesota. Actually Ashley is the mom; the patient was her seven-year-old daughter, Camerynn, who has cerebral palsy, developmental delays and a rare brain disorder. Camerynn now has a "medical home"—another new term in health which basically means she is treated by a primary care practice that coordinates all her care, that knows how to manage chronic disease and cares about doing it right. "Our experience before the medical home," Ashley recalled "was we were really rushed at our appointments. And with a complicated child, you need time to talk to the doctor." Ashley was invited by Camerynn's pediatrician to help create the medical home to serve special needs children and their families.

Camerynn no longer has to wait more than an hour for her frequent appointments. Her complex condition is flagged in her electronic medical record, so when Ashley calls, the schedulers automatically book Camerynn for a longer appointment—20 to 40 minutes instead of the standard 10. The clinic doors finally were adapted to handle wheelchairs; special scales can accommodate disabled children.

Ashley doesn't have to give her daughter's complicated medical history over and over and over again to 13 different specialists; they have her record on the computer "and they know what's normal for that child." The electronic medical record is even accessible at the emergency room if Camerynn or other children in the program end up there (and even in a medical home model, where complex conditions are well-managed, E.R. visits may be reduced but not completely eliminated). And the doctors now use "picture boards" so young children or those like Camerynn who can't speak well can point to images to communicate—what hurts, and how much.

Three parent representatives regularly meet with the medical staff and care coordinator—and the care coordinator actually coordinates. "It's a huge improvement. She'll make appointments for all the specialists. And instead of a three or four week wait, it's a quick turnaround," said Peterson, who now serves on all sorts of boards, councils and volunteer groups—in addition to going to school to become a special education teacher.

* * *

Jean Klein, who is in her 80s, played Mrs. Santa Claus for 25 years for her local business association in Colorado. She and her husband were in real estate, and they had a good life. When Al had a heart attack, he got good care. Klein always found that if she hugged the doctor, Al would get even better care. Then she got sick. She woke up on life support with double-pneumonia. She survived. "They brought me back twice." Her young doctor ("I'm old enough to be her grandmother," Klein said.) saw something special in the elderly woman and invited her to join a patient advisory group where patients could help the doctors see the treatment from the patients' perspective. Klein had a few simple suggestions that made a big difference.

"The doctor looks at the computer, he talks to you, you say yeah, sure, and then you go out. Your cell phone rings. You drive off. You remember you forgot to go to the lab. You have to call the office... We came up with the idea of letting him (the doctor) put everything he wants you to do in that computer. Then he pushes ‘Print,' and by the time you get out to the desk, you can see it for yourself." The "After Visit Summary" helps patients keep better track of tests, appointments, referrals and their medications, and if they are elderly it make it easier for them to share it with family members too.

"Think of all the old wimpy people who aren't going to be calling back," Klein told the doctor (whom she also hugged). "This will save you a lot of time."

* * *

Margaret Murphy, from Cork, Ireland, lost her son Kevin in 1999. He was 21. He didn't need to die. "Every aspect of his point of contact (with the care system) failed him," she told the IHI conference. His care in both Ireland and the United States was a comedy of errors—except that it was a tragedy not a comedy. His "patient journey," as she calls it, of misdiagnosis, mistreatment and miscommunication (potentially life-saving information slapped on a sticky note instead of in his chart) turned her into a dedicated international patient safety advocate, part of an international movement. The goal: to make sure there are no more deaths like Kevin's.

Stay tuned for more on Richard Scholtz and mapping.

QUALITY: There's No Place Like (a Medical) Home

Guy Clifton M.D. — Thu, 17 Apr 2008 16:29:00 -0400

What if we told you a program in North Carolina reduced Medicaid spending in one year by close to $244 million while improving care? The N.C. program offered primary care doctors a $3 per-patient, per-month payment to manage the patients on top of the usual fees for clinic visits. It also organized a multi-disciplinary team of medical personnel to assist the patients. The result: doctors spent more time with patients, coordinating treatment for chronic conditions and reducing hospitalizations. The overall quality of care improved.

The Patient-Centered Primary Care Collaborative (PCPCC)-a broad coalition of business leaders, policymakers, primary care physicians, and other stakeholders is looking carefully at success stories like North Carolina's to see how our whole health care system can redevelop our primary care infrastructure to control costs and improve quality in our country. After all, there's a reason it's called primary care.

