Medical Homes

HEALTH REFORM: Four Goals for "Dysfunctional, Disorganized and Wasteful" System

Joanne Kenen — Tue, 24 Nov 2009 18:20:00 -0500

Dr. Jack Wennberg, the father of the Dartmouth Atlas, and Shannon Brownlee, the author of Overtreated and a New America colleague, recently posted on the Health Affairs blog, recapping four major goals for repairing the "dysfunctional, disorganized, and wasteful delivery system."

1. Improve the science of health care delivery.

The stimulus package boosted comparative effectiveness research, and the health reform bills in Congress would build on that. But studying effectiveness of treatments, in isolation, isn't enough, they argue. We also need to develop a "science of health care delivery" which they call a "black box." Patients with similar conditions are treated in very different ways and we aren't doing the necessary research into how to best to allocate resources and deliver the most effective care.

2. Foster the expansion of organized systems of care.

These new systems, often described as Accountable Care Organizations, would reward providers that show they can be efficient and use resources judiciously -- while delivering high quality care. Shared savings (giving providers a portion of the savings during a transition period) gives the providers an incentive to bring down costs.

3. Informed patient choice (rather than informed consent) should become the standard of care.

Patients facing elective surgeries, tests, and procedures often don't understand exactly what they are consenting to -- or what options they may have.This can lead to higher costs when they get treatment that they may not have chosen (ie surgery instead of giving physical therapy a chance), and it may encourage malpractice suits. Shared decisionmaking could reduce unwanted care, they write, but to make this the norm providers need to be paid for the time and tools they employ. (Medical homes, the authors write, are a good payment fit for informed choice.)

4. Constraining the undisciplined growth in health care capacity and spending.

The health reform bills get most of their CBO-scored savings from cutting provider payments. But Wennberg and Brownlee content that these equal-opportunity cuts (no distinction between high quality efficient hospitals and the most wasteful ones) is a lost opportunity. They would like to see Medicare's payment clout employed to "encourage slower spending growth and greater accountability." Those who demonstrate high quality and cost accountability should be eligible for bonuses, and those that fail to restrain excess spending should face penalties (nick the payment "updates"). That would save some money in the near term but "but more importantly, it would serve as a signal that Medicare is serious about reducing future spending growth." Alternatively, payment updates could be reduced in a high-cost growth region, discouraging the "local medical arms races" that add to excess utilization and skyrocketing costs.They write:

Either way, reducing updates to high-growth regions or specific providers should discourage the easy flow of money from bond and equity markets for hospital expansion, and could spur the most inefficient providers to participate in ACOs and other shared savings programs. The key here is encouraging local providers to consider how to slow -- or even reduce -- local spending on unnecessary care. Some communities that have successfully held down costs did so by merging hospitals and eliminating unneeded capacity.

Wennberg et al also weighed in on the controversy (some emanating from University of Pennsylvania's Richard Cooper) over whether the vast Dartmouth Atlas research into geographic variation in Medicare spending adequately took health status into account, ie did the "high spending" hospitals spend more because their patients were poorer and sicker, or because they were less efficient. Wennberg and Brownlee post data showing that even in apples-to-apples comparisons (ie looking at academic medical centers in poor, urban, black communities, or even at two academic medical centers in the same community) the variations persist. Kaiser Health News recently wrote about Cooper, the controversy he engenders, and other health policy experts' assessment.

HEALTH CARE: Medical Home Model Catching On

Joanne Kenen — Tue, 20 Oct 2009 18:18:00 -0400

People hear "medical home" and they aren't exactly sure what it means. Judith Graham of the Chicago Tribune explains.

It's a new model of primary care that can address a lot of what drives us crazy in U.S. medicine (at least those of us with doctors and insurance). There isn't yet precise agreement on what a medical home is, or who it should serve, but usually the idea is a way to improve primary care, with particular emphasis on prevention and control of chronic conditions such as asthma or diabetes.

So instead of long waits and rushed visits, Graham writes, imagine this:

The phone rings and it's the doctor's office reminding you that it's time for your flu shot and to have your cholesterol levels tested.

"Oh, and Mrs. Smith, I know you have diabetes," the nurse continues. "How is everything going? Do you need anything from us?"

A week later, there's an e-mail from your physician on your BlackBerry. "Mrs. Smith, I adjusted your medications at our last visit. If you're having any side effects, please call," he writes.

The medical home concept usually entails a team approach. A physician or physicians works with nurses, physicians' assistants and health coaches. The doctor directs the overall care, and takes the lead on the more complex or compelling conditions. (For other posts we've written on successful medical homes in a variety of settings, including some adapted by solo practitioners, see here, here, here, and here)

A pioneer in this field is Seattle-based Group Health Cooperative (part of the Health Care CEOs for Health Care Reform) Early data show that its medical homes have reduced emergency room visits by 29 percent and hospitalizations by 11 percent while improving quality of care, according to a September report in the American Journal of Managed Care.

Routine tests are arranged before an appointment, not after, so the doctor has the results when the patient comes in. Nurses follow up by phone when a patient goes to the ER or the hospital. Doctors make phone calls and email patients -- activities which can be very efficient for follow up and monitoring but which doctors in traditional care settings don't get paid for.

For medical homes to work we'll need to change how doctors are paid (which health reform would do, up to a point, and which private insurers are also starting) Electronic health records are also essential. People sometimes worry that medical homes will be like the HMOs of the 1990s -- and in some ways they will. But the HMO model easily became about restricting care because that's how the economic incentives worked. The medical home model, in contrast, has built-in rewards for quality of care. Medical homes thrive when and only when the patients thrive.

HC4HR: Better Care at Lower Costs with Medical Homes

Paul Testa — Thu, 09 Jul 2009 20:27:00 -0400

There's a scene in the 1996 movie Independence Day where Harvey Fierstein (right), trapped in traffic trying to escape the shadow of an ominous alien ship, calls his doctor's office. Informed that Dr. Katz is not available, Fierstein screams "For $300 an hour, you can put me through to his house in the Hamptons!"

Had Fierstein been a patient with access to Group Health Cooperative's medical homes, his doctor could have called him, reminded him to take his blood pressure medication and scheduled a date for a follow-up visit.

On Wednesday, we began a series of blog posts that will highlight the innovative work being done by members of Health CEOs for Health Reform -- a New America Foundation coalition of industry CEOs and physicians committed to improving our health system.

Today, we'll examine the innovations in primary care made by the Group Health Cooperative -- a consumer-governed, integrated health care system covering over 600,000 individuals and delivering care in one of the largest integrated group practices in the Pacific Northwest. In the video below, Group Health president and CEO, Scott Armstrong, MBA, explains why his organization decided to adopt a medical home model for primary care, how they restructured their system, and the impressive results that followed.

With Congress considering private sector health insurance cooperatives as a possible alternative to a public health insurance option, Group Health has drawn national attention. As Armstrong told The New York Time's Kevin Sack recently:

There's a kind of accountability to the patients in our system ... And when you bring the principles of a cooperative to bear, patients feel responsibility for holding the system together and for their own health.

Features of Group Health make it quite unusual, even within the finite world of insurance cooperatives. Yet the lessons from Group Health's experience in revamping its primary care model can be applied to our health care system as a whole.

Group Health started its transformation after seeing within its own network of providers the kind of variations in cost and quality of health care documented across the U.S. by the Dartmouth Atlas and Atul Gawande. In January 2007, it started a medical home pilot at its Factoria Medical Center. Now Group Health plans to introduce the medical home model in all its medical centers by 2010. What follows are some key points to take away from Group Health's experiences:

Strengthening the patient-doctor relationship:

One of the hallmarks of a medical home model -- however you define it -- is that it strives to give doctors more time. Medical homes give doctors more time to spend with patients and more time to do the kinds of things that can keep people healthy but are generally not reimbursed (or reimbursed poorly) under current payment models. Group Health expanded its primary care staff by 30 percent, allowing it to: reduce physician panel sizes (the number of patients under each doctor's care); increase multidisciplinary teams of doctors, physician assistants, nurses, medical assistants, and clinical pharmacists; and extend appointment times from 20 minutes to 30.