Primary care matters. Just take a look at MedPAC, the WSJ's Health Blog, the NEJM or my forthcoming book, Flatlined—you'll see an airtight case for expanding primary care and changing how we pay for it and provide it. At the PCPCC's annual stakeholders meeting Wednesday, I was encouraged to see how such how changes are being translated into reality through the paradigm of "medical homes." These "homes" are the locus of patient-centered, accountable, primary care delivered in one place by one doctor or group of doctors assisted by a multi-disciplinary team. This model is being tested in both public and private sector initiatives across the country. (See the PCPCC''s recent guide for purchasers here).

This energized meeting was packed with individuals and institutions committed to seeing real change in primary care. It was only fitting then, that my colleague Len Nichols, Ph.D., gave the keynote address. Len placed the concept of the medical home within the broader framework of national health reform. He emphasized the potential for medical homes to realign the incentives of our health care system toward a model of "shared savings." Physicians would be paid for the quality—not just the quantity—of care they deliver.

We get what we pay for in health care, and right now we're not paying primary care doctors to act as stewards of their patient's health. In fact, the typical Medicare patient has multiple specialists and even more than one primary care doctor most of whom do not know what the others are doing. Yet, in many areas of the country, primary care doctors are taking no new Medicare patients because they are paid so poorly and their role in managing care is so devalued. The result is poorly coordinated medical care of variable and often mediocre quality. The doctors who are trapped in this bad system do not like it any more than the patients. It is a case of good people working in a bad system, and it can't be changed fast enough.

Experiences like the state of North Carolina have shown that investing in primary care can improve quality AND reduce costs. Coalitions like the PCPCC are trying to determine the details of how primary care doctors should be paid and supported in managing patients. The task ahead is to create a sustainable model so that primary care becomes the backbone of U.S. medical care. It will be like the old days when most people had a trusted doctor to guide them through the medical system, to manage their chronic conditions without hospitalization where possible, and to provide preventive care so that they did not develop illnesses. I believe that this dream is on the way to becoming a reality.

QUALITY: Taking Care of the Boomers

Joanne Kenen — Mon, 14 Apr 2008 17:47:00 -0400

More bad news for those of us who plan on getting old some day. The Institute of Medicine just released Retooling for an Aging America: Building the Health Care Workforce which reminds us there are not going to be enough doctors and nurses to deal with the geriatric needs of the 78 million baby boomers who start reaching age 65 in 2011. The authors said Medicare, Medicaid, and other health plans should pay higher rates to encourage more docs to learn about geriatrics. It also recommended training for family members and other aides who do a lot of the heavy lifting (literally and metaphorically) for the elderly. In many parts of the country, it noted, dog groomers and manicurists are required to get more training than the people who take care of our seniors.

"We face an impending crisis as the growing number of older patients, who are living longer with more complex health needs, increasingly outpaces the number of health care providers with the knowledge and skills to care for them capably," said committee chair John Rowe, professor of health policy and management, Mailman School of Public Health, Columbia University, New York City.

This isn't the first report to remind us that geriatricians are underpaid relative to other specialties. A geriatrician earned $163,000 on average in 2005 compared with $175,000 for a general internist—even though the geriatrican has extra years of training. (Neither of them earn as much as many specialists.) Registered nurses who work in nursing homes or other long-term care facilities typically work more hours but earn less than nurses in other settings. Remember that the Boomers can be expected to age (and die) differently than earlier generations. They will live longer and many will live healthier, but they will also have multiple chronic diseases. Today, the report said, the typical 75-year-old has three chronic conditions and takes at least four prescription drugs. Someone has to coordinate their care.

The IOM recommended that ALL health care providers get some training in geriatrics as virtually all of them (OK, not the pediatricians) will treat at least some elderly people. The report considered too whether we need to rethink some of the roles and responsibilities of providers. Maybe we should allow a certified nursing assistant to administer some medications, freeing the R.N. to manage the more complicated needs of a chronically-ill elderly patient.

The report said Medicare needs to improve what it pays, and change its focus from short-term, acute crises to managing chronic and age-related conditions. Lawmakers are beginning to get that message. Last week, it was reported that Senate Finance Committee Chairman Max Baucus (D-MT) wants to beef up Medicare payments for primary care in the doctors' pay package he's working on. Whether the specialists go for that remains to be seen.