More Coordination and Better Communication

In his presentation during a recent HC4HR briefing on Capitol Hill, Armstrong described his own experience, as a patient, with Group Health's medical home model. He received an email one morning saying his lab reports had come. Using Group Health's electronic medical record, he was able to securely access the results online. To his disappointment, he saw that his cholesterol was too high. A few hours later, Armstrong got a call from his doctor, telling him, yes, the cholestoral was still too high. Not only had the doctor already adjusted the medication, the prescription had been sent to the pharmacy (e-prescribing) and the new meds would be mailed to Armstrong in the next couple of days. Efficient, fast, and convenient.

Rapid Change and Real Results

Group Health's efforts have paid off. Relative to baseline estimates, ER visits for patients in Group Health's medical home dropped by almost 30 percent. Avoidable hospital admissions declined by 11 percent. Those savings alone, Armstrong argued, can more than pay for the investments needed in primary care. Overall quality measures increased, as did employee satisfaction. Group Health's vice president for primary care, Michael Erikson, believes the reductions in turnover and recruitment costs for physicians and other clinical staff may save the organization up to $2 million a year. Based purely on the testimonies posted by real doctors to Group Health's medical home blog, Erikson maybe on to something. Patricia Boiko, a family practice physician, writes:

Two years ago, I was at wits end. When I entered a room with a patient my first words were always, "Sorry, I am running late". I was frustrated at the lack of time to look up issues or call consults while the patient was in the room. I was always back logged with results and getting answers to patients.

That all has changed. Gradually over the last two years, I have arrived! I walked into each room today within 15 minutes of the appointment time, completely prepared for the visit. I prepped the MA [medical assistant] with all the things that would aide the efficient and complete care of each [patient] before they were seen. I called a consultant today who was too busy to discuss a case with me and preferred me to refer the [patient]. I called another consultant who was able to give me advice over the phone as to how to work up the patient. The patient was happy not to have to see another doctor and is on her way to appropriate diagnosis and treatment. I am not backlogged with calls, labs, or consultations. The work gets done today and the rework is at a minimum. I am truly happy in the practice and able to tell patients how great the GH Medical Home system is.

Check back next week, as we examine more examples of what works in health care and check out this Health CEOs for Health Reform white paper for practical policies that can transform health care in America.

HEALTH REFORM: A Call for Precision

Health Policy — Wed, 03 Jun 2009 15:00:00 -0400

A lot of new terms have entered the health care lexicon—but they don't always mean the same thing to everyone. We have a common vocabulary but not necessarily a common language. We asked Robert Berenson, MD, of the Urban Institute to guest blog on the need for precision.

It's encouraging that so much of the health care conversation in Washington is about delivery system reform, in particular the challenges posed by the intensive and expensive needs of people with multiple chronic diseases. It's also a little disconcerting. We're all talking, but are we talking about the same things?

We need more clarity, more precision.

How are we defining chronic conditions? I have a colleague who says it's like marriage—"It lasts a year or longer. It limits what you can do. It needs care."

Yes, it's funny. But it helps us think about what the definition should be. Under a liberal definition of chronic conditions, by last count I have at least four and fast approaching five, but I would say that I am in excellent health. Is having a certain number of chronic conditions what we're talking about? Or are we talking about those conditions that interfere with our ability to work, to function, to take care of daily activities? Is it a disease that puts us on a trajectory that will lead to death? Is care management the same thing as care coordination?

Medical homes (which mean very different things to different health system change advocates) can help care for people with chronic conditions. The emphasis on wellness and care coordination, on education and intervention, can help prevent people from developing these conditions, and or can keep people stable and living fairly healthy normal lives for quite some time even when they do develop these diseases.

But what about patients with cognitive deficits and difficulties with the activities of daily living? That's a different category. Can they even, physically, get to their medical home? Or does the medical care have to come to the patient's home? What if a patient has five diseases and is homebound for all intents and purposes but doesn't qualify for home health services under Medicare and isn't on Medicaid?

We also tend to talk about primary care as the focus for care management. But for someone with progressive Parkinson's, the patient will surely be seeing a neurologist as the principal care physician for that condition. Should the neurologist also be the care coordinator or should we be more explicitly defining co-management of patients? Or a nephrologist or a dialysis center where the patient goes three days a week for someone with kidney disease? Most older people with one chronic disease do in fact have others, and their care is complex and demanding.

There is no Holy Grail; we'll probably need different solutions for patients at different points in their disease trajectories. So far, we have not provided rigor to discussions of chronic care coordination, assuming somehow that the same model should apply regardless of which chronic conditions are under consideration. We have a lot to do; it will be easier if we can all agree on what we are talking about.

HEALTH CARE: Where Have All the Medical Students Gone?

Joanne Kenen — Wed, 20 May 2009 16:42:00 -0400

Where have all the medical students gone?

No, Pete Seeger has not written the anthem for health reform circa 2009. (Although it's not a bad idea).

It's the headline of a blog post from Bob Doherty of the American College of Physicians, who spends a lot of time peering into the primary care equivalent of a crystal ball, trying to see if anyone's home. (We are mixing our metaphors here but at least it reflects the fragmented nature of our health care system).

Doherty, Senior Vice President of Governmental Affairs and Public Policy for the ACP, accompanied 100 med students and internal medicine residents at a recent ACP leadership day on Capitol Hill. Their goal was to help restore primary care to its rightful place in the American medical universe.

He knows that unless something changes, preferably as part of an overhaul of the whole health system to improve access to preventive care and to improve coordination of care, young doctors are not going to enter primary care in adequate numbers.

Doherty writes:

Right now, about one out of three doctors in the U.S. are in primary care specialties, compared to the 50/50 mix found in other countries with higher performing health care systems. This would be bad enough, but unless next year's graduating class (and the ones that follow) are given a reason to look more favorably on primary care, fewer than one in five physicians will be in primary care. We know this because only 17% of U.S medical school graduates in 2008 expressed a desire to go into primary care, an all time low. We also know from studies that without more primary care physicians, the American people will experience higher cost of care and lower quality.

Doherty believes that we can't place the blame on young doctors for shunning primary care; we created the system that thwarts them. "If we really believe that patients should have a personal physician who is trained in comprehensive and longitudinal care, then we would show this to our medical students. We would pay primary care doctors better, reduce the paperwork and hassles ...associated with primary care, pay off their debt, and expose them to the joys of primary care in their training."

The ACP earlier this month put out a white paper on the primary care workforce. Among the key points:

Establish a permanent national commission on the health care workforce to plan and set targets for increasing primary care capacity to meet the present and anticipated US health care needs.
Med school loan forgiveness and related incentives for doctors-in-training to go into primary care.
Better Medicare payments for primary care—not necessarily at the expense of specialists.
Growth of patient-centered medical homes and other innovations designed to improve prevention, wellness, and care coordination.

These aren't the only ideas out there for fixing primary care. (Ask any nurse practioner). But if we don't take action soon, Pete Seeger may revise his folk classic, "If I had a Hammer." After all, what good's a hammer if there's no one to test your reflexes with it?

HEALTH REFORM: Mixed Results from Medicare Experiments

Kyle Noonan — Thu, 12 Feb 2009 16:22:00 -0500

In a promising sign for health care delivery system reform, a Pennsylvania nonprofit substantially reduced costs and improved outcomes for Medicare patients with chronic illness in a care management study. The success of this trial—and the limited accomplishments of others in this experiment—provides more evidence of the need to involve physicians in any disease management reform.

The February edition of JAMA describes 15 care coordination trials started in 2002 by CMS. The pilots tested the ability of care coordination programs to keep elderly, chronically ill patients out of the hospital, on diet and exercise regimens, and otherwise improve health and lower spending.

The results demonstrate three major points. First, the concept of a patient-centered medical home may not be easy to put into practice, but it can work. The Pennsylvania pilot gave high-utilization patients monthly visits and coordinated care from a nurse. The nurse encouraged lifestyle changes and developed a relationship with the patient. The pilot restructured care around the patient, and the nurse served as a sort of medical home for the patient.

Second, as Robert Berenson of the Urban Institute has posted on this blog before , successful disease management must involve the provider. Both of the successful pilots, in Pennsylvania and Iowa, included regular personal contact between a provider (in these cases, a nurse) and the patient. Since patients look to their providers, generally physicians, for responsibility for their health care, any disease management reform must include provider involvement. Past Medicare pilots that failed to save money because they attempted to involve outside entities in a patient's health rather than the provider.

Third, as the study author pointed out, it is challenging to get either providers or patients to change their behaviors. Most of the pilots struggled to get patients to exercise, improve their diet, stop smoking, and make other lifestyle changes necessary to improve health and reduce cost. Similarly, physicians who are used to operating as "lone rangers" without oversight of their work have a difficult time changing to a new model. The lesson here is that patients and providers need incentives to change their behavior. (See the USA Today story on financial incentives to quit smoking.) Any comprehensive reform has to provide appropriate incentives to improve health and cut costs.

So it is possible to save money and improve outcomes with a new care management model, but to work, it must be structured for success. (See our post on a previous Medicare pilot .) It needs to provide appropriate incentives, involve providers, and focus care on the patient. Hopefully the results of this experiment will inform future attempts at delivery system reform.

QUALITY: UnitedHealth, IBM Launch Medical Home Pilot

Kyle Noonan — Mon, 09 Feb 2009 16:59:00 -0500

Not waiting for action from the federal government, some private companies are searching for ways to drive down health care costs while preserving, or even improving, quality. In today's New York Times, Reed Abelson reports on a pilot medical home program started in Arizona by I.B.M., one of the state's biggest employers, and UnitedHealth Group, its insurer. The pilot will give 26 doctors at seven medical groups more direct responsibility for coordinating the care of 7,000 patients. UnitedHealth will also begin to pay doctors for overall quality of care, not just for the services provided.

Medical homes are a promising way to improve patient care and control health care costs. The medical home model gives patients a "home base," a physician who coordinates the patient's path through surgeries, specialists, and other care. It is seen as a particularly promising tool for managing chronic disease. In North Carolina's Medicaid program, assigning patients to a physician at a community clinic (their "medical home") has saved the state millions since FY2004. Both Senate Finance Committee Chair Max Baucus and the Medicare Payment Advisory Commission are interested in expanding medical homes in Medicare.

Like so many American companies, I.B.M. is struggling with the soaring costs of insuring its workers. "What we buy is garbage," Dr. Paul Grundy, I.B.M.'s director of health care transformation, told the Times in a frank description of the high costs and poor outcomes of their current system of insurance. The Arizona experiment should contribute to the growing body of evidence on medical homes and help inform federal policymakers crafting comprehensive health care reform.

IN THE STATES: Primary Care Progress in New Orleans

Joanne Kenen — Thu, 05 Feb 2009 14:28:00 -0500

Having visited New Orleans and the Gulf Coast 18 months after Katrina, and having seen first-hand the stresses on the hospitals, ERs, clinics, mobile health vans and other health centers, it's heartening to hear even a little bit of good news emanating from that struggling city. Good news is what we heard yesterday about the progress toward building a viable, community-based primary care system in a city that had long been focused on big downtown hospitals, costly specialist care, and very, very busy, crowded ERs. In fact, storm-ravaged, long-suffering, stressed-out (add your favorite cliché here) New Orleans may show the rest of us a thing or two about how to create a patient-centered primary care system.

The Kaiser Family Foundation has done a lot of work tracking the Katrina recovery, and keeping it in the public eye. We've brought you some of their surveys and reports before. They also helped fund a recent Katrina documentary, "The Old Man and the Storm." Filmmaker June Cross (friend and colleague disclosure) showed part of the film and led a panel discussion about the Gulf Coast at Kaiser's Washington headquarters Wednesday. You can watch the whole documentary on Frontline's web site, and learn more, including some of the public and mental health challenges, on June's ongoing "Katrina Road Home" reporting project.

But what caught our attention at the Kaiser forum were remarks from Clayton Williams of the Louisiana Public Health Institute, who was on hand for the panel. We originally met Williams in New Orleans in 2007 and his briefing then left us rather overwhelmed by the daunting tasks of recovery. He left us more upbeat this time. With a $100 million grant from CMS, 80 primary care clinics in neighborhoods and schools are now serving people in four storm-struck parishes (aka counties). The network of clinics includes neighborhood primary care centers, school-based care, behavioral/mental health centers, dental care, and mobile clinics that can reach into particularly under-served areas. And they are providing primary care the right way—38 of the centers have been certified as patient-centered medical homes. Williams said they are hoping for a waiver that will let New Orleans spend more of its DSH money (usually for hospitals that serve a disproportionate share of the poor) in the community, instead of in a hospital.

Williams' goal isn't to create a health system for the uninsured. He just wants to create a good health system for everyone, focused on primary and preventive care. Given the economic status of New Orleans, though, many of the patients are in fact uninsured. He told us that the clinics served 140,000 people from September 2007 to September 2008. About 45 percent were uninsured, 26 percent on Medicaid, and the rest with commercial insurance or Medicare. That doesn't mean the clinics have reached everyone who needs health care in New Orleans. Nor can they provide all the follow-up specialist care that's needed. So this isn't a rewoven safety net. But it's a step toward recovery. And a step toward making at least a portion of New Orleans' health care system better than it was before the levees broke.

QUALITY: If I Had Hammer...

Paul Testa — Tue, 27 Jan 2009 19:54:00 -0500

You wouldn't ask a plumber to build your house. Nor would you expect a dermatologist to manage your heart disease.

The difference is that in the first case, people hire a general contractor to make sure that the job is done by right people at the right price at the right time. In the second case—well that's exactly the problem according to a recent issue brief by Cato's Arnold Kling and Michael Cannon.

Kling and Cannon begin their discussion noting that "credible estimates suggest that one-third of health care spending is wasted." They problem, as they and many others see it, is in the way health care is delivered. As treatments have become more complex, health care has become less coordinated. Patients with multiple chronic diseases see multiple specialists, with no "project manager" in charge of coordinating a patient's care and overall health. The lack of accountability and communication leads to higher costs and worse outcomes. The problem, the authors argue, is perpetuated by fee-for-service payment and exacerbated by state regulations (the Cato authors are libertarian after all...),

The solution lies in creating more integrated systems of care modeled on principles of corporate organization to lower transaction costs; promote cooperation and standardization; and can realign incentives for quality.

More than their specific vision of health care system fit for the Harvard Business Reviews, what impressed us most was how similar the authors' core arguments and ideas were to other calls we've heard for delivery system reform from across the political spectrum. Just today, Health Affairs released a web exclusive (abstract) from the National Quality Forum's Janet Corrigan and Dwight McNeill on Building Organizational Capacity: A Cornerstone of Health System Reform." Others have made similar arguments promoting accountable care organizations or medical homes (which as our colleague, Joanne Kenen once posted, might be more aptly named medical neighborhoods).

One health wonk's idea of better corporate organization is another's vision of care coordination. The emerging consensus on the means as well as the ends of delivery system reform create can lay the foundation for broader health reform. It's up to Congress and the Obama Administration to build off that foundation bringing in the necessary pieces of cost, coverage and financing reforms to create a truly sustainable health care system that works for all Americans.

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

Joanne Kenen — Wed, 17 Dec 2008 15:34:00 -0500

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